bluuebunny/crossref_metadata_2025_split huggingface dataset:
2152 A Novel Technique Using Hemostatic Spray and Endoscopic Stent-in-stent for Palliation of Hemorrhaging Esophageal Cancer
Authors: Khalid Ammara , Al-Salameh Nizar , Pluskota Christopher , Khara Harshit S. 
Published: October 2019

INTRODUCTION:
Most esophageal cancers present at an advanced unresectable stage; thus, the main focus is on palliative treatment and symptom management to improve quality of life. Esophageal stents in combination with radiation therapy are commonly used to palliate dysphagia and bleeding in these patients. We describe a novel case of an advanced metastatic esophageal cancer presenting with a massive GI bleed, treated successfully with hemostatic spray and stent in stent technique.

CASE DESCRIPTION/METHODS:
A 61-year-old male with recent diagnosis of stage IV esophageal adenocarcinoma was transferred to our hospital with a massive GI bleed. He had undergone an emergent EGD at that facility with unsuccessful endoscopic hemostasis of the profusely bleeding esophagus mass. We performed a repeat EGD, that showed a 20 cm long, diffusely bleeding partially obstructing malignant esophageal tumor. We achieved successful endoscopic hemostasis with the use of the hemostatic spray, followed by EUS-guided fiducial marker placement at the proximal and distal ends of the tumor in preparation for stereotactic radiation therapy. The entire length of the tumor was then stented using the 20 mm × 15 cm and a 20 mm × 8 cm through-the-scope fully covered esophageal metal stents with a stent-in-stent technique for tamponade of bleeding and palliation of dysphagia. He did not have any further rebleed episodes and was able to successfully receive palliative radiation as outpatient with improved quality of life at 6 months follow up.

DISCUSSION:
Treatment of advanced esophageal cancers is mainly based on palliative management. Chemo or radiation therapy can provide palliation in patients with unresectable disease. Our case highlights the use of a novel approach with combined use of hemostatic spray and stent-in-stent technique as a bridge to radiation therapy after adequate control of tumor bleeding, facilitating palliative radiation therapy and improved quality of life and survival.
2155 A Minimally Invasive Approach to Resection of a Duodenal Neuroendocrine Tumor Using the Full-Thickness Resection Device
Authors: Walsh Leonard , Groff Andrew , Moyer Matthew 
Published: October 2019

INTRODUCTION:
The Full-Thickness Resection Device (FTRD) allows for diagnostic and therapeutic endoscopic full-thickness resection (EFTR) of lesions that are unresectable with conventional endoscopic techniques. The device offers a minimally invasive approach to full thickness resection of intestinal and rectal lesions, and ensures safe tissue closure with over-the-scope-clip (OTSC) technology. We report a patient in whom the FTRD system was used for R0 resection of a duodenal neuroendocrine tumor.

CASE DESCRIPTION/METHODS:
A 68 year-old-male with history of Barrett’s esophagus was found to have a low-grade neuroendocrine tumor of the duodenal bulb on surveillance upper endoscopic screening. Computed tomography (CT) imaging of the abdomen revealed a hypervascular duodenal bulb mass, without obvious extension to the wall, lymphadenopathy, or evidence of metastasis. Endoscopic ultrasound (EUS) with fine needle aspiration (FNA), revealed a 1.2 cm mass arising from the submucosal layer with pathology indicating a low-grade neuroendocrine tumor. Due to the small tumor size, EFTR by FTRD was planned. Upon advancing the endoscope with the FTRD system attached, a non-bleeding neuroendocrine tumor was visualized (Figure 1). The mass was carefully pulled into the cap and after banding, ligation and cutting; there was a full thickness en bloc resection with all layers of the duodenum apparent (Figure 2). Pathology of the specimen documented a grade 2 neuroendocrine tumor with clean margins, confirming R0 resection (Figure 3). The patient was discharged the same day without associated complications.

DISCUSSION:
Upper gastrointestinal endoscopy and histologic examination are essential for diagnosis of duodenal neuroendocrine tumors, and EUS should follow for determination of size and depth of infiltration as well as determination of locoregional lymph node involvement. Multiple factors, such as tumor size, location, and grade need to be considered when determining treatment options. The FTRD system offers a novel endoscopic treatment approach to tumors extending beyond the submucosa that require full thickness resection and would otherwise require higher risk surgical intervention. The technology allows for safe tissue closure, valid histologic evaluation of the en-bloc specimen, and minimal thermal injury, thus reducing the morbidity and cost otherwise associated with surgery. Our case illustrates the successful R0 resection of a T2, grade 2 neuroendocrine tumor using the FTRD.
2157 A Novel Case of Plasma Cell Leukemia Diagnosed by Endoscopic Ultrasound With Fine-Needle Biopsy
Authors: Joseph-Talreja Mairin , Cummings Donelle , Chum Christopher , Cheung Derrick 
Published: October 2019

INTRODUCTION:
There are numerous reports of endoscopic ultrasound (EUS) with fine needle aspiration (FNA) used to diagnose plasmacytoma of the GI tract but, to our knowledge, this is the first report of plasma cell leukemia diagnosed by EUS with fine needle biopsy (FNB).

CASE DESCRIPTION/METHODS:
A 78 year old woman presented with exertional chest pain, dyspnea, and unquantified unintentional weight loss. CT chest showed bilateral pleural effusions, left pleural soft tissue masses, and multiple paravertebral soft tissue masses. Thoracentesis was non-diagnostic. She re-presented a month later with the same symptoms. Repeat imaging revealed enlargement of the lesions and the decision was made to pursue EUS-FNB to obtain tissue for diagnosis. On endoscopy, the patient was found to have gastric erosions and two non-bleeding, ulcerated nodules in the fundus. Biopsies resulted in chronic gastritis and h.pylori. EUS described one enlarged lymph node visualized in the middle para-esophageal mediastinum, surrounded by hyperechoic hazy soft tissue. The lymph node measured 30.6 mm by 18.5 mm, with irregular, poorly defined margins. A second lymph node was found in the peri-pancreatic region, measuring 19.4 mm × 15 mm. FNB was performed. The pathology report from both nodes identified sheets of atypical plasma cell proliferation which stained positive for CD138 and CD56. Flow cytometry revealed a proportion of 40% IgG Lambda-restricted plasma cell population. These findings, taken in the context of a known M-spike and circulating atypical IgG lambda-restricted plasma cells on peripheral blood smear, established the diagnosis of plasma cell leukemia with soft tissue component. Unfortunately, it was felt that the patient would not be able to tolerate chemotherapy and she was sent home with hospice.

DISCUSSION:
While EUS-FNA is used frequently to evaluate lesions in the upper GI tract, this is the first reported case, to our knowledge, of EUS-FNB used to diagnose a plasma cell leukemia. In this case, the diagnosis was confirmed, not on peripheral smear or with cytology from pleural fluid, but from the biopsies we obtained. This is a good example of how EUS-FNB can often be the safest and easiest way to obtain adequate tissue samples from intrathoracic or intraabdominal lesions to facilitate diagnosis.
2169 Endoscopic Stricturotomy via Argon Plasma Coagulation With Balloon Dilation for Refractory Colonic Stricture Secondary to Crohn’s Disease
Authors: Ali Saad Emhmed , Tripathi Nishant , Bautista Robert-Marlo , Gabr Moamen , Mardini Houssam , Frandah Wesam 
Published: October 2019

INTRODUCTION:
Stricture is a significant complication in patients with Crohn’s disease (CD). Up to 80 % of patients will require at least one surgery for stricture, fistula, or abscess during their lifetime. The current treatment modalities are surgery, endoscopic balloon dilation (EBD), or endoscopic stricturotomy (ES) via a needle-knife or electrosurgical knife. We report a combined endoscopic stricturotomy via argon plasma coagulation (APC) with balloon dilation in a patient with refractory benign colonic stricture due to Crohn disease.

CASE DESCRIPTION/METHODS:
A 56-year old man with a twenty-seven-year history of Crohn’s disease presented to the clinic with chronic right-sided abdominal pain. He has two to three bowel movements a day. He is a non-smoker, denied alcohol, or illicit drug use. He had prior use of anti-TNF inhibitor with secondary loss of response. Current medication included azathioprine, esomeprazole, and ustekinumab injection every eight weeks. Vital signs were normal. The abdomen was soft, non-tender, no organomegaly, normal bowel sounds, and normal rectal exam. Labs revealed hemoglobin 14.2 g/dl, leukocyte count 7k/mm3, platelets 393k/mm3, urea nitrogen 13 mg/dl, creatinine 1.0 mg/dl, CRP 0.9, mg/dl and fecal calprotectin 59 ug/g. Magnetic resonance enterography (MRE) was performed and revealed severe short segment stricture of the mid ascending colon (Figure 1). He underwent a colonoscopy, and it showed a benign-appearing, severe non-traversed stricture measuring 3 cm in length x 1.1 cm in inner diameter in the ascending colon (Figure 2). Coagulation for tissue destruction and stricturotomy using pulsed argon plasma at 1.5 liters/minute and 40 watts was accomplished, followed by balloon dilator up to 15 mm with significant improvement in the luminal narrowing (Figure 3). The site was traversed, and the cecum was inspected. The patient was seen in the clinic two months later, and he was doing well, and his abdominal pain was resolved.

DISCUSSION:
Surgery is still considered to be the standard therapy in patients with a colonic stricture. Endoscopic stricturotomy has emerged as a promising modality to avoid or minimize the need for surgery. Up to our knowledge, using the APC mediated ES has not been reported. So, we report the successful use of this technique combined with balloon dilation in a patient with severe CD- associated benign stricture. The clinician should be aware of such procedure as an effective treatment modality in refractory benign colonic stricture.
2179 Placement of Palliative Stent With Guidance of a Percutaneous Transhepatic Stent
Authors: Poola Shiva , Jampala Nannaya , Mudireddy Prashant 
Published: October 2019

INTRODUCTION:
The incidence of pancreatic cancer has increased in the last decade. There have been improvements in pancreatic cancer through a multidisciplinary approach including chemotherapy, surgery, and radiation. The Whipple procedure is the mainstay operation for pancreatic head tumors; however, long term complications include cholangitis and pancreatitis. Cholangitis can be managed with drainage or stenting. Although PTC stent allows for drainage of the biliary system, an obstruction may call for internal stent placement. This case highlights placement of a stent using a pre-existing PTC drain for guidance.

CASE DESCRIPTION/METHODS:
A 71-year-old Caucasian male with history of pancreatic cancer status post a Whipple and chemoradiation presented with obstructive jaundice. EGD demonstrated a malignant stricture of the afferent jejunal limb. Attempted endoscopic stenting was unsuccessful. An 8.5 Fr PTC with internal and external biliary drainage catheter was performed by IR with the internal drainage catheter placed beyond the stricture. The patient over the course of the next month had decreased output from his biliary drain and was re-admitted with increased bilirubin and leukocytosis. The external/internal biliary drain catheter was replaced without significant improvement. A repeat EGD and ERCP demonstrated a PTC drain in the afferent jejunum and using a biliary wire through the side hole of the PTC drain, the PTC drain was removed over the wire. An uncovered metal stent was placed across the afferent jejunal stricture into the normal jejunal limb. Post procedurally the patient had improved LFTs. However, the patient had an interval rise in bilirubin and ALP. EGD demonstrated a clogged stent and a pigtail plastic stent was placed through the preexisting metal stent to prevent recurrent clogging. After the patient had improvement in his LFTs.

DISCUSSION:
Management of biliary obstructions requires biliary drainage with either a stent or surgical drainage. This case highlights a multi-step approach for management of a malignant biliary obstruction. After identifying an obstruction, an internal metal stent was placed in a rendezvous approach. Endoscopic metallic stent placement is a common for malignant biliary obstructions in jaundiced pancreatic cancer patients. In an event of an occluded metal stent, placement of a plastic stent is effective for management. This patient had a biliary obstruction after metallic stent placement prompting placement of a plastic pigtail stent within the metal stent.
2183 Endoscopic Management of Efferent Loop Syndrome Using Axios Lumen-Apposing Metal Stent
Authors: Zivari Kaveh , Waintraub Daniel J. , Fazio Richard M. , Weinberger Jonathan , Chernobelsky Leonid , Moshenyat Isaac , Khodorskiy Dmitriy O. 
Published: October 2019

INTRODUCTION:
Efferent loop syndrome (ELS) is a rare post gastrectomy syndrome that can occur following Billroth-II or Roux-en-Y reconstruction. The most common loop syndrome after gastric surgery is afferent loop syndrome (ALS), however efferent loop syndrome has been reported. ELS may occur due to a mechanical obstruction of the efferent limb due to an anastomotic stricture, malignancy, volvulus, intussusception, internal hernia or abdominal adhesion after surgery. Presentations include abdominal distension and vomiting and rarely pancreatitis or cholangitis. We present a case of efferent loop syndrome managed with an Axios lumen apposing metal stent (LAMS).

CASE DESCRIPTION/METHODS:
79 year-old male with a history of gastric adenocarcinoma status post distal gastrectomy with Billroth-II reconstruction one month prior to admission presented with abdominal pain and nausea. Computed tomography of the abdomen revealed distended stomach with contrast, dilated biliary limb with collapsed distal jejunum and no passage of contrast distal to the anastomosis (Image 1). Upper endoscopy (EGD) revealed a friable gastrojejunostomy anastomosis with a patent afferent limb and a nearly obstructed stenosis at the efferent limb suture line. A 20 × 10 mm A-LAMS was deployed across the stenosed efferent limb under direct visualization and fluoroscopic guidance (Images 2 and 3). Follow up upper gastrointestinal series confirmed brisk passage of contrast into the efferent limb. The patient clinically improved and a repeat EGD revealed a patent efferent limb and a dislodged Axios LAMS which was endoscopically removed.

DISCUSSION:
ELS and ALS can be managed surgically or endoscopically. Endoscopic options include dilation and enteral stenting. Dilation may require multiple sessions and stenting utilizing self-expanding metallic stents (SEMS) may be limited by tumor in-growth in the setting of malignant obstruction. LAMS creates a de-novo fistulous tract to bypass an obstruction while its saddle shape provides anti-migratory properties and allows apposition of two gastrointestinal lumens. While LAMS has been reported in ALS, there are only rare reports in the management of ELS. Our case highlights a case of successful management of ELS with Axio LAMS.
2216 Toxic Epidermal Necrolysis and Drug-Induced Liver Injury Secondary to Oseltamivir
Authors: Shaikh Abdullah S. , Zaibaq-Krill Jenine , Merwat Shehzad N. , Merwat Sheharyar 
Published: October 2019

INTRODUCTION:
Multiple antibiotics have the well documented adverse reactions of Stevens-Johnson syndrome, toxic epidermal necrolysis, and liver injury. Oseltamivir is not known to cause any of the above reactions. We present a patient who suffered both toxic epidermal necrolysis and drug induced liver injury (DILI) secondary to oseltamivir.

CASE DESCRIPTION/METHODS:
A 40-year-old female with systemic lupus erythematosus (SLE) on hydroxychloroquine and azathioprine for several years presented with community acquired pneumonia and rash concerning for Stevens-Johnson syndrome (SJS). She was also found to have newly elevated liver chemistries in a hepatocellular pattern. Her only new medication was oseltamivir which had been started 48 hours prior to presentation for empiric treatment of influenza. She was transferred to our tertiary care academic medical center burn unit for further management of SJS which eventually progressed to toxic epidermal necrolysis (TEN) (confirmed via dermatopathology). On arrival to our institution, her pattern of abnormal liver chemistries evolved into that of a cholestatic hepatitis with a peak conjugated hyperbilirubinemia of 16.7mg/dL, alkaline phosphatase of 1087 U/L, AST of 400 U/L, and ALT of 708 U/L. Her TEN started to improve with supportive care and cessation of oseltamivir. She underwent MRCP which revealed possible bile duct stricturing without biliary ductal dilatation. Her ANA was positive with a titer of 1:640, anti-smooth muscle antibody was negative, anti-mitochondrial antibody was negative, and IgG level was within normal limits. She underwent liver biopsy which was consistent with drug induced liver injury. Her liver chemistries eventually started to improve and she was discharged from the hospital with continued improvement on follow up.

DISCUSSION:
Oseltamivir is an antiviral sometimes used for influenza infection. Very few reports exist regarding oseltamivir’s association with SJS/TEN, and even less on its association with liver injury. Our case is unique in that a patient developed both TEN as well as drug induced liver injury secondary to oseltamivir which are rare but important differential diagnoses to be aware of for patients who develop rash or elevated liver enzymes while being treated with oseltamivir.
2221 A Case of Rare Escape Mutation Type G130N and Conundrum of Heptitis B Serology
Authors: Lakkasani Saraswathi , Jayasingam Rajasingam M. , Barham Shaker , Siegel Arthur M. , Depasqule Joseph 
Published: October 2019

INTRODUCTION:
Hepatitis B (HB) virus is a global public health problem as it affects more than 300 million patients around the world. It's well known that once we have Anti-HBs, seroconversion takes place, and that's a marker of viral clearance and immunity. In view of their important protective role, occurrence of anti-HBs and HBsAg is perplexing. Although this has been reported in 5-20% of cases of Chronic Hep B, it remains a confusing finding to many physicians who are unaware of the existence, explanation and implications of this finding. Herein, we will present a case of such a pattern.

CASE DESCRIPTION/METHODS:
A 49-year-old male with diabetes and hypertension was found to have elevated liver enzymes on routine blood work. Further workup resulted in diagnosing chronic hepatitis B. The patient’s viral serology results were positive for HB core antibody, HB surface antibody, HB surface antigen, HB e antigen, and a viral load of 1,500,000 IU/ml. Liver enzymes were elevated with ALT of 250U/L and AST of 180U/L. No masses were detected on liver ultrasound. Blood sample was sent to Center for Disease Control and analysis revealed a mutation G130N within the major hydrophilic region of surface antigen. The patient was started on Entecavir. After 12 months, the VL became undetectable. Serology was still positive for both HB s Ag and Ab but he successfully achieved HB e Ab +ve status. Liver enzymes normalized.

DISCUSSION:
The expected pattern in chronic HB is the presence of HBsAg and lack of anti-HBs. The mechanism underlying the coexistence of HBsAg and anti-HBs remains unclear. Mutations in the viral DNA were initially suggested by researchers to explain how the subtypes of the HBsAg and anti-HBs were heterologous. It was shown that there is a relation between this special serological profile and mutations in S gene region, particularly in the 'a' determinant of the major hydrophilic region of the surface antigen, including one located at G130N. Aside from mutations in the S gene region, the presence of heterologous subtype-specific antibodies, superinfection with a new HB strain, occult HB reactivation and false positivity for anti-HBs are other possible explanations. These patients might harbor an augmented HBV replicative capacity and HBV reactivation upon receiving immunosuppression. Antiviral prophylaxis must be considered before starting immunosuppressive drugs. It was also reported that coexistent HBsAg and anti-HBs independently increased the risk of advanced fibrosis and hepatocellular carcinoma.
2240 Hepatocellular Carcinoma With Vascular Invasion and Cardiac Metastasis: A Case of Veno-Occlusive Disease Causing Progressive Liver and Renal Failure
Authors: Dasu Neethi R. , Khalid Yaser , Walters Richard , Lal Kailash , Parikh Nishant 
Published: October 2019

INTRODUCTION:
Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver. The most frequent sites of metastasis are the lungs, the bones, the lymphatics, and the brain. We present a case of a 61-year-old female found to have advanced stage HCC with isolated metastasis to the right atrium and IVC, which is extremely rare with incidence of 2.7-4.1%. Prognosis is very poor.

CASE DESCRIPTION/METHODS:
A 61-year-old female presented with two weeks of generalized weakness and diarrhea. Physical exam revealed bilateral lower extremity edema. Laboratory data revealed a cholestatic injury pattern with an R factor of 1.1. CT of the abdomen and pelvis showed abdominal lymphadenopathy and a 3-cm mass in the right hepatic lobe. Diagnostic paracentesis showed a serum-ascites albumin gradient (SAAG) of 1.9 and a fluid protein of 2.7 g/dL. Treatment with lactulose, fluids, and albumin improved her mental status, but the patient’s renal function and diffuse edema continued worsening. Following a therapeutic paracentesis of 4 liters of peritoneal fluid, she had a primary hepatocellular injury pattern with R factor 14. With an alpha-fetoprotein (AFP) level of 1700, the diagnosis of HCC was confirmed. An echocardiogram showed a bilobed mass in the inferior portion of the right atrium. Magnetic resonance venography revealed occlusion of the right intrahepatic portal vein. Fine needle aspiration biopsy confirmed hepatocellular carcinoma. Due to having end-stage HCC, Child-Pugh Class C with expected survival less than 3 months, only palliative treatment was offered.

DISCUSSION:
HCC with isolated metastasis to the right atrium presents with right heart failure, manifesting as lower extremity edema, jugular venous distention, and ascites as seen in our patient. Only 1.2-4.1% of all HCC have metastasis to the heart, with around 17 reported cases in the literature of isolated metastasis to the heart. Our patient had an extremely rare case of an isolated right atrium metastasis of HCC. Sorafenib is the first line treatment option for advanced HCC but the delay in diagnosis, as well as our patient’s complex presentation, limited treatment. We recommend that echocardiography should be routinely performed for all patients with advanced HCC to prevent unexpected and fatal cardiovascular complications. This case illustrates the subtle presentation of HCC and that early diagnosis is key for treatment. Further studies need to investigate the current and novel treatment options for both HCC and cardiac metastasis.