bluuebunny/crossref_metadata_2025_split huggingface dataset:
2648 A Case of Amebiasis in a Patient With Familial Hypertriglyceridemia Complicated by Recurrent Pancreatitis
Authors: Sang Jessica , Lewis Jason 
Published: October 2019

INTRODUCTION:
Amebiasis disproportionately affects people in developing countries because poor sanitation conditions increase the risk for pathogen acquisition. In the United States, individuals who travel to endemic areas and men who have sex with men are two groups at higher risk of exposure. The following case highlights the importance of exposure history and avoiding anchoring bias. The patient’s constellation of symptoms could be explained by his history of chronic pancreatitis and pancreatic insufficiency, but upon further investigation he was also found have an infective enteritis.

CASE DESCRIPTION/METHODS:
A 44-year-old man with a past medical history significant for type 2 diabetes mellitus, idiopathic small fiber neuropathy, and familial hypertriglyceridemia complicated by recurrent pancreatitis was admitted for recurrent symptoms of nausea, vomiting, non-bloody diarrhea, and abdominal pain. Within the previous year, the patient had a PEG-J tube placement for nutritional support in the setting of severe pancreatitis complicated by acute fluid collections. On arrival to the emergency department, he was tachycardic and labs revealed a leukocytosis of 18 × 103 µL, lipase of 510 U/L, and normal LFTs. The CT scan showed a stable pancreatic pseudocyst and no suggestion of acute pancreatitis. Imaging did reveal mild thickening and dilated loops of small bowel consistent with enteritis in the left mid and left lower abdomen. Stool pathogen panel sent during previous admission had returned positive for Entamoeba histolytica (E. histolytica). The patient endorsed drinking well water from his backyard and using it to flush his PEG-J tube.

DISCUSSION:
The majority of amebiasis cases are asymptomatic, however 10% are associated with significant morbidity and mortality. E. histolytica is one of four species of intestinal amebae and the one related most to symptomatic disease. Malnutrition, which was present in our patient, is a risk factor for severe disease. Studies have shown that interaction between the host’s intestinal flora and E. histolytica may influence pathogenic behavior. Our patient's treatment regimen consisted of metronidazole, which is active against the trophozoite stage, and paromomycin, which eliminates intraluminal cysts. His source of exposure was likely the well water which was uncovered through a detailed exposure history.
2649 A Case of Primary Intestinal Lymphangiectasia in an African American Adult Male With Intermittent Abdominal Pain and Diarrhea
Authors: Abdallah Abdallah , Karim Ahmed , Alnakshabendi Imad , Alnakhabendi Ibrahim 
Published: October 2019

INTRODUCTION:
Primary intestinal lymphangiectasia is a rare type of protein losing enteropathy in which there is a localized or diffuse ectasia of the enteric lymphatic causing leakage of protein into the intestinal lumen. Here, we describe a case of Primary Intestinal Lymphangeictasia in a patient presenting with chronic intermittent abdominal pain and diarrhea.

CASE DESCRIPTION/METHODS:
Patient is a 56-year-old African-American male with history of COPD, DM, morbid obesity, GERD who presented to our office as a referral after hospitalization for for evaluation of abdominal pain and diarrhea. Patient was hospitalized for 3 day duration of epigastric pain and watery diarrhea. There, he was noted to have hypocalcemia, hypoalbuminemia, and trace urine proteinuria. Lactate was normal. CT abdomen pelvis showed nonspecific Jujenitis. He was treated empirically with Intravenous antibiotics and discharged home. During follow up visits, initial comprehensive workup for inflammatory bowel disease, celiac disease, stool pathogens, thyroid panel, lipid panel, Alpha-1-Antitrypsin stool clearance, and HIV were all unremarkable. Patient subsequently underwent colonoscopy and EGD. Colonoscopy revealed sigmoid diverticulosis and internal hemorrhoids. EGD revealed nonspecific jejunitis. He had yet another hospitalization for worsening similar acute abdominal pain. During his second hospitalization, labs showed mild leukocytosis, CT abdomen and pelvis revealed jejunal edema. He was taken for diagnostic laparoscopy which only showed mild ascites and thickening of the jejunum. Surgical pathology unfortunately was inconclusive. Patient followed up again as an outpatient and underwent small capsule endoscopy which revealed lymphangiectasia at the jejunum. Patient was referred to a dietitian where he was placed on high protein and Medium chain triglycerides diet.

DISCUSSION:
Primary Intestinal Lymphangeictasia is a rare cause of protein losing enteropathy that can manifest as non-specific abdominal pain and diarrhea. In this case, the patient had chronic intermittent abdominal pain and diarrhea which required capsule endoscopy in order to diagnose and was missed on surgical pathology. Much like an Inflammatory Bowel disease which can take several studies and biopsies in order to diagnose, albeit different pathophysiology, Primary intestinal lymphaniectasia is a rare cause of abdominal pain that should be on the differential when evaluating chronic intermittent severe abdominal pain and diarrhea of unknown etiology.
2654 Metastatic Squamous Cell Carcinoma to the Small Bowel Masquerading as Crohn’s Disease: A Diagnostic Dilemma
Authors: Mony Shruti , Patel Krishen , Taunk Pushpak 
Published: October 2019

INTRODUCTION:
Head and neck squamous cell carcinoma (HNSCC) is the sixth most common type of cancer in the world. The presence of distant metastasis after the initial treatment of head and neck cancers is associated with a poor prognosis. The most frequent site for distant metastasis of HNSCC is lung, followed by mediastinal lymph nodes, bone and liver. Metastatic squamous cell carcinoma (SCC) to the small bowel is an extremely rare occurrence. We present a unique case of a patient with HNSCC who presented with small bowel obstruction and concern for Crohn’s disease (CD) but was ultimately diagnosed with metastatic SCC.

CASE DESCRIPTION/METHODS:
A 67 year old Caucasian male with a history of SCC of the left pinna and epiglottis on cisplatin chemotherapy and radiation therapy, presented with 2 weeks of intractable nausea, vomiting, and peri-umbilical abdominal pain. Lab work revealed leukocytosis with WBC 16,000. CT abdomen and pelvis was notable for dilated small bowel loops and a long segment thickening of the distal ileum causing a partial small bowel obstruction (Figure 1).  His symptoms persisted despite nasogastric decompressiontube and antibiotics. An abdominal MRI showed similar findings of long discontinuous segments of diffuse distal small bowel thickening, luminal narrowing and mural enhancement with concern for small bowel CD. Given these findings, an empiric course of steroids was initiated. Patient’s symptoms improved and he was discharged from the hospital..To further evaluate the small bowel, he underwent a retrograde balloon enteroscopy, which showed subtle findings of multiple sub-centimeter distal ileal nodules (Figure 2), but no other abnormalities. Biopsies of the nodules returned as metastatic poorly differentiated squamous cell carcinoma (Figure 3).

DISCUSSION:
Small bowel metastasis represents less than 10% of malignant tumors of the small bowel. Small bowel metastasis from HNSCC is an unusually rare occurrence and to date, there is minimal literature on it’s occurrence. Clinical presentation is variable with acute or sub-acute intestinal obstruction, ileus, gastrointestinal hemorrhage or bowel perforation. Here, we present an unusual case of small bowel metastasis from HNSCC, which is unique given the initial radiologic findings suggestive of CD. Thus, clinicians must be cognizant of the metastatic potential of squamous cell cancer in order to prevent delayed diagnosis and avoid devastating consequences.
2664 You're Breaking My Heart: Carcinoid Heart Disease
Authors: Biglin Mary , Swanson Garth 
Published: October 2019

INTRODUCTION:
Neuroendocrine tumors (NET) are rare tumors affecting the gastrointestinal tract and lungs with ∼8,000 cases diagnosed in the US each year. About 80% of small intestinal NET have metastasized to the liver and present as carcinoid syndrome with flushing, diarrhea, bronchospasm and heart failure, as the liver is unable to metabolize vasoactive substances. Carcinoid heart disease can occur in ∼60% of patients with carcinoid syndrome and is a late complication that can be associated with significant morbidity due to right sided heart failure.

CASE DESCRIPTION/METHODS:
A 60 year old female with anxiety and breast cancer presented to an outside clinic with chronic diarrhea. She began experiencing 10–20 watery stools daily for over a year but lost 8 pounds over the last four months. An upper and lower endoscopy done for evaluation of chronic diarrhea was normal. Stool studies revealed a negative stool culture, clostridium difficile PCR and normal fecal elastase, but laboratory studies showed an elevated chromogranin A (23,940 ng/ml), serotonin (1668 ng/ml) and urinary 5-HIAA (112 mg/day). A CT of the abdomen revealed multiple liver lesions. Liver biopsy was non-diagnostic. Four months later she sought a second opinion but soon after developed new onset ascites and lower extremity edema so was admitted to the hospital for further evaluation. Echocardiogram showed severe tricuspid regurgitation with the leaflets tethered and fixed in an open position. Cardiac MRI showed late gadolinium enhancement of tricuspid valve leaflets which was consistent with carcinoid heart disease. Repeat liver biopsy revealed grade 2 well differentiated NET, with presumed small bowel origin. She received octreotide and underwent mechanical tricuspid valve replacement.

DISCUSSION:
Carcinoid syndrome is a rare finding but is important in the differential of chronic diarrhea. This case also portrays the prolonged natural history of carcinoid syndrome with the late complication of carcinoid heart disease. Inability of upper and lower endoscopy to locate small bowel carcinoids can lead to a delay in diagnosis, and in 18% of small bowel carcinoids the primary location is not identified. Early identification and treatment of NET tumors can avoid late morbid conditions such as carcinoid heart syndrome.
2667 Can't You GIST Move Over?
Authors: Likhtshteyn Michelle , Arroyo-Mercado Fray Martin M. , Iqbal Sadat , Botti Evan , Diks John , Anklesaria Ava 
Published: October 2019

INTRODUCTION:
Gastrointestinal stromal tumors (GISTs) are a common mesenchymal tumor of the GI tract. Here we present a case of a 60-year-old male with a 33.5 × 27 cm GIST arising from the greater stomach curvature, increased in size from 18.1 × 13.4 cm in five months; an alarming growth rate for a tumor known to grow slowly.

CASE DESCRIPTION/METHODS:
60-year-old male with history of GIST and HTN presented to the hospital with abdominal pain and shortness of breath. Physical exam revealed decreased bowel sounds and diffuse tenderness to palpation in the right and left lower quadrants. Patient had previously been diagnosed with a 18.1 × 13.4 cm GIST 5 months prior, and was positive for CKIT (CD117) and DOG1, with 6 mitotic figures/21 HPFs (Figure 1). The patient was lost to follow up and never started on Imatinib. Over a span of five months, the necrotic mass had doubled in size with a repeat CT scan on admission showing a 33.5 × 27 cm GIST (Figures 2 and 3) arising from the greater stomach curvature, invading the left hepatic lobe and compressing the inferior vena cava (IVC). During this admission, he was also found to have bilateral pulmonary embolism, with large clot burden and right heart strain. An IVC filter would have been ideal for prevention of further clot migration, however the compression of the IVC by enlarging GIST prevented intervention. Patient was treated with heparin and started on Imatinib as an outpatient, patient is doing well and following with oncology.

DISCUSSION:
GISTs can be found in any part of the gastrointestinal tract, with predominance in the stomach. GISTs are often asymptomatic and diagnosed incidentally or they may present with nonspecific symptoms such as early satiety, abdominal pain, anemia, GI bleed or gastric outlet obstruction. Treatment options are dictated by risk of progression which is determined by size (≥3 cm), location, and mitotic count. [1] While the exact rate of tumor growth is unknown, studies have shown a range of 1.2 to 50.7% per annum [2]. On representation to the hospital five months after initial diagnosis, our patients’ mass had increased in size by 54% which surpasses documented growth rates. His mass also created significant compression and prevented integral placement of an IVC filter. While GIST tumors are traditionally thought to be slow growing tumors our case highlights the importance of earlier intervention in high-risk patients; metastatic and compressive complications could have been avoided for this patient had he returned for initial follow-up.
2674 Laying a Gastric Wall Abscess to Rest
Authors: Haberstroh William , Steinberg Joshua M. , Benjamin Stanley , Palese Caren 
Published: October 2019

INTRODUCTION:
Gastric wall abscess (GWA) or localized suppurative gastritis is a purulent inflammatory process of the submucosa of the stomach associated with high mortality rates. GWA can be a rare complication of subepithelial lesions (SEL), such as ectopic pancreas (pancreatic rest), GIST, and leiomyosarcoma. Our report is the fourth demonstrated case of pancreatic rest associated GWA and the first in an extensive literature search with successful treatment without adjunctive surgical resection.

CASE DESCRIPTION/METHODS:
38-year-old healthy female presented to our Gastroenterology clinic for persistent abdominal pain with nausea and vomiting after being evaluated 3 days ago at an outside hospital (OSH) (Table 1). She was diagnosed with gastritis and sent home on omeprazole. At our institution, she described her pain as sharp, constant, non-radiating and diffuse, but worst in the epigastrium postprandially. Social history was remarkable for 1-2 drinks per day and recent travel to Peru 3-4 weeks prior. As she appeared acutely ill, the patient was referred to ED, with initial work up remarkable for blood pressure of 93/54 and WBC of 13.5. EGD revealed a large submucosal gastric mass in the distal gastric antrum with central umbilication and expressible white purulent material (Figure 1). She was started on pip/tazo and ID was consulted. Micro was largely negative; however, culture of purulent material was unable to be processed. Pathology showed active gastritis, focal ulceration, and necro-inflammatory tissue without evidence of malignancy. Cytology revealed purulent exudate associated with bacterial colonies consistent with abscess. The patient clinically improved and was discharged home on Augmentin. In outpatient follow up, patient reported continued improvement. Follow up EGD revealed resolution of abscess, however pancreatic rest was seen in the gastric antrum (Figure 2).

DISCUSSION:
GWA is a rare and highly morbid condition commonly located in the antrum or pylorus. Exact pathogenesis may be due to direct bacterial seeding or hematogenous spread. Strep species are the most commonly isolated bacteria. GWA is rarely also associated with a SEL, in our case being a pancreatic rest, or ectopic pancreatic tissue. Treatment for SEL associated GWA has traditionally been surgical removal with either partial gastrectomy or wedge resection. Our case report demonstrates the safety and efficacy of drainage and medical management alone.
2676 An Extranodal Presentation of Peripheral T-Cell Lymphoma, Not Otherwise Specified as Primary Gastric Lymphoma, With Coexistence of HTLV-1
Authors: Bandaru Praneeth , Barakat Mohamed , John Febin , Aamar Ali , Quintero Eduardo 
Published: October 2019

INTRODUCTION:
Peripheral T- Cell Lymphoma, not otherwise specified ( PTCL-NOS) is a subtype of T-cell lymphoma that typically presents as primary nodal lymphoma, however can rarely present as primary extranodal lymphomas with stomach being the most common extranodal site. Here we present a unique case of PTCL-NOS gastric lymphoma with coexistence of HTLV-1, which is usually associated with Adult T-cell lymphoma/leukemia.

CASE DESCRIPTION/METHODS:
A 58 year old man with known hypertension and a chief complaint of abdominal discomfort, fatigue, occasional black stools and unintentional 10 lb weight loss of 2 months duration was seen in clinic. Vital signs, physical exam were normal except for conjunctival pallor. Labs revealed Hb of 7 gm/dL and elevated LDH. CT scan of the abdomen revealed an 11 × 12 × 12.6 cm poorly defined inseperable mass, in the left upper abdomen (Figure 1). Upper endoscopy (EGD) with Endoscopic ultrasound (EUS) revealed a large, ulcerated, nearly circumferencial, fungating mass that appeared to erode through the cardia of the stomach. Biopsy and immunohistochemical (IHC) staining revealed pleomorphic lymphocyte cells positive for CD2, CD3, CD5, CD4(70%), CD7 (20%), CD8 (30%), CD43 and CD45 (20%) (Figure 2). KI-67 index was 80% suggestive of high grade PTCL-NOS, with necrosis (Figure 3). H. pylori and HTLV-1 antibody were positive. Pretreatment PET scan and bone marrow biopsy did not reveal additional site involvement. He was subsequently started on CHOEP regimen and triple therapy for H.Pylori. Repeat imaging after the 4th cycle revealed an interval decrease in the size of the stomach mass with no new lesions.

DISCUSSION:
Primary Gastric lymphomas account for 3-4% of all the stomach malignancies, mostly B-cell (85-90%) in origin followed by PTCL-NOS. Biopsy is obtained by EGD in most cases and EUS is being increasingly used to evaluate for locoregional spread. Early diagnosis and initiation of treatment with CHOP/CHOEP regimen is crucial for better outcomes. Pan imaging, FDG PET, bone marrow biopsy are critical for staging, tumour activity and for followup to check for response. Radiation, surgery, bone marrow transplantation are used as adjuvant to chemotheraphy in select patients. Coexistence of HTLV-1 in a PTCL-NOS patient make our case unique and this gives scope for further research to verify if there is any association exists between PTCL-NOS and HTLV-1.
2678 To the Heart of the Matter: A Case of Left Ventricular Assist Device Erosion at the Texas Heart Institute
Authors: Pathan Sabina , Sparkman Jordan , Kaur Manreet 
Published: October 2019

INTRODUCTION:
Left ventricular assist devices (LVADs) are used in patients with advanced systolic heart failure as a bridge to cardiac transplant or as destination therapy. LVADs provide a survival benefit in this population but pose a significant risk of infection, typically of the driveline. Gastrointestinal-related infectious complications of LVADs, including erosion into the GI tract, or a device-related enteric fistula are less common. Here we present a case of enteric LVAD erosion discovered while investigating unusual blood culture results.

CASE DESCRIPTION/METHODS:
A 52 year old man with history of alcohol-related cardiomyopathy now with LVAD and chronic driveline infections with Stenotrophomonas, E. cloacae, MRSA, and MSSA on suppressive antibiotics was admitted to our hospital after outpatient blood cultures grew C. albicans. He reported fatigue and forty-pound weight loss during the previous three months. He denied fevers, abdominal pain, nausea, vomiting, change in appetite or early satiety. On admission, the patient was afebrile. On physical exam, he was in no distress, the abdomen was soft and not tender. There was purulent drainage from the driveline site, unchanged from prior admissions. Given his unusual history of bloodstream infections with Lactobacillus, Enterobacter, E. coli, and now Candida, there was concern for a bowel connection to the LVAD. Cross-sectional imaging with PO contrast revealed expected positioning of the LVAD abutting the gastric body and significant hardware scatter artifact, limiting the examination (Figure 1). The patient therefore underwent bidirectional endoscopy and EGD revealed two areas of ulceration and exposed LVAD hardware eroding into the greater curvature of the gastric body (Figure 2). The patient underwent subsequent explant and replacement of the LVAD. Two defects in the gastric body, one near the cardia and the other near the antrum were repaired by omental flap placement and gastrorrhaphy. A peri-gastric abscess was also drained.

DISCUSSION:
LVADs have revolutionized the management of advanced heart failure, however one-half of patients will develop a device-related infection within nine months of implantation. Although less common, GI-related LVAD infections, including enteric erosion and fistula formation, require a high index of suspicion. Non-invasive testing is suboptimal given limitations of current imaging modalities. Therefore, these patients should undergo upper and lower endoscopy for direct visualization and timely diagnosis.
2679 An Unusual Presentation of Invasive Gastric Adenocarcinoma
Authors: Wankhade Charudatta , Kratzer Marykate , Jacob Bobby , Paz Sandra Gomez , Desai Jiten , Singh Davinder , Khan Nausheer 
Published: October 2019

INTRODUCTION:
Gastric cancer rarely occurs before the age of 40, but it’s incidence rises thereafter and peaks in the seventh decade of life. Most patients with gastric cancer in the United States are symptomatic and already have advanced disease at the time of presentation. We present a case where neither the patient history nor physical exam provided any early indication to the diagnosis of gastric adenocarcinoma.

CASE DESCRIPTION/METHODS:
A 32-year old Jamaican female was admitted for right lower quadrant abdominal pain since five days. Pain was constant, sharp, radiating from the pelvis to lower back. Review of systems was positive for dyspnea on exertion and 35-pound weight loss over past 3 months. She denied any past medical or surgical history, alcohol and tobacco use. Family history was significant for breast cancer in an aunt. On physical exam patient was afebrile, blood pressure and pulse were 120/76 mmhg and 86/min respectively. She had right lower quadrant tenderness on deep palpation but rest of the physical exam was unremarkable. CT thorax, abdomen and pelvis was negative for PE but demonstrated mediastinal, hilar, retroperitoneal and mesenteric lymphadenopathy. Infectious and autoimmune workup were unremarkable. Endoscopic intervention revealed a 7 cm ulcerated friable gastric mass near the pylorus and internal hemorrhoids on colonoscopy. Biopsy of the mass revealed poorly differentiated gastric adenocarcinoma. Hospital course was complicated with pericardial tamponade. Pericardial biopsy revealed metastatic poorly differentiated carcinoma. Patient was not a candidate for chemotherapy as she was spiking fevers on antibiotics. After over a month long hospital course, patient succumbed to multi-organ dysfunction related to her malignancy.

DISCUSSION:
Greater than 50% of patients present with unresectable locally advanced or metastatic gastric adenocarcinoma. The American Society for Gastrointestinal Endoscopy recommends endoscopic surveillance for high-risk individuals. Mass endoscopic/radiologic screening is not recommended in United states. Patients with advanced stage IV disease as in our patient, are usually referred for palliative therapy depending on their functional status. Our case illustrates an unusual presentation of a primary gastric mass, however with careful history, physical examination and timely endoscopic intervention, we can possibly prevent the significant delay in diagnosis and allow for timely management of gastric adenocarcinoma.