bluuebunny/crossref_metadata_2025_split huggingface dataset:
1611 Not All Polyps Are Created Equal: Schwann Cell Hamartoma Incidentally Found on Screening Colonoscopy
Authors: Tetangco Eula Geralyn , Rassameehiran Supannee , Yap John Erikson 
Published: October 2019

INTRODUCTION:
Majority of colorectal polyps are epithelial in origin, such as adenomas (tubular, tubulovillous, and villous) and serrated polyps (hyperplastic, traditional serrated, sessile serrated). Mesenchymal polyps are rare, but detection is improving with high-quality screening colonoscopies. Mucosal Schwann cell hamartomas (MSCH) of the gastrointestinal tract are mesenchymal tumors that were first described in 2009. The median age at diagnosis is 59 years (range 34-88 years), with a slight female predominance.

CASE DESCRIPTION/METHODS:
A 70-year-old white male with coronary artery disease, persistent atrial fibrillation, and obstructive sleep apnea was referred for screening colonoscopy. This revealed 2 sessile polyps (Paris 0-1s) in the sigmoid colon, measuring 2 mm and 7 mm in size. The polyps were completely removed by cold biopsy polypectomy and cold snare polypectomy, respectively. The second polypectomy site oozed slightly and was closed using 2 hemoclips, with anticipation that the patient would be resuming anticoagulation the same day. Pathology of the polyps were consistent with mucosal Schwann cell hamartoma, staining positive for S-100 protein.

DISCUSSION:
MSCH are a group of neuronal polyps purely composed of Schwann cells that are positive for S-100 in a strong, diffuse pattern, with both nuclear and cytoplasmic staining. They typically cause no symptoms and may present as small polyps (1-8 mm) incidentally found during colonoscopy, predominantly in the rectosigmoid. They are not associated with any inherited syndromes. The diagnosis is made after excluding other lesions that resemble spindle cell proliferation and other neuronal tumors. These include neurofibroma, leiomyoma, and gastrointestinal stromal tumor (GIST). Neurofibromas, while also composed of Schwann cells, are often associated with neurofibromatosis type 1 (NF1). NF1 is usually accompanied by multiple cutaneous neurofibromas. Purely colorectal neurofibromas without skin manifestations are extremely rare. GIST can be easily excluded by negative immunoreactivity of c-Kit and CD117. Leiomyomas stain positive for smooth muscle actin. In summary, MSCH’s are rare lesions with a benign course and no known association with inherited polyposis syndromes. Diagnosis depends on pathology demonstrating lack of axons on pathology, and immunohistochemistry staining strongly for S-100 protein. Our case highlights that accurate diagnosis can prevent overly aggressive or unnecessary treatments.
1614 Asymptomatic Intestinal Spirochetosis With Colonic Ulcerations
Authors: Catinis Anna M. , Hudson Catherine T. , Stibbe Jason R. , Raines Daniel 
Published: October 2019

INTRODUCTION:
Both the origin and commensal or pathogenic nature of intestinal spirochetes (IS) in humans are poorly understood. Colonization is predominantly found in homosexual males and in HIV patients.1 Homosexual males have shown colonization rates up to 20.6-62.5% leading scientists to hypothesize that IS could be sexually transmitted.2 Colonization can be associated with severe clinical symptoms like persistent diarrhea and rectal bleeding, especially in children.3 Therefore, a greater understanding of clinical presentation and risk factors is needed.

CASE DESCRIPTION/METHODS:
A 51-year-old asymptomatic male with compensated alcoholic cirrhosis presented for a screening colonoscopy. He denied NSAID use and a personal or family history of inflammatory bowel disease. Colonoscopy revealed multiple clean-based ulcers in the cecum and ascending colon. Histologic examination of the specimens on H&E stain revealed colonic mucosa with focal, acute inflammation and microorganisms consistent with spirochetes. No granulomas, crypt architectural distortion, or dysplasia were identified. The fuzzy, basophilic fringe-like microorganisms were positive for GMS and PAS stains and negative for FITE stain. The findings were consistent with IS and the patient was treated with metronidazole.

DISCUSSION:
The clinical significance of IS in humans is not well defined. Presentation may vary from asymptomatic to causing chronic diarrhea, rectal bleeding, abdominal pain, and weight loss. IS can be associated with immunodeficiency, alcoholism and drug abuse, poor hygiene, sexual practices, and concomitant bowel content stasis. Pathology reveals presence of spirochetes in the brush border. Transmission electron microscopy reveals spirochetes attached to enterocytes with associated shortened or depleted microvilli. Often endoscopy in IS-infected patients is normal, but in this rare presentation of intestinal spirochetosis, ulcerations of colonic mucosa were noted. Metronidazole is an effective treatment.4-5
1625 Colonic Schwannoma Identified in Asymptomatic Middle-Aged Female
Authors: Yeroushalmi Kevin , Hajar Rabab , Rizvon Kaleem 
Published: October 2019

INTRODUCTION:
Schwannomas are typically benign tumors of the neural sheath. Schwannomas of the colon are extremely rare entities; in fact, when schwannomas occur in the gastrointestinal tract, the colon is considered the least likely site. Schwannomas of the colon were previously misdiagnosed as gastrointestinal stromal tumors; however, with advances in immunohistochemical staining, the number of cases of intestinal schwannomas has gradually increased. Colorectal schwannomas can be divided into three clinicopathologic types: spindle cell, epithelioid, and plexiform. Here, we present a unique case of a colonic spindle cell schwannoma encountered in an asymptomatic patient on routine colonoscopy.

CASE DESCRIPTION/METHODS:
A 50-year-old female with no significant past medical history presented to gastroenterology clinic for routine colorectal cancer screening. The patient denied abdominal pain, nausea, vomiting, diarrhea, constipation, rectal bleeding, or weight loss. She also denied family history of neurofibromatosis. Physical examination was unremarkable. Laboratory studies showed that the patient had microcytic anemia (hemoglobin 10.9 g/dl, MCV 59 fL) but were otherwise unremarkable. A colonoscopy was subsequently performed and revealed a 6 mm sub-epithelial lesion in the sigmoid colon. Biopsy showed colonic mucosa with mild chronic inflammation and multiple spindle cell aggregates confined to the lamina propria (Figure 1). Cytological atypia, mitoses, and necrosis were identified in the biopsied specimen (Figure 2). Immunohistochemical assays demonstrated lack of reactivity to CD68, CD117, and DOG-1. The spindle cells were strongly positive for S100, confirming the diagnosis of mucosal Schwann cell hamartoma.

DISCUSSION:
Rectal bleeding, colonic obstruction, and abdominal pain are the three most common presenting symptoms for colorectal schwannoma; however, our patient denied any of these symptoms. The management of intestinal schwannomas remains controversial. Surgical resection with adequate margins remains the treatment of choice. Several sources question whether radical resection based on oncologic principles is necessary given the benign nature of these tumors. Our patient was managed conservatively with routine surveillance. Repeat colonoscopy performed approximately 3 months after the initial colonoscopy revealed no signs of recurrence or metastases. This case supports the notion that these rare mesenchymal tumors are commonly benign and aggressive therapeutic interventions are likely unnecessary.
1664 A Herald Bleed: A Case Report of an Aortoenteric Fistula Causing an Acute Lower Gastrointestinal Bleed
Authors: Bhatti Sundus , Omer Endashaw 
Published: October 2019

INTRODUCTION:
Aortoenteric fistula (AEF) is a rare, life-threatening condition with an incidence of 0.007/million. Primary AEF arises de novo, secondary AEF (SAEF) occurs following abdominal aortic aneurysm (AAA) repair. Majority of AEF’s involve the duodenum, due to proximity to the aorta. It may present as an exsanguinating herald GI bleed, associated with high mortality rates. SAEF has a 45.8% mortality rate in the first month.

CASE DESCRIPTION/METHODS:
A 66-year-old female presented with sudden onset of large volume bright red blood per rectum (BRBPR). She denied any prior episodes of GI bleed, alcohol or NSAID use and had never had prior endoscopy. She mentioned cholecystectomy and hysterectomy as her only surgical interventions. On examination she was hemodynamically unstable, lethargic and had a midline abdominal scar. Digital rectal exam showed BRBPR. Her lab workup showed: Hgb 9.5, Hct 29%, platelets 147000, INR 1. An emergent EGD was negative. Colonoscopy showed a 5 cm, pulsatile submucosal mass with an actively bleeding ulcerated area. Epinephrine was injected for temporary hemostasis. A hemoclip was placed to mark the site for potential embolization, as the lesion was not amenable for definitive endoscopic intervention. A stat CT angiogram of the abdomen and pelvis revealed a large left external iliac artery (LEIA) pseudoaneurysm in the region of the clip placed during colonoscopy. Vascular surgery emergently placed a LEIA stent. It appeared the patient had an open aorto-bi-iliac bypass 15 years ago for a AAA which resulted in the development of SAEF. She did well post operatively.

DISCUSSION:
AEF is important to consider in older patients who present with large volume hematochezia. The presence of prior signs of abdominal surgery should raise suspicion for SAEF as it is difficult to diagnose because of its rarity. The commonest symptom of SAEF is gastrointestinal bleeding. Other symptoms are fever, sepsis, pulsating abdominal or groin mass, abdominal or back pain. CT and GI endoscopy are frequently used for diagnosis. Without treatment AEF often proves to be fatal. Treatment of AEF includes volume resuscitation, antibiotics, and aortic repair. Given our patient's bleed with tenuous clinical status, large body habitus, medical comorbidities, poor functional status as well as previous aorto-bi-iliac bypass, decision was made to approach the pseudoaneurysm endovascularly, despite possible presence of vessel-enteric fistula, as she was deemed unstable for an open approach.
1686 Laparoscopic-Assisted Endoscopic Submucosal Dissection of Early Gastric Adenocarcinoma
Authors: Kudaravalli Praneeth , Schaberg Kurt , Cavnar Michael , Gabr Moamen 
Published: October 2019

INTRODUCTION:
A 69-year-old man underwent esophagogastroduodenoscopy (EGD) a year ago which showed intestinal metaplasia without dysplasia in the gastric antrum and incisura. A repeat EGD showed a single plague in the distal esophagus and erosive gastritis. Biopsies revealed high grade dysplasia (HGD) in the gastric cardia and extensive intestinal metaplasia in the rest of the stomach. A subsequent endoscopic ultrasound and CT imaging of chest, abdomen and pelvis revealed no evidence of extraluminal extension or distant metastasis. Given the tumor location surgical resection would require a total gastrectomy. After consultation with surgical oncology, a decision was made to attempt endoscopic submucosal dissection (ESD) with laparoscopic assistance.

CASE DESCRIPTION/METHODS:
In this video report, an initial EGD was performed which confirmed a superficial gastric ulcer in the cardia. A laparoscopic gastrotomy with placement of the 15mm laparoscopic port was performed. The endoscope with a cap was introduced through the port directly into the stomach. The lesion in the gastric cardia was visualized in a retrograde direction. ESD was performed using a Dual-J Knife. A 15mm area was resected. The ESD site was examined for any perforation, bleeding or defects and none were noted. Following the endoscopic portion of the procedure, the abdomen was re-insufflated and inspected for signs of perforation and none were found. The gastrotomy was then closed. On gross pathologic examination the gastric cardia specimen measured 1.9 × 1.7 × 0.3 cm. Microscopic examination revealed well differentiated (G1) focal intramucosal adenocarcinoma arising in a background of intestinal metaplasia with HGD. Tumor invaded lamina propria but no invasion of muscularis mucosa was identified. All margins were uninvolved by carcinoma and dysplasia. The final pathologic stage of the resected specimen was pT1a. Given the findings, lymph node disease was determined to be extremely low and less invasive ESD was expected to be curative 1, 2. A follow up EGD 2-months post-procedure showed no evidence of recurrence.

DISCUSSION:
In conclusion, tumors of the gastric cardia are among the most technically difficult lesions to be removed by ESD with curative rates around 66% 3. This decreases further with tumors located in the anterior hemisphere or have deep submucosal invasion. Laparoscopic assistance provides a head on view for a full thickness ESD. Our case demonstrates this technique is safe and effective.
Watch the video: http://bit.ly/2LuEe7N.
1703 Hematemesis: A Turn of the Screw
Authors: Prakash Sameer , Mirza Asadullah , Salagundla Nethuja , Shepherd Kaylee 
Published: October 2019

INTRODUCTION:
Anterior cervical discectomy and fusion (ACDF) in combination with locking plates is considered the standard treatment for cervical spinal trauma, tumors and degenerative disc disease. We present a case of upper gastrointestinal bleed resulting from delayed pharyngoesophageal perforation due to loosened screw in the presence of normally positioned hardware.

CASE DESCRIPTION/METHODS:
A 43-year-old male with hypertension, bradycardia status post pacemaker, cervical stenosis status post C3 -C6 fusion 1 year prior came to the ER with chief complaint of throat and chest pain followed by one episode of hematemesis noticing a 2 cm screw in vomitus. Initial vitals showed T 36.4, HR 78, BP 139/94, RR 18, and SpO2 96% on RA. Cervical spine x-ray showed intact plate of cervical spine with missing screw. Patient was admitted to the ICU and gastroenterology was consulted. Gastrografin swallow study did not show extravasation of contrast and subsequent endoscopy showed extensive soft tissue swelling in the left hypopharynx without purulent exudate. Bedside fiberoptic laryngoscopy showed left pharyngeal posterior wall prominence extending from inferior to tonsil to tip of epiglottis with intact overlying mucosa. Head and neck surgeon recommended non-operative intervention, so the patient was started on broad spectrum antibiotics through the PICC line. He was started on clear liquid diet and advanced to full liquids. His blood count remained stable and he had no further hematemesis. Outpatient follow up showed satisfactory recovery.

DISCUSSION:
Pharyngoesophageal injuries following ACDF are rare with an incidence of <2%. Most perforations are identified in immediate or early postoperative period and result from iatrogenic injury during the procedure and carry high mortality rates. Early local symptoms include neck swelling, dysphagia, fever and subcutaneous emphysema leading to mediastinitis. Fistula formation, microcytic anemia and neck mass are the most common late presentations. Xray of the neck, contrast swallow studies and flexible endoscopy can help locate perforation. When conservative treatment fails or there is systemic involvement, this requires hardware removal, debridement and suture closure of the defect with or without sternocleidomastoid muscle, superior omohyoid muscle, or pertoralis major flap enforcement to reduce the risk of failure. Patients presenting with upper GI bleed, signs of neck infection, and history of cervical spine plating should be evaluated for hardware-related complications.
1708 Case of Secondary Achalasia Presenting Several Years After Nissen Fundoplication With Improvement After Endoscopic Dilatation: “Rare but Not Forgotten”
Authors: Bhardwaj Gaurav , Nawaz Waqas , Guddati Harish , Hertan Hilary 
Published: October 2019

INTRODUCTION:
Secondary Achalasia is an esophageal motor disorder presenting with clinical, radiographic and manometric features that mimic those of primary achalasia except that it has a known etiology such as gastroesophageal junction (GEJ) tumor, antireflux surgery, gastric banding or gastrectomy. We present a rare case of secondary achalasia as a remote consequence of a laparoscopic Nissen fundoplication (LNF).

CASE DESCRIPTION/METHODS:
A 59 year old woman with a history of diabetes mellitus, gastroesophageal reflux disease (GERD), hiatal hernia status post LNF with hernia repair eight years ago, presented with dysphagia to solids and liquids with a 24-pound weight loss over the last 3 months. On presentation, physical exam and initial laboratory data were unremarkable. Computerized tomography of the chest showed esophageal dilatation with an obstruction at the GEJ. Upper endoscopy revealed a large amount of impacted food in the lower third of the esophagus which was removed with a Roth net, and the GEJ was traversed by the scope with significant resistance. On retroflexion evidence of a Nissen fundoplication was found at the GEJ with a tight appearing wrap. The GEJ was dilated using Savary dilators over a guide up to a diameter of 14 mm with remarkable improvement of the symptoms. An esophagogram done post dilatation showed transit of the barium contrast through the GEJ.

DISCUSSION:
GERD is the most common pathologic condition affecting the upper gastrointestinal tract. While most patients respond to medical therapy, LNF has become the gold standard for antireflux surgery in patients with medically refractory disease. Transient dysphagia occurs in 40% to 70% of patients after LNF in the early postoperative period due to edema, slipped, migrated or too tight fundoplication or a missed diagnosis of primary achalasia and nutcracker esophagus. However, it can also occur many years after the operation due to hiatal stenosis secondary to severe fibrotic reaction and anterior angulation of the GEJ. EGD is a good initial diagnostic tool and resistance or inability to pass a gastroscope through the EGJ should raise suspicion of secondary achalasia with a background history of LNF. GEJ tumor should always be ruled out with careful examination. Dilatation of the GEJ is done using wire guided Savary dilators or through the scope balloon dilators. Our case highlights the importance of an aggressive evaluation and careful interpretation of a patient presenting with dysphagia with a remote history of fundoplication.
1739 Mediastinal Syndrome: A Rare Etiology of Dysphagia
Authors: Then Eric O. , Chishti Umair Shafiq , Ofosu Andrew , Are Vijay S. , Maddika Srikanth , Gaduputi Vinaya 
Published: October 2019

INTRODUCTION:
Breast cancer with metastasis involving the esophagus is a rare phenomenon. Most cases involve metastasis to the mediastinum resulting in esophageal compression. Less commonly these cases will metastasize directly to the mucosa or submucosa of the esophagus. Here we present a rare case of breast cancer metastasizing to the mucosal layer of the esophagus in addition to the mediastinum, resulting in esophageal compression.

CASE DESCRIPTION/METHODS:
Patient is a 73 year old female with a medical history of left breast cancer with known metastasis to the lung, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypothyroidism, and osteoporosis who presented to the emergency department complaining of worsening dysphagia for the past 3 months. She began having dysphagia to solids that slowly progressed to include liquids. Notable workup included a complete blood count with a hemoglobin of 10.9 gm/dL. The gastroenterology service was then consulted and performed an upper esophagagastroduodenoscopy which showed severe narrowing in the mid to lower esophagus with unhealthy appearing mucosa with contact oozing and desquamation. Multiple biopsies were taken from this area which returned showing metastatic carcinoma, consistent with breast primary. Immunohistochemical stains showed the neoplastic cells were positive for ER, and negative for p63, supporting the diagnosis. The patient then underwent PET scan which showed hypermetabolic posterior mediastinal lymphadenopathy causing extrinsic esophageal compression. During her admission the patient was able to tolerate pureed diet and was discharged to follow with oncology where she would undergo further treatment with Fulvestrant and Palbociclib.

DISCUSSION:
Breast metastases of mucosal and submucosal layers of the esophagus are extremely rare as esophageal involvement is usually secondary to mediastinal carcinosis. Diagnosis of breast cancer metastasizing to the esophagus is difficult as esophageal involvement can occur without clinical symptoms in a considerable number of patients with breast cancer. The most common clinical manifestations include dysphagia, accompanied by weight loss, anorexia and vocal dysfunction. Chemotherapy and hormonal therapy are the initial treatment of choice given that they significantly affect survival. Endoscopic placement of a stent should be reserved to those patients who do not have a significant improvement of dysphagia after treatment, or in cases of trachea-esophageal fistulas.
1825 Esophageal Stricture Due to Esophageal Lichen Planus and Its Successful Management Using Local Corticosteroid Injection
Authors: Jencks Kara J. , Abdulla Hamza , Qiu Suimin 
Published: October 2019

INTRODUCTION:
Lichen planus is an inflammatory disease that typically involves the skin, nails, oral cavity and the genital areas. Involvement of the esophagus is rare. We report a case with severe progressive esophageal lichen planus treated with submucosal injection of triamcinolone into the esophagus with symptomatic improvement and decreased need for esophageal dilation.

CASE DESCRIPTION/METHODS:
A 64-year-old Caucasian female presented to the GI clinic for evaluation of progressive dysphagia of 1 year. She has been doing well until she had a severe choking episode while swallowing a tablet. Physical examination revealed red, atrophic plaques on the buccal mucosa as well as vaginal erythema and atrophy. Tongue biopsy was performed which showed lichenoid inflammation with dermatitis and spongiosis consistent with the diagnosis of lichen planus (Oral-Gingival-Vaginal syndrome). The patient was started on 75mg of prednisone for 1 month followed by a slow taper. A barium swallow showed a short, smoothly marginated stricture of the proximal esophagus at the C6-C7 level with approximately 75% narrowing. EGD showed a stricture in the proximal esophagus at 18cm. Remaining upper and mid esophagus showed multiple lesions with peeling of mucosa and areas of mucosal hemorrhage. Biopsies of the stricture showed small fragments of squamous mucosa with lymphocytic infiltrate and necrotic keratinocytes (Civatte bodies). Esophageal bougie dilations were performed for management of dysphagia. As the upper stricture required repeated dilations [every 1-2 months] and other management options were either ineffective or not tolerated, local sub mucosal corticosteroid injection (Kenalog-40) into the proximal stricture was attempted along with esophageal dilations. This resulted in decrease the average frequency of dilations and ultimately she became symptom free since except for occasional pain with swallowing food and intermittent esophageal spasms.

DISCUSSION:
The diagnosis of esophageal lichen planus is often difficult. However, this disease should be suspected amongst middle age to older women presenting with progressive dysphagia. Treatment with systemic corticosteroids remains the mainstay of treatment in esophageal lichen planus. However, in those unable to tolerate steroids due to side effects, non-responsive progressive disease or individuals who are experience frequent relapses after discontinuation of systemic steroids, corticosteroid injection is a safe and effective alternative therapy.