bluuebunny/crossref_metadata_2025_split huggingface dataset:
3135 A Case of Epstein-Barr Virus (EBV) Mediated Acquired Hemophagocytic Lymphohistiocytosis (HLH) Presenting With Upper GI Bleed (UGIB)
Authors: Jariwala Ravi , Harris Patrick , Catron Tom , Shoreibah Mohamed 
Published: October 2019

INTRODUCTION:
HLH often follows a fatal disease course with inflammation due to uncontrolled proliferation of macrophages causing multi-organ failure. Acquired HLH presents in adults secondary to infection (most commonly CMV or EBV) or malignancy. Several case reports have linked gastrointestinal bleed (GIB) to acquired HLH. We present a case of acquired HLH presenting with UGIB.

CASE DESCRIPTION/METHODS:
A 34 year old man with a history of chronic active EBV (CAEBV) presented from clinic for treatment of acquired HLH flare. He was diagnosed with HLH secondary to CAEBV infection 1.5 years prior and has been treated with steroids, rituximab, and etoposide with plans for stem cell transplant. Exam was notable for fever 102°F and hepatosplenomegaly. Labs were notable for EBV quant >1 million IU/mL, new CMV quant 7000 IU/mL, elevated ferritin, transaminitis, lactic acidosis, pancytopenia, and labs consistent with DIC (fibrinogen 155 mg/dL, D-dimer 1,082 ng/mL, platelets 41.6 × 103/cmm). He later developed episodes of hematemesis preceded by vomiting, requiring transfer to MICU due to hemodynamic instability. Abdominal ultrasound was without cirrhosis. EGD showed a 5 mm non-bleeding Mallory-Weiss tear (MWT) with stigmata of recent bleeding and clot extending down to GEJ; no intervention was conducted. The following day, he had more episodes of hematemesis. Emergent EGD showed large burden of clots in the esophagus extending to the GEJ; the clots were aspirated until mucosal defect could be visualized, revealing ulcerations with one actively oozing (Figure 1). Three hemostatic clips were placed followed by the application of hemospray with complete cessation of bleeding (Figure 2).

DISCUSSION:
HLH has been associated with GIB manifesting as diffuse or isolated ulceration anywhere in the GI tract. Here we present a patient with HLH who had a GIB that manifested as hematemesis and was found to have endoscopic evidence of MWT. About 80-90% of MWT heal spontaneously. However, this patient's coagulopathy manifesting as DIC resulting from his HLH prevented spontaneous healing leading to hemorrhagic complications. His GIB required clipping and the addition Hemospray aided in achieving hemostasis and hemodynamic stability. Hemospray's efficacy has been shown in peptic ulcer bleeds and cancer related GIB, however, there is minimal data on its use in acute esophageal bleed making this a unique case. Overall, this case highlights the GI complications of HLH and the importance of endoscopic management in controlling such a bleed.
3137 Metastatic Melanoma to the Stomach: A Rare Cause of Upper Gastrointestinal Bleeding
Authors: Buckshaw Ricky , Decker Robert , Shah Shashin 
Published: October 2019

INTRODUCTION:
Upper gastrointestinal bleeding is a common diagnosis with annual incidence of hospitalization reported as 100 per 100,000 individuals. The most common causes are generally recognized to be esophageal varices or peptic ulcer disease. Neoplasm in the stomach is a less common cause, and is usually due to primary gastric adenocarcinoma. The gastrointestinal tract can also be a site of metastases, however malignant melanoma is a relatively rare cause of upper gastrointestinal bleeding, accounting for less than 3% of all severe cases of bleeding.

CASE DESCRIPTION/METHODS:
A 76-year-old male with a history of coronary artery disease status post drug-eluting stent, ischemic cardiomyopathy, hyperlipidemia and melanoma of the face treated thirty years prior, who presented to the emergency department (ED) with hematemesis and melena for 2-3 days along with progressively worsening dyspnea and fatigue. The patient had recently started aspirin and clopidogrel following cardiac stent placement. Upon evaluation in the ED, the patient's vitals were stable. A physical exam revealed pallor with poor capillary refill. There was no abdominal tenderness. Lab work revealed hemoglobin 5.6, which increased to 7.6 after two units of packed red blood cells, white blood cells 13.3, serum creatinine 1.35, troponin 0.37. The patient was evaluated by gastroenterology who recommended esophagogastroduodenoscopy. The patient was admitted to low level monitoring for continued blood transfusion requirement.

DISCUSSION:
The patient was initially managed with intravenous volume resuscitation. EGD showed large gastric ulcer with heaped margins along the greater curvature of the stomach with a visible vessel, for which an endo clip was placed for hemostasis. Biopsies were obtained which later revealed to be metastatic malignant melanoma (+S100 and +MART1). Next-generation sequencing was performed demonstrating negativity for BRAF, NRAS, and KIT mutations. Patients with metastatic melanoma to the GI tract have an overall poor prognosis with life expectancy as short as four months. With the rising incidence of melanoma and its subsequent GI metastasis, it is important to recognize metastatic disease early and potentially decrease the chance of life-threatening complications, which may lead to an early death. Approximately 4% of patients with gastrointestinal melanoma are diagnosed prior to death. Evaluation with endoscopy may be a powerful detection technique in patients diagnosed with melanoma and could detect early disease.
3138 Unusual Gastrointestinal Petechial Bleeding of the Small Bowel Associated With Newly Diagnosed Chronic Myeloid Leukemia
Authors: Dinh Brian , Triplett Drew , Agrawal Sangeeta 
Published: October 2019

INTRODUCTION:
Chronic myeloid leukemia (CML) often is diagnosed in the chronic phase based off routine laboratory analysis in asymptomatic patients with findings include splenomegaly, anemia, leukocytosis, and thrombocytosis. Patients less commonly present with bleeding due to platelet dysfunction. In the case presented, a patient presented with unusual petechial bleeding of the small bowel found on video capsule endoscopy (VCE) as the initial symptom of undiagnosed CML which is highly atypical.

CASE DESCRIPTION/METHODS:
A 79-year-old Caucasian male with a past medical history significant for atrial flutter status-post ablation (not on anti-coagulation) presented to the emergency room with maroon colored stools for 2 days with no other complaints. He denied abdominal pain, nausea, vomiting, or weight loss. Physical exam was benign with vital signs within normal limits. Laboratory analysis revealed white blood cell count of 84.9 t/cmm with 89.9% segmented neutrophils and hemoglobin (HGB) of 10.2 g/dL (previous HGB 14.4 g/dL). The patient was admitted for gastrointestinal (GI) bleeding and malignancy work up. HGB down trended to 7.7 g/dL and an esophagogastroduodenoscopy (EGD) was performed showing no abnormalities. Due to the continued drop in HGB, a colonoscopy was performed which showed old blood in the colon with no identifiable source of bleeding. VCE, interestingly, showed multiple clustered pinpoint petechiae in the ileum. Concurrently, it was suspected that the patient had underlying CML given absence of infection and findings of 1% blasts, basophilia, and eosinophilia. Bone marrow biopsy showed hypercellular bone with myeloid hyperplasia with FISH positive for BCR/ABL confirming CML. It was unknown if the VCE findings may have been related to the patient's newly diagnosed CML.

DISCUSSION:
Anemia is observed in about a third of the patients with newly diagnosed CML depending on the degree of tumor burden. Due to platelet dysfunction, patients may present with bleeding. Because of the significant HGB drop and melena, GI bleeding work up was initiated and ultimately identified a highly unusual source of bleeding. The VCE yielded unexpected images of petechial hemorrhage within the small bowel which was most likely secondary to the underlying malignancy. The case highlights the importance of ruling out sources of GI bleeding in the setting of severe anemia rather than anchoring on the diagnosis of CML. To our knowledge, these VCE findings have not been documented in CML.
3139 Variceal Bleeding, Beyond the Liver Disease: Case Report
Authors: Badi Ahmed M. , Abuhamira Mohamed 
Published: October 2019

INTRODUCTION:
Varices are dilated blood vessels in the esophagus or stomach caused by portal hypertension. They cause no symptoms unless they rupture and bleed, which can be life-threatening (1). We report unusual cause of variceal bleeding which is polycythemia rubra Vera causing splenic vein thrombosis. Splenic vein thrombosis (SVT) is known as one of the rare causes of upper gastrointestinal bleeding and is mostly seen in the fifth decade of life and male sex (2).

CASE DESCRIPTION/METHODS:
39 years old Lady presented to the emergency room with history of hematemesis and melena for 2 days. She had chronic headache for that she is advised to take paracetamol but did not work, so she took ibuprofen. She had more epigastric pain for which she took continuous ibuprofen too. She never had symptoms of dizziness, black out/syncope or palpitations with/without standing. Although she had active hematemesis and melena but her hemoglobin never dropped below 10 g/dl. She had no history of any chronic illness or surgical intervention. She was not smoker and denied alcohol intake. Gastroscopy revealed: Esophagus: normal, no varices Stomach: full of blood and there is large clot in the fundus. Large fundal varices (tortuous and complex). Isolated gastric varices IGV1: 2 large FIII ulcer seen in the fundus with one visible blood vessel seen on one gastric fold just near to gastroesophageal junction (Dieulafoy's lesion) which is typical for location. One rubber band was applied on the visible vessel. 1 mg histoacryl was injected in varices and hemostasis is maintained. Duodenum: normal.

DISCUSSION:
isolated obstruction (mainly due to thrombosis) of the splenic vein usually results in left-sided portal hypertension and isolated fundal varices formation. This syndrome is a rare cause of gastrointestinal bleeding. Pancreatic diseases are among the most common etiologies of splenic vein obstruction. Renal disorders are rarely reported as a cause of splenic vein thrombosis 3. We screen for most thrombophilia causes (Table 1). So, we deal with patient with Non cirrhotic liver. Isolated splenic vein thrombosis. Massive splenomegaly Negative hemophilia screen. No evidence of pancreatitis or pancreatic mass on cross sectional imaging. When we review her lab we noted that she had persistently high WBC, platelet and Hematocrit despite GI bleeding, so we screened for myeloproliferative Disorders, and we found mutation for JAK 2 exon 12 is positive. And this patient met the WHO criteria for polycythemia Vera. thrombophilia screen negative.
3140 An Unfortunate Triad: GI Bleed Due to Refractory DLBCL Complicated by Occlusive Thrombus of the Inferior Vena Cava
Authors: Cirac Ana , Niec Rachel , Crawford Carl V. , Wan David 
Published: October 2019

INTRODUCTION:
Ileal ulcers are circumscribed, inflammatory and necrotic erosive lesions on the mucosal surface of the ileum and can have specific etiologies such as Crohn's disease, NSAID-intake, intestinal tuberculosis and eosinophilic enteritis. Here, we report a symptomatic terminal ileal ulcer caused by a diffuse large B-cell lymphoma (DLBCL).

CASE DESCRIPTION/METHODS:
A 71 year-old male with a history of gastrointestinal bleeds (GIB) due to ulcers presented with weight loss and small bowel obstruction due to a terminal ileum mass and was diagnosed with an EBV-negative DLBCL after a right hemicolectomy. In the setting of refractory disease (RCHOP, Ibrutinib and Lenalidomide on trial, salvage with DHAX) he presented again with an active GIB with hematemesis and dark stools, an EGD was normal but a colonoscopy showed a lymphoma of the terminal ileum (TI). Clinical examination showed no abnormalities. Initial work up showed mild anemia and elevated creatinine (1.68). A CT abdomen and pelvis showed a progressive disease with new circumferential thickening of the small bowel in the right abdomen. A PET showed a progressive lymphadenopathy throughout the abdomen and pelvis. The GIB was managed with IV pantoprazole and sucralfate. A biopsy of the terminal ileum mass showed a recurrent DLBCL. The patient was considered for a regeneron trial but developed nearly occlusive deep vein thrombosis (DVT) that extended into his inferior vena cava (IVC) and led to a DVT in his left subclavian vein, so that he no longer was a candidate for trial. Given the active GIB, he was planned for the placement of an IVC filter, however, the occlusive thrombus in the IVC prevented the procedure. The goals of best supportive care were discussed with the patient.

DISCUSSION:
The gastrointestinal (GI) tract is the most common extranodal site involved by lymphomas. While GI tract involvement is usually secondary during progression of the disease, primary GI tract lymphoma is relatively rare. Diffuse large B-cell lymphomas are the most common lymphomas affecting the GI tract. GI lymphomas present with unspecific clinical features and are therefore difficult to distinguish from other conditions. The diagnosis is made by pathology. In this case, a biopsy was obtained from the TI mass confirming the diagnosis of refractory DLBCL with GI involvement. This patient developed an unfortunate combination of multiple complications interacting with the respective treatments.
3144 Dieulafoy Lesions: A Rare Case of Recurrence
Authors: Martinez-Tapia Ana , Duarte-Chavez Rodrigo , Mehta Sagar V. , Chaput Kimberly J. , Wey Bryan 
Published: October 2019

INTRODUCTION:
Dieulafoy lesions (DL) are thickened arteriole malformations commonly found in the stomach that account for less than 2% of acute gastrointestinal (GI) bleeds. Conventional treatment is endoscopic and rarely requires surgical intervention. The risk of recurrence is low, especially in previously treated patients.

CASE DESCRIPTION/METHODS:
A 59-year-old male with past medical significant for hypertension (HTN), previous DL treated with gastrectomy for recurrent bleeding and multiple packed red blood cell (pRBC) transfusion 18 years ago presented for evaluation of palpitations. Review of system was positive for melena and lightheadedness with unremarkable physical examination. The patient was not on anticoagulation or anti-platelet agents. Laboratory test resulted in a hemoglobin (Hgb) of 8 g/dL. Upper endoscopy revealed non-bleeding ulcers in the stomach and colonoscopy revealed three polyps with no obvious source of bleeding. Hgb continued to trend downward and patient required multiple pRBC transfusions. Capsule endoscopy was performed at discharged, but patient was readmitted for a repeat episode of melena. Result of the capsule endoscopy revealed a clot in stomach with active bleeding in duodenum. Repeat endoscopy showed a DL in the proximal stomach which required placement of three clips to control the hemorrhage. Patient was discharged on omeprazole with no recurrent symptoms.

DISCUSSION:
DL are arterioles with thickened caliber that can protrude through a defect in the submucosal base without signs of ulceration. The pathogenesis is not clear, but likely secondary to a congenital abnormality of the blood vessels or a thrombotic event of the arteriole causing necrosis. The distribution of DL is equal in all ages but has a male predominance. Risk factors include heart disease, use of anticoagulants or anti-platelet agents and alcohol exposure; However, the mechanism by which they exert their effect is controversial. Surgery was the preferred treatment for DL, but now is less common with more endoscopic techniques available. Our patient had certain risk factors that could have led to his original lesions, such as hypertension. The risk of recurrence following endoscopic treatment is less than 9% and less with surgical resection, which would suggest an underlying contributing factor. DL need to be included in the differential diagnosis for GI bleeding, even in previously treated patients, given there are underlying factors that have yet to be elicited contributing to recurrence.
3147 Acinar Cell Carcinoma—A Rare Cause of Gastrointestinal Bleed: A Case Report
Authors: Chaudhari Rahul B. , Shirodkar Manoj A. , Ho Immanuel K. , Kirkland Matt L. 
Published: October 2019

INTRODUCTION:
Acinar cell carcinoma is a rare pancreatic exocrine tumor that comprises approximately 1-2% of adult pancreatic tumors. We present a case of this rare tumor in a patient who presented with recurrent GI bleed.

CASE DESCRIPTION/METHODS:
A 48 year female with history of brain AV Malformaation, Chiari malformation s/p brain surgery and platelet storage pool disease presented to our hospital with worsening fatigue and shortness of breath, and a question of melena, and was found to be anemic at Hgb of 6.5. She underwent an upper endoscopy which revealed bright red blood in the second part of duodenum with questionable AV Malformations that were treated with Argon Plasma Cauterization. She received blood and platelet transfusions and was discharged with Hb of 12.7. Several days later she had an outpatient colonoscopy which was normal. One month after that, she was readmitted with increasing fatigue, dyspnea and periumbilical abdominal pain and was found to have Hgb 8.7. She also noted to have recurrent melenas. A repeat upper endoscopy was performed with the addition of a side viewing duodenoscope. This revealed an ulcerated mass involving the ampulla with mild oozing of blood. Hemostasis was achieved with epinephrine injection after biopsies were taken. Biopsies revealed an epithelial neoplasm, but a specific diagnosis was elusive. Subsequent PET scan showed focal uptake in the second part of the duodenum. She underwent pylorus preserving Whipple without any complications. The pathology of the surgical specimen revealed the mass to be an acinar cell carcinoma. The pArient had a stable postoperative follow up and improved clinically with repeat Hgb three week later of 11.3.

DISCUSSION:
Acinar cell tumor is a rare pancreatic exocrine tumor that usually affects males more than female. Mean age at presentation is usually 60. The presenting symptoms are non-specific and include abdominal pain, nausea, vomiting and weight loss. As biliary tract involvement is rare, jaundice is uncommon. Lipase hypersecretory syndrome from elevated lipase secretion causing Schmid triad (subcutaneous fat necrosis, polyarthritis, eosinophilia) is also rare (<10%). In our case, the presentation with GI bleed is exceedingly unusual. The treatment of local disease is surgical. No clear treatment guideline exists for patients in whom complete surgical resection for curative intent is not possible.
3150 Deep Venous Thrombosis in Ulcerative Colitis
Authors: Baid Shreya , Gupta Kapil , Marcus Akiva , Bagatell Stuart 
Published: October 2019

INTRODUCTION:
Inflammatory bowel disease (IBD) has a variety of both intestinal and extraintestinal manifestations. Among the range of extraintestinal manifestations of IBD, venous thromboembolism (VTE) is a rare complication with high morbidity and mortality. VTE can present in patients with both active disease, which is more prevalent, or in well-controlled disease, which suggests a prothrombotic risk in patients with IBD. The case below is a classic presentation of VTE in IBD, and raises questions involving lifelong anticoagulation.

CASE DESCRIPTION/METHODS:
A 62 year old male with ulcerative colitis presented to the office with a 2-week history of constant, achy pain in his right leg associated with swelling and stiffness of his right lower extremity. A right lower extremity venous duplex ultrasound revealed extensive thrombosis from the popliteal vein up to the common femoral vein. Despite a discussion about possible sequelae of untreated VTE such as further clot extension, acute pulmonary embolism, and death, the patient opted for outpatient treatment with lifelong apixaban. His swelling improved, and although he has had prior IBD exacerbations with significant bleeding, since the patient has been on apixaban, he has not had any significant bleeding.

DISCUSSION:
Patients with IBD have a threefold higher risk of VTE than the general population. Research suggests that it may be due to a complex interplay between inflammation and coagulation. Treatment of acute VTE in IBD patients has not been clearly defined and currently is similar to most patients. Consequently, the duration of anticoagulation is not established, and it is imperative to establish specific guidelines due to the risk of recurrent VTE in IBD. Currently, there are no data on the role of primary VTE prophylaxis for IBD patients in the outpatient setting and no specific biomarkers to identify IBD patients at risk. Future research should assess the prothrombotic risk in IBD to assist clinicians in preventive measures. Additional studies are needed to address the use of screening tests such as ultrasound or biomarkers. In this case, the patient was placed on lifelong apixaban due to his underlying risk factor of ulcerative colitis and showed clinical improvement with no significant bleeding. This case helps highlight the concern for major bleeding in a patient who has had previous significant major bleeding episodes during IBD exacerbations. In conclusion, VTE is a significant complication that should not be overlooked in patients with IBD.
3153 Occult Adenocarcinomas in Crohn's Disease Related Strictures: A Case Series
Authors: Singh Kevin N. , Singh Amandeep , Philpott Jessica 
Published: October 2019

INTRODUCTION:
Small bowel tumors account for ∼2.3% of all gastrointestinal cancers. Strictures are frequent complications of Crohn's disease, but malignant ileal strictures are uncommon and their diagnosis is often challenging.

CASE DESCRIPTION/METHODS:
We retrospectively reviewed three cases of terminal ileum adenocarcinomas that developed in ileal strictures. In this case series, three patients with CD developed occult adenocarcinoma within an ileal stricture diagnosed only after surgery. In all of the patients, an underlying stricture was thought to have caused obstructive symptoms but there were no imaging or endoscopic findings suggestive of underlying malignancy. Subsequently, all patients underwent surgery and, unexpectedly, one patient was found to have a tumor within the ileal stricture intra-operatively and the remaining two were diagnosed post-operatively after histopathological examination. Though the findings of adenocarcinomas were unexpected, two of the three patients were over 60 years of age and had over 30 years of disease prior to their diagnosis.

DISCUSSION:
Conclusions: The diagnosis of adenocarcinomas arising within ileal strictures is uncommon and often challenging for clinicians. 2. Many cases are diagnosed only intra-operatively or post-operatively after histopathological examination in the absence of imaging studies or endoscopy that suggest the presence of underlying malignancy.