bluuebunny/crossref_metadata_2025_split huggingface dataset:
1613 A Case of Extreme Fatty Expulsion Per Rectum
Authors: Baloch Luqman , Carney Spencer 
Published: October 2019

INTRODUCTION:
The purpose of colonoscopies (CLN) is primarily for the prevention & management of disease in the lower gastrointestinal (GI) tract. Colonoscopies can often find fleshy masses found to be benign polyps, colorectal cancer, and even lipomas. These masses are rarely passed through the GI tract. The mechanism of spontaneous expulsion is thought to be primarily from auto-amputation. This auto-amputation occurs when a polyp or mass on a pedunculated stalk twists upon itself. It continues to twist until becoming free from the mucosal layers inside the GI tract. This allows the mass to be free to pass into rectal vault & present as a bowel movement. Though this mechanism is known, spontaneous expulsion of such fleshy masses is thought to be quite rare.

CASE DESCRIPTION/METHODS:
A 48-year-old male with a past medical history of a partial small bowel obstruction & atrial fibrillation (AF) on rivaroxaban presented to ED with complaints of intermittent abdominal pain & an abnormal bloody bowel movement. Prior CLN in 2014 was negative except for benign polyps. Patient described his stool as an "abnormal mass.” On gross evaluation the stool was noted to be a large yellow/tan fatty mass measuring 4 × 3.4 × 5.3 cm. Histological examination showed benign adipose tissue separated by thin fibro-vascular septae. Evaluation with CLN showed an 18mm pedunculated polypoid lesion on a thick 15mm stalk in the descending colon. The head of the lesion was found to be erythematous with granulation tissue on its surface consistent with recent removal of a large polypoid lesion. Cold forceps were used to biopsy the lesion & revealed benign submucosal lipomatous neoplasm.

DISCUSSION:
Lipomas are non-malignant neoplasms composed of adipose tissue. They can often be found throughout the body and rarely present in the GI tract. If present in the GI tract they are often found to be submucosal & in the colon. Majority are asymptomatic but can produce symptoms if > 2 cm. This patient’s lipoma was noted to be > 4 cm. This patient presented with intermittent lower abdominal pain, changes in bowel habits, passage of fresh blood per rectum, recurrent AF episodes, along with passing a lipomatous mass. After expulsion of this mass the patient noted decreased episodes of AF. This case & its findings demonstrate that spontaneous expulsion of a lipoma can occur via similar mechanisms of auto-amputation for polyps as previous cases have shown. It also reminds us the relationship between abdominal pathologies & the propensity for AF.
1617 Colon Ischemia as Initial Presentation of Amyloidosis: A Rare and Challenging Diagnosis
Authors: Boktor Moheb , Saraiya Neeyma , Moore Samantha A. , Balani Jyoti , Alexander Jonathan , Burstein Ezra 
Published: October 2019

INTRODUCTION:
Amyloidosis is a systemic disease rarely involving gastrointestinal tract (GIT) and requires a high index of suspicion to diagnose. GI presentations including abdominal pain, bleeding, malabsorption or protein losing enteropathy. Predisposing conditions are plasma cell dyscrasia, chronic inflammatory conditions or hemodialysis. We present case of Amyloidosis involving entire GIT presented with severe colon ischemia required total colectomy.

CASE DESCRIPTION/METHODS:
A 59-year-old man with 6 months history of abdominal pain, bloating and constipation. He tried laxatives with partial relief. A colonoscopy revealed ulcerations in the sigmoid colon with biopsies consistent with ischemic colitis. CT angiography of the abdomen showed patent vessels with no findings to explain ischemic changes. A colonoscopy repeated 3 months later showed persistent inflammation in the sigmoid colon. He, subsequently, was diagnosed with multiple myeloma and initiated on bortezomib and dexamethasone. A few weeks after initiating this treatment, he presented to ED with significantly worsened abdominal pain, distension and nausea. CT A/P revealed thickening from the rectum to the descending colon with proximal dilation, concerning for pneumatosis and ischemic colitis. He was taken emergently for a total colectomy with end ileostomy. Pathology revealed that he, in fact, had extensive amyloidosis (transmural, interstitial, and vascular involvement) with hemorrhage and necrosis throughout the removed colon as well as the removed portion of the ileum with positive margins. There have been prior reports of colonic ischemia after initiation of bortezomib however this does not appear to be culprit in this case given the patient’s findings on initial colonoscopy prior to starting the medication.

DISCUSSION:
Amyloid deposition infiltrates multiple organs. GIT involvement is common, rectal biopsy can confirm diagnosis. However, severe colon ischemia is uncommon presentation. Our patient presented with severe ischemic colitis and pneumatosis on CT scan. Prior to this, he had 2 colonoscopies, EGD, and abdominal fat biopsy all was non-diagnostic. He subsequently, had total colectomy, pathology revealed Amyloidosis. Duodenal biopsies confirmed small intestine amyloidosis. Colon ischemia due to Amyloidosis is rare. Diagnosis is challenging but can lead to detrimental consequences when it is delayed. Early diagnosis is critical in preventing progressive disease and potentially fatal complications.
1618 TB or Not to Be: What’s Truly Going On?
Authors: Debesai Meron , Oak Rachana , Mikityanskiy Yevgeniy , Trillo John , Thomas Jessen 
Published: October 2019

INTRODUCTION:
Granulomatous disease of the colon has a constellation of symptoms that is usually attributed to an inflammatory condition such as ulcerative or crohn's colitis. Generally, suspicion for Mycobacterium Tuberculosis (TB) or Mycobacterium Avium (MAC) colitis is low and diagnosis can be difficult. We present a case of abdominal pain in a young individual found to be MAC colitis.

CASE DESCRIPTION/METHODS:
Our patient was a 29-year-old male with history of hemorrhoids and appendectomy 1 month prior who presented with complaints of recurrent and diffuse abdominal pain. Patient stated the pain had been ongoing for the last two months, denying constitutional symptoms but endorsed alternating constipation and diarrhea with episodic blood in the stool for ten years. He denied any family history of inflammatory bowel disease or malignancy and recently immigrated from Pakistan 4 years ago. Physical examination only exhibited abdominal tenderness upon palpation. Review of pathology report from recent appendectomy showed granulomatous appendicitis suggestive of TB. Investigations revealed a positive beta-quantiferon with mild elevation of fecal calprotein, ASCA, and normal inflammatory markers. Stool studies were negative for infectious organisms but showed growth of acid-fast bacilli with Mycobacterium Avium Complex being isolated. CT scan of abdomen displayed extensive colitis of ascending colon and cecum with dilatation of the terminal ileum. Patient underwent colonoscopy revealing a polypoid mass in the cecum with biopsy consistent with prolapse of mucosa.

DISCUSSION:
Mycobacterium tuberculosis and Avium Complex are infections predominantly seen in immuno-deficient individuals and in those from developing countries. Diagnosis can be difficult because there are no specific symptoms for colonic infection and less than a quarter of cases have radiological evidence of active or healed pulmonary infection. TB infections of the abdomen comprises roughly 5% of worldwide TB infections with mycobacterium avium being the rarest. Predominatly infections in the GI tract are seen within the terminal ileum due to the bacilli’s affinity for lymphoid tissue with large colon infection being uncommon. Although, TB has been labeled “the great imitator,” other disease states such as MAC colitis may also present as possible IBD versus TB and a broader differential should be considered.
1619 Not All Intra-Peritoneal Free Air Is Created Equal. Pneumatosis Cystoides Intestinalis Causing Massive Pneumoperitoneum After a Colonoscopy, a Benign Finding
Authors: Pineda Bonilla Jonh J. , Volosenco Ion , Raza Tahir , Lindsey Justin 
Published: October 2019

INTRODUCTION:
Pneumoperitoneum is the presence of free air in the peritoneal cavity. Visceral perforation, obstruction, and infection are the most ominous causes and usually present with signs of acute peritonitis requiring emergent surgery.

CASE DESCRIPTION/METHODS:
A 60-year-old man was found to have extensive colonic wall bullae (pneumatosis coli) in the transverse colon during a colonoscopy (Figure 1). Contrast-enhanced abdominal computed tomography (CT) 6 days later detected free air in the peritoneal cavity, the umbilical subcutaneous fat, and pneumatosis intestinalis in the distal transverse colon (Figure 2). Patient reported mild abdominal distension which quickly improved, otherwise he was asymptomatic. His abdomen was distended, but benign with no signs of peritoneal irritation. His laboratory work was unremarkable with normal white blood cell count and lactic acid. He was managed conservatively with nothing by mouth, intravenous fluids and systemic antibiotic therapy. He completed a 10-day course of antibiotics at home. A CT abdomen 2 months later showed complete resolution of the pneumoperitoneum (Figure 3).

DISCUSSION:
Prompt diagnosis of pneumoperitoneum and its cause is crucial, and it may require timely surgical intervention. However, there are causes of pneumoperitoneum that do not require surgery; these cases must be readily distinguished. One of the etiologies of asymptomatic pneumoperitoneum is rupture of the sub-serosal cysts present in the colonic wall of patients with idiopathic pneumatosis cystoides intestinalis. Primary pneumatosis intestinalis (15% of cases) is a benign idiopathic condition in which thin-walled cysts develop in the submucosa or subserosa of the colon. The secondary form (85% of cases) is associated with obstructive pulmonary disease, as well as with obstructive and necrotic gastrointestinal disease, infection, inflammatory bowel disease, medication-induced (chemotherapy and steroid), autoimmune disease, immunosuppression, and connective tissue disorders. In conclusion, intraperitoneal air is not always related to life-threatening conditions e.g. visceral perforation requiring invasive interventions; sometimes it is related to benign causes, one of them which we mentioned in our case. Therefore, the correlation should be made with the clinical presentation, frequent abdominal exams, imaging findings, and laboratory tests to prevent unnecessary interventions.
1622 A Rare Case of Small Cell Carcinoma of the Rectum
Authors: Jencks Kara J. , Le Thanh-Truc , Shabot Marc 
Published: October 2019

INTRODUCTION:
Small cell carcinoma (SCC) of the rectum is very rare, with an incidence rate of 0.2% of all colorectal malignancies. Amongst all primary SCCs of the gastrointestinal tract, the rectum is the least common site of occurrence. We present a rare case of SCC of the rectum of unknown primary.

CASE DESCRIPTION/METHODS:
A 58-year-old male with a past medical history of prostate adenocarcinoma (gleason 4 + 3 = 7, previously treated with chemoradiation and brachytherapy) presented with a one year history of rectal pain and hematochezia. Laboratory results were significant for hemoglobin of 14.2 grams/dL, platelets 185,000/microliter, prostate specific antigen of < 0.06 nanogram/mL. Computerized tomography scan of the chest and abdomen/pelvis revealed mild circumferential rectal thickening, prostatic brachytherapy seeds, increased size of pelvic lymph nodes, and a lytic lesion in the 7 th rib. A colonoscopy was performed with findings of a 4 centimeter ulcerated, non-circumferential, non-obstructing rectal mass just above the dentate line. Pathology from rectal biopsies was consistent with small cell carcinoma; immunohistochemistry was positive for AE1/AE3, CD56, Synaptophysin, and Thyroid Transcription Factor-1. Bone biopsy of the rib lesion was also consistent with small cell carcinoma. A magnetic resonance imaging of the prostate was obtained which demonstrated an enhancing focal lesion in the right apical peripheral zone, suggestive of recurrence of prostate malignancy. A prostate biopsy was not obtained as it would not affect the overall treatment plan. The patient was started on etoposide and cisplatin with plans to be closely monitored for disease response.

DISCUSSION:
Small cell carcinoma of the rectum remains a very rare diagnosis and there is only a paucity of information limited to brief case reports. Our patient’s case is unique in that he has a previous history of prostate adenocarcinoma and there have been hypotheses that certain prostate stem cells can differentiate into SCC; a prostate biopsy would have provided a more definitive answer as to the source of this patient’s primary malignancy. Regardless, the proposed treatment of SCC remains the same (whether this is of primary rectal origin or metastatic prostate SCC to the rectum) and involves chemotherapy along with consideration of surgery/radiotherapy based on the extent of disease.
1624 Metal Stent Insertion for Malignant Obstruction of a Colostomy
Authors: Wehbeh Antonios , Rahal Mahmoud A. , Fatima Hala 
Published: October 2019

INTRODUCTION:
Malignant obstruction of a colostomy is a rare occurrence that is traditionally treated with surgical intervention; however, there are no clear recommendations for management when surgery is not feasible. Here we report a case of successful placement of a colonic stent for malignant stomal obstruction due to metastatic cervical cancer.

CASE DESCRIPTION/METHODS:
A 47-year-old female with a history of metastatic cervical cancer presented with abdominal distention and minimal stool output from her colostomy for 2 weeks duration. She was diagnosed with cervical cancer three years prior. Her disease progressed rapidly despite treatment and was complicated by rectovaginal fistula for which she underwent laparoscopic diverting colostomy. The patient noticed an enlarging mass near the ostomy site which was biopsied and showed metastatic adenocarcinoma of endocervical origin. Examination revealed a benign abdomen with palpable peristomal subcutaneous masses. A CT scan showed a large heterogenous abdominal mass causing compression and obstruction at the level of the colostomy with significant proximal colonic dilation, measuring up to 8 cm. As a temporizing measure a rubber catheter was passed through the stoma for decompression. Given the extensive metastatic disease she was not a candidate for any operative intervention, and subsequently endoscopic stent placement was pursued. Colonoscopy was performed showing a severe stenosis 4 cm in length at the surgical stoma. A 25 mm × 6 cm self-expandable covered metal stent (SEMS) was successfully placed with the distal edge visible externally but not protruding beyond skin level. Her obstructive symptoms resolved shortly after the procedure. Two months later, a CT scan showed a patent stent still in place without recurrent colonic obstruction.

DISCUSSION:
Stenosis and malignant colostomy obstruction are among the complications of stoma construction. Surgery is usually the traditional treatment of these complications, but data is limited concerning the management of patients that are not good surgical candidates. There are very few case reports describing the use of either covered or uncovered SEMS for colostomy obstruction, all of which remained patent until the patients’ death 1.5 – 6 months later. In conclusion, metal stent insertion for malignant obstruction of colostomy could be a viable palliative treatment option in patients who are not operative candidates.
1629 A Rare Case of Large Cell Neuroendocrine Carcinoma of the Colon
Authors: Chiu Yiu-Ting T. , Michael Sherif , Morgan Kelli , Mokhtari Navid , Kavanaugh Mindie , Morris James D. , Manas Kenneth J. 
Published: October 2019

INTRODUCTION:
Colorectal cancers are some of the most common cancers worldwide. Histologically, the vast majority of these cancers are adenocarcinomas. Neuroendocrine tumors of the colon are much less common, and large cell neuroendocrine carcinomas (LCNEC) are even rarer, accounting for less than 1% of all colorectal cancers. Furthermore, LCNEC is a very aggressive tumor with a tendency towards early metastasis. We present a case of LCNEC in a female who initially presented with symptomatic anemia.

CASE DESCRIPTION/METHODS:
A 69-year-old female with a PMH of HTN presented to the hospital complaining of fatigue for 2 weeks. The patient also admitted to abdominal pain and weight loss for 5 months, but denied any frank blood loss. The patient’s family history was significant for colon cancer in her mother and grandson. Despite this, the patient had never had a colonoscopy. Initial labs showed a Hgb of 6. After the patient was resuscitated, endoscopy was performed. EGD showed antral gastritis, while colonoscopy showed a large ulcerated and oozing cecal mass. A staging CT showed hepatic metastasis. The patient’s preliminary pathology report stated the cecal mass was an invasive, poorly differentiated adenocarcinoma. Surgery was consulted, but due to metastasis, they recommended palliative chemotherapy. Oncology was consulted and planned for FOLFOX chemotherapy. The patient’s final pathology report differed from the initial diagnosis, stating the colon mass was a LCNEC, which was supported by the fact that the tumor cells were immunoreactive for chromogranin, synaptophysin and CD56 and immunonegative for CDX-2 and CK20. On outpatient follow-up 2 weeks later, patient was noted to be dehydrated with worsening appetite and pain, so she was admitted. The patient’s condition continued to deteriorate however, and after a thorough discussion, the patient elected for home hospice.

DISCUSSION:
With improved screening helping to detect colonic lesions earlier, death rates from most colorectal cancers have been dropping. However, a diagnosis of LCNEC portends a poor prognosis as these tumors are very aggressive with a median overall survival of 10 months. Surgery is often the primary means of treatment, however that poses a problem with LCNECs, as most have already metastasized by the time of diagnosis. In our patient, her metastatic disease precluded surgery and her rapid decline made chemotherapy less tenable. This case helps highlight the importance of screening awareness, especially in patients with a family history.
1632 Rectal Endometriosis: An Atypical Presentation
Authors: Torralba Ericson J. , Suraweera Duminda B. , Park Sunhee 
Published: October 2019

INTRODUCTION:
Endometriosis is a condition in which endometrial tissue is implanted outside of the uterus. Patients with gastrointestinal involvement experience pelvic pain, rectal bleeding and abdominal pain which may be associated with menstruation. Often patients are misdiagnosed or have significant delays in diagnosis, especially in the setting of negative imaging. While endometrial lesions that penetrate the bowel mucosa are rare, endoscopy can play a vital role in the correct clinical setting. We present a rare case of rectal endometriosis that was diagnosed primarily through colonoscopy.

CASE DESCRIPTION/METHODS:
A 46-year-old woman with a history of uterine fibroids was referred to our center for evaluation of severe intermittent rectal pressure for the previous four months. Patient reported that her pain was associated with bowel movements and improved after evacuation. She denied blood in her stool. She had undergone a transvaginal ultrasound and magnetic resonance imaging (MRI) of her pelvis that demonstrated a decrease in size of her uterine fibroids from prior imaging. The bowel was noted to be unremarkable on MRI. She was referred to our clinic for further management of possible irritable bowel syndrome. The patient had a benign abdominal exam and rectal exam revealed internal hemorrhoids. Colonoscopy was subsequently scheduled and showed unremarkable ileum and colon, however approaching the anal verge, a nodularity was found in the rectum with a somewhat hard consistency. Several biopsies were collected. Ink was injected proximal to the nodularity for reference. Pathology review of the biopsies were consistent with endometriosis with no evidence of dysplasia or malignancy. Immunohistochemical stains were positive for estrogen receptor (ER), paired-box gene 8 (PAX 8) and pankeratin, markers for endometriosis. The patient was referred for rectal endoscopic ultrasonography (EUS) to determine the depth of invasion. She follows with gynecology where further treatment options are being discussed.

DISCUSSION:
Gastrointestinal endometriosis serves as the most common site for extra-gynecologic localization and affects 3-38% of women presenting with the endometriosis. Endometriosis is commonly misdiagnosed and often mistaken for other pathologies, resulting in delays in diagnosis, unnecessary testing and mismanagement. For women of childbearing age who present with persistent pelvic pain and associated symptoms of endometriosis, colonoscopy may serve as a primary method for diagnosis.
1634 Extracolonic Neoplasm From Colonic Polyps: A Case of Metastatic Prostate Cancer Diagnosed From a Colonic Polyp
Authors: Haque Zohaib , Almoghrabi Anas , Attar Bashar M. , Elkhouly Mohamed A. , Nwaichi Chineme , Vohra Ishaan , Majeed Muhammad 
Published: October 2019

INTRODUCTION:
Prostate Cancer is the 2nd most common cancer among men in the US. Prostate Cancer frequently metastasizes to the bones, lymph nodes, lungs, liver, and brain. Very rarely, patients can develop metastases to the GI tract. We are presenting a patient that was diagnosed with metastatic prostate cancer after a colon biopsy.

CASE DESCRIPTION/METHODS:
A 61-year-old gentleman with no significant past medical history, presented with constipation, weak urinary stream, in addition to remote fall followed by lower back pain, trouble ambulating, and an unintentional 40 lb weight loss. He did not have any history of melena, hematochezia, abdominal pain or family history of cancers Examination was only evident of tenderness overlying lumbar vertebrae. He underwent CT Abdomen/Pelvis which showed sclerotic vertebral bone lesions in addition to abnormal thickening of the mid to lower rectal wall with adjacent perirectal soft tissue masses suspicious for rectal cancer with adjacent conglomerate lymphadenopathy/tumor. Colonoscopy revealed diminutive sigmoid sessile polyps which was removed by cold snare and cold biopsy in addition to an area of ulceration in the proximal rectum. Surprisingly the pathology of the polyps and rectal ulceration was consistent with metastatic prostate adenocarcinoma. He is planned to be started on chemotherapy with Docetaxel.

DISCUSSION:
Prostate cancer may invade the rectum however it remains rare to have metastatic colonic polyps from a prostate cancer. It has been reported to discover metastatic colonic polyps from breast, lung, skin (melanoma) cancer, however the finding of metastatic colonic polyps from a prostate cancer is rare and portends a sinister prognosis. In the light of this infrequent finding it becomes imperative to consider an extracolonic cause as the source of a colonic polyp especially in patients with known or in suspicion for a primary cancer. The mechanism of metastasis to the colonic is thought to be by hematogenous or lymphatic spread, however, rectal involvement often occurs by local tissue invasion. The clinical scenario in our patient is peculiar since there were no prior diagnoses of primary cancer. An extracolonic metastatic polyp may sometimes be the earliest sign of recurrent prostate cancer.