bluuebunny/crossref_metadata_2025_split huggingface dataset:
1476 Early Detection of Mantle Cell Lymphoma Recurrence With Colonoscopy
Authors: Singh Amardeep , Bali Atul , Bal Bikram 
Published: October 2019

INTRODUCTION:
Non-Hodgkin Lymphomas (NHL) are a group of malignancies that are derived from immature B cells, T cells and natural killer cells. The incidence of NHL is 19.6 per 100,000 per year in the United States. Mantle cell lymphoma (MCL) is a type of NHL which arises from mature B cells and has a more aggressive clinical course, accounting for 6% of all NHL cases. This amounts to approximately 4200 new cases in the US every year. MCL has a strong predilection for the gut with 92% of patients exhibiting gastrointestinal infiltration.

CASE DESCRIPTION/METHODS:
Our patient is a 68-year-old Caucasian male referred for a routine screening colonoscopy. History was notable for MCL involving the hard palate diagnosed in February 2013. This was initially treated with R-CHOP therapy with subsequent Rituximab maintenance. Patient relapsed in February 2015. His relapse was treated with FCR therapy which was completed in June 2015. Follow up bone marrow biopsy was negative. In June 2016 he had recurrence of the malignancy on his hard palate, requiring treatment with local radiation. After completion of radiation, surveillance imaging with integrated whole body PET/CT demonstrated no further activity. He was deemed to be in remission and maintained routine biannual oncologic follow up for three years. Routine screening colonoscopy performed in May 2019, revealed a polyp in the transverse colon, and an additional polypoid lesion in the rectum. Biopsy revealed atypical lymphoid infiltrate consisting of medium sized lymphocytes that were positive for CD5, CD20, CD10, PAX5, Bcl-2, and cyclin D1. Morphology, immunofluorescence, and FISH were positive for t11:14, with pathology being consistent with mantle cell lymphoma. Patient has been referred back to his oncologist to discuss further treatment options.

DISCUSSION:
Our case illustrates the importance of endoscopic surveillance in patients with MCL. While PET/CT is invaluable in the surveillance of multiple malignancies, it maybe inadequate in determining remission and recurrence of MCL. The National Comprehensive Cancer Network (NCCN) recommends that both upper endoscopy and colonoscopy be performed to assess treatment response and remission in this population. Given the high incidence of GI involvement in MCL, incorporating routine endoscopic surveillance as part of MCL management may be an important step for early detection of disease recurrence in this high-risk population.
1483 Full Thickness Resection Device for the Removal of a Submucosal Sigmoid Carcinoid Tumor
Authors: Patel Pratik , Phan Ethan , Gollol Raju Narasimha Swamy , Mudireddy Prashant 
Published: October 2019

INTRODUCTION:
Colonic neuroendocrine tumors (NETs) are rare neoplasms, but they carry the worse prognosis. Management of these tumors is difficult and may result in repeated interventions and prolonged surveillance. Endoscopic Full Thickness Resection (FTR) is not currently included in the guidelines for management of NETs. This case describes a technically and histologically successful FTR of a sigmoid goblet cell carcinoid tumor.

CASE DESCRIPTION/METHODS:
A 61-year-old male presents for screening colonoscopy and was found to have an 8 mm submucosal mass in the distal sigmoid. Pathology of biopsies showed hyperplastic colonic mucosa with marked reparative stromal and epithelial changes and mixed features of prolapse. He was referred to our institution for EUS of the submucosal lesion, which revealed hypoechoic submucosal lesion in distal sigmoid measuring 7.4 × 4.7 mm. FNA was attempted but unsuccessful as the mass was small and mobile. Therefore, decision was made to perform endoscopic mucosal resection (EMR). Pathology on EMR of sigmoid lesion revealed goblet cell carcinoma. Deep and lateral margins were positive. Chromogranin A level was mildly elevated. He was referred to surgical oncology who recommended 3 month surveillance colonoscopy given low Ki index. CT Scan of Abdomen and Pelvis as well as Octreotide scan were both negative for distant metastases. At 3-month follow up colonoscopy, the decision was made to use Full Thickness Resection Device (FTRD) of the sigmoid lesion given positive margins. Pathology of FTRD was consistent with neural sheath tumor and deep and lateral margins were negative. Repeat colonoscopy revealed well healed scar at site of FTRD and cold biopsies around the scar were benign. He will follow up in 3 years for repeat colonoscopy.

DISCUSSION:
Primary colonic neuroendocrine tumors are rare but are generally more aggressive and carry the worst prognosis dependent on stage. Current consensus guidelines for the management of local regional NETs recommend endoscopic resection via polypectomy, EMR or endoscopic submucosal dissection. There have only been a few reported cases of the use of FTRD to treat submucosal carcinoid tumors in the colon. Success rates for endoscopic full thickness resection of gastric tumors has been described in the literature with success rates of up to 100%. High success rates of FTRD on colorectal lesions, not NETs, have also been noted. Given this, FTRD should be considered as a more definitive modality for treatment involving submucosal carcinoid tumors.
1491 Colo-Colonic Intussusception: An Unusual Complication of Bowel Preparation
Authors: Le Han N. , Kwiatt Michael E. , Chaaya Adib 
Published: October 2019

INTRODUCTION:
Intestinal intussusception is the telescoping or invagination of a proximal bowel segment into a distal segment. It is a relatively common entity in the pediatric population, but only about 5% of all intussusceptions occur in adults. Approximately 90% of adult intussusceptions are secondary to an anatomical or pathological condition. We present a case of colo-colonic intussusception induced by bowel preparation for colonoscopy in the setting of large transverse colonic mass.

CASE DESCRIPTION/METHODS:
A 57-year-old gentleman with a history of metastatic melanoma was evaluated for iron deficiency anemia. On physical examination, the patient was pale and chronically ill appearing with a benign abdominal exam. Endoscopic evaluation showed an ulcerated mass in the duodenum and a large 5 cm tumor in the proximal transverse colon. While undergoing bowel preparation for repeat colonoscopy to assess response to chemotherapy, the patient developed acute, diffuse abdominal pain associated with nausea and vomiting. He was found to have an acute colo-colonic intussusception with total colonic obstruction. The patient underwent emergent surgery and recovered well.

DISCUSSION:
We hypothesize that our patient's colo-colonic intussusception was induced by hyperperistalsis of the colon as a result of bowel preparation. The patient was already at risk for both small bowel and colonic intussusception given the large size of both intestinal masses. Our case is unique in that he developed the intussusception while taking the bowel preparation. The altered peristaltic activity of the bowel in the setting of a large colonic mass created an area of constriction and distal relaxation which led to the invagination of the proximal bowel segment into the distal segment. With advances in endoscopy and new techniques, such as endoscopic submucosal dissection, we have the ability to remove larger polyps measuring more than 5 cm in size. Endoscopists need to inform their patients of the potential complication of bowel preparation induced colonic intussusception requiring emergent surgery while prepping for large polyp removal.
1495 A Case of Non-Typhoidal Salmonella (Salmonella Saintpaul) Bacteremia
Authors: Ramachandran Rajarajeshwari , Azhar Maria , Jani Niraj 
Published: October 2019

INTRODUCTION:
The Center for Disease Control and Prevention (CDC) estimates 1.2 million illnesses and 450 deaths occur due to non-typhoidal Salmonella annually in the United States. Among the different kinds of Salmonella, S. typhimurium and S. enteritidis are the most common serotypes. S. Saintpaul infection is rare and the last outbreak was reported in 2008. We are presenting the case of a 52-year-old woman with S. Saintpaul bacteremia.

CASE DESCRIPTION/METHODS:
53-year-old woman with history of bipolar disorder and gastroesophageal reflux disease (GERD) was admitted to the hospital with diarrhea for 2 days. She was noted to be in septic shock and was treated with fluid resuscitation and vasopressors. Examination: temperature 37 °C, blood pressure 66/36 mmHg, pulse 111/minute and saturating 97% on room air. Cardiovascular and respiratory examinations were normal. Abdomen - no tenderness, no peritoneal signs and hyperactive bowel sounds. Laboratory data: white cell count 2.82 × 103/μL, hemoglobin 8.2 g/dL, platelets 152 × 103/μL, sodium 129 mEq/L, potassium 2.6 mEq/L, chloride 93 mEq/L, bicarbonate 15.2 mEq/L, creatinine 5.0 mg/dL, AST 93 IU/L, ALT 35 IU/L, alkaline phosphatase 145 IU/L, total bilirubin 0.5 mg/dL. Blood culture -positive for group B Salmonella. Clostridium difficile PCR - negative. Stool culture - positive for group B Salmonella and was later identified as Salmonella Saintpaul serotype. CT abdomen and pelvis without contrast - wall thickening and inflammatory stranding involving the right hemicolon and the hepatic flexure. Patient was given intravenous antibiotic therapy and follow up blood cultures did not demonstrate growth of Salmonella. Patient's condition steadily improved and she was eventually discharged home.

DISCUSSION:
Salmonellae are Gram-negative, rod-shaped bacilli and are classified into typhoidal and nontyphoidal groups based on their serotype. Common sources of non-typhoidal Salmonella infection are contaminated food or water and contact with infected animals. In our patient's case, her family raised chicken for eggs and we suspect that to be the source of infection.
1499 Segmental Colitis Associated With Diverticulosis (SCAD): A Rare Cause of Hydroureteronephrosis
Authors: Bazarbashi Ahmad Najdat , McCarty Thomas R. , Al-Obaid Lolwa , Homenko Daria 
Published: October 2019

INTRODUCTION:
Segmental Colitis Associated with Diverticulosis (SCAD) is a rare inflammatory condition affecting segments of bowel with diverticulosis. We present a case of a patient with imaging revealing left colonic wall thickening and left sided hydroureteronephrosis, and work-up confirming a diagnosis of SCAD.

CASE DESCRIPTION/METHODS:
An 85-year-old female with a history of cognitive impairment, uterine cancer status post hysterectomy, and previous episode of diverticulitis 5 years prior presented to our institution with fevers, chills, and flank pain. Symptoms began 3 days prior to presentation with no associated abdominal pain, nausea, vomiting, hematochezia, or changes to her bowel movements. Upon arrival, her vital signs were within normal limits and physical exam disclosed left flank tenderness. Laboratory data revealed leukocytosis to 17 K/uL with unremarkable hematocrit, basic metabolic panel, and liver chemistries. Urinalysis was positive for pyuria with nitrites and leukocytes. CT abdomen and pelvis revealed short segment of sigmoid colonic, adjacent lymphadenopathy, left psoas abscess, and moderate left hydroureteronephrosis (Figure 1). She was initially treated with antibiotics and left-sided percutaneous nephrostomy tube placement. Colonoscopy was deferred due to concern for high risk of complications in favor of conservative management; however, repeat imaging 4 weeks later revealed unchanged thickening of the mid-sigmoid colon extending into left pelvic sidewall and interval increase in the left psoas collection with concern for fistulizing chronic diverticulitis or potential malignancy. She subsequently underwent exploratory laparotomy with lower anterior resection and ileoclonic resection for tethered and fistulizing small bowel to a left lower quadrant phlegmon. The sigmoid colon was also attached to the phlegmon and pathology revealed diverticulitis with extensive old fibrosis and reactive lymphadenopathy without evidence of malignancy or histology suggestive of IBD. As such, the final diagnosis was SCAD-associated hydroureteronephrosis, and she recovered well without complication.

DISCUSSION:
Often mistaken for IBD or colorectal cancer, SCAD is an inflammatory condition that should be considered in patients with history of diverticulosis and features suspicious for segmental colonic inflammation. This case reinforces understanding and highlights hydroureteronephrosis as a rare complication seen in a patient with SCAD.
1502 Colon Polyp as Rare Manifestation of Breast Cancer Metastasis
Authors: Ghavimi Shima , Nasir Umair M. , Panchal Dayna , Choi Catherine , Fidan-Ozbilgin Ozlem , Verma Siddharth 
Published: October 2019

INTRODUCTION:
Breast cancer is the most common cancer in women worldwide. The leading cause of morbidity and mortality is due to distal metastasis. While metastasis to the brain, bones, lungs, liver and adrenal glands is usually seen, metastasis to the gastrointestinal tract is a rare, with colorectal involvement being an even rarer entity. We present a case of metastatic breast cancer presenting as a benign-appearing polyp on a colonoscopy.

CASE DESCRIPTION/METHODS:
A 56-year-old female with no significant past medical history except for schizophrenia presented with chief complaints of left breast mass with diffuse lymphadenopathy. Biopsy of the mass revealed invasive ductal carcinoma which was ER/PR (+) and HER2 (−) on immunohistology. PET/CT revealed diffuse bone metastasis. Contrast brain MRI showed isolated cerebellar brain lesion suggestive of neoplasm, likely secondary to the metastatic lesion. Patient was evaluated by Radiation oncology and radiation therapy started. During the hospital course, she was noted to have a gradual decrease in hemoglobin from 11 to 8.6 g/dl, while the reticulocyte count was normal. Although fecal occult blood testing was negative, Gastroenterology was consulted and EGD revealed gastritis and biopsies revealed inflammatory gastritis that was negative for H.Pylori. Colonoscopy revealed a 4 mm sessile polyp in the transverse colon (Figure 1). Biopsy of the polyp was consistent with adenocarcinoma which was ER/PR (+) (Figure 2) and HER2 (−) on immunohistology. Additional nuclear staining with breast markers including mammoglobin, and gross cystic disease fluid protein-15 was performed, and metastatic breast cancer was highly suggested. Unfortunately, due to the advanced nature of her breast cancer and poor overall nutritional status, the patient expired.

DISCUSSION:
In a review of cases reporting primary breast cancer with metastasis to the gastrointestinal tract, invasive lobular carcinoma of the breast is much more frequently represented. In our case presented above, the diagnosis was invasive ductal carcinoma of the breast with metastasis to the transverse colon. Diagnosis of metastasis to the colon may be difficult, as symptoms may be nonspecific. Due to this, patients with this entity often present late in disease progression. PET/CT often are non-contributory and do not show colonic metastasis. In conclusion, while gastrointestinal, especially colorectal, metastasis is rare, metastatic breast cancer can mimic a benign-appearing colon polyp on colonoscopy.
1503 A Rare Case of Nivolumab-Induced Early Onset Immune-Mediated Colitis With Normal Appearing Mucosa
Authors: Shahzad Sheikh , Mansoor Muhammad Sohail , Naseer Usman , Khan Abdul Moiz , Batool Asra 
Published: October 2019

INTRODUCTION:
Programmed Cell Death Protein 1 (PD-1) inhibitor, nivolumab, is increasingly being used for the treatment of advanced neoplasms including melanoma, renal and metastatic lung cancers. Side effects of nivolumab include Immune-mediated colitis (IMC) with a median time to onset between 6-18 weeks. We present a patient with adenocarcinoma of the lung who developed IMC within a week of initiation of nivolumab.

CASE DESCRIPTION/METHODS:
A 75-year old male with a history of recurrent stage IIIA adenocarcinoma of lung presented with a one-week history of 5-6 non-bloody liquid bowel movements (grade 2 colitis) with nocturnal episodes. His symptoms started within a week of initiation of nivolumab. The patient had persistent diarrhea despite overnight fast and had associated severe abdominal cramps and nausea. His vital signs were stable on presentation and physical exam was significant for clinical dehydration and tenderness to palpation in the LLQ. CT A/P and AXR were unremarkable while infectious workup including C. Difficile was negative. His stool guaiac, fecal elastase, and serum lipase were negative while his inflammatory markers including ESR, CRP and fecal calprotectin (193 μg/g) were elevated. A colonoscopy was performed which showed normal appearing mucosa while random colon biopsy demonstrated increased intra-epithelial lymphocytes, surface epithelial injury, expansion of lamina propria by mononuclear inflammatory infiltrate and scattered crypt abscesses. CMV immunochemical stain was negative. Nivolumab was discontinued following biopsy result and the patient was started on oral prednisone 40 mg bid with the resolution of diarrhea within 2 weeks of treatment. He was later transitioned to oral budesonide.

DISCUSSION:
IMC is more commonly seen with Cytotoxic T-Lymphocyte Antigen 4 (CTLA4) inhibitors as opposed to PD-1 inhibitors especially nivolumab. Although the average time of onset of nivolumab associated colitis ranges between 6-18 weeks, early onset IMC is rare but possible as in our case. IMC can have an atypical presentation with early onset diarrhea and normal appearing mucosa as in our case. Clinicians need to have a high index of suspicion for IMC while taking care of patients receiving PD-1 inhibitors presenting with diarrhea or abdominal pain.
1505 Relapsed Angioimmunoblastic T-Cell Lymphoma Presenting as Severe Colitis With Bowel Perforation
Authors: Hussien Merna , Mehta Amit , Buffie Charlie , Tafesh Zaid , Wan David 
Published: October 2019

INTRODUCTION:
Angioimmunoblastic T-cell lymphoma (AITL) is a subtype of the uncommon peripheral T-cell lymphomas that usually presents as acute onset of systemic B symptoms and generalized lymphadenopathy. Here, we report a case of a woman with relapsed AITL involving the descending, sigmoid colon, and rectum, presenting as persistent diarrhea and bowel perforation.

CASE DESCRIPTION/METHODS:
A 78-year-old woman who was diagnosed with AITL in 2002 and had been stable on continuous therapy of romidepsin for the past 2.5 years for relapsed disease, presented with a 6-week history of diarrhea, fatigue, and decreased appetite. The diarrhea was watery, non-bloody, occurred 4-5 times a day, with fecal urgency and incontinence. The patient denied any abdominal pain, nausea, vomiting, or fever. There was no recent change in her medications, and no recent history of travel or contact with children or pets. During the 6-week period, she was hospitalized twice and was initially thought to have infectious colitis, for which she was given ciprofloxacin, metronidazole, and re-hydration therapy. Abdominal CT showed severe left-sided colitis with multiple enlarged perirectal and mesenteric lymph nodes. Upon her third admission, infectious etiologies were ruled-out and sigmoidoscopy showed markedly edematous and erythematous rectum. Biopsies from the rectum and sigmoid colon showed dense atypical T-cell infiltration consistent with involvement of her previous AITL. Her hospital course was further complicated by bowel perforation and polymicrobial positive blood cultures. She refused surgery and was referred to home hospice for palliative care.

DISCUSSION:
AITL is an aggressive peripheral T-cell lymphoma that is believed to arise from CD4 positive follicular helper T-cells. It accounts for 1-2% of non-Hodgkin lymphoma cases and has a higher incidence among Asian/Pacific Islanders and Hispanic Whites in the United States. Initial presentation commonly includes generalized lymphadenopathy, fever, unintentional weight loss, and night sweats. With progression, it can commonly involve the bone marrow, spleen, skin and soft tissues. However, gastrointestinal involvement is rare. In 1996, Goenka et al. reported AITL presenting as colonic polyps. We are reporting a case of AITL progressing to involve the descending, sigmoid colon, and rectum, whose presentation was initially mistaken for infectious colitis. However, due to high clinical suspicion, sigmoidoscopy was performed and biopsies confirmed the diagnosis of AITL of the colon.
1506 Poisoned by Indian Herbal Medicine: An Inconspicuous Cause for Abdominal Pain
Authors: Srivats Sudarshan , Zhang Danmei , Buffie Charlie , Wan David , Maltz Charles 
Published: October 2019

INTRODUCTION:
Symptoms of lead poisoning are nonspecific and include abdominal pain, constipation, irritability, weight loss, and anemia. Sources of exposure in adults are predominantly occupational (ex. batteries, paint, cable, or wires), but also include herbal remedies, or cookware. Here, we report a case of lead poisoning after oral intake of Ayurvedic supplements.

CASE DESCRIPTION/METHODS:
A 35 y/o man presented with 6 weeks of worsening diffuse abdominal pain and cramping, SOB, fatigue and nausea. Patient denied diarrhea, vomiting or weight loss. He traveled to India earlier this year. Examination was notable for severe abdominal tenderness and slight distention. Initial work up including CBC, CMP, UA and LFTs were notable for a normocytic anemia with a Hb 9.5 (baseline 16). Stool was brown and guaiac negative. Serum haptoglobin, LDH, B12 and iron studies were within normal limits. Abdominal CT and US were unremarkable. EGD showed no bleeding. Additional work-up such as GI PCR, Meckel scan, urine PBG, blood lead level (BLL) and C1-INH were ordered. However, Hb kept dropping without improvement in pain. On day 3 of hospitalization, he was started on laxatives for constipation and discharged after improvement in bowel movements and abdominal pain with outpatient follow up for his anemia. Lab results later revealed a BLL of 78.4 ug/dL, and a blood smear showed basophilic stippling of erythrocytes, consistent with lead poisoning. On further interview, patient noted taking Ayurvedic supplements obtained in India with last intake 3 weeks prior to admission. Patient stopped his herbal medication and was started on oral succimer and eventually switched to dimercaprol. Samples of the supplements were sent out for testing.

DISCUSSION:
Given that many differentials for abdominal pain and anemia were ruled out, less common causes were investigated, such as AIP, intestinal angioedema, and lead poisoning. Once absorbed, lead deposits in the blood, soft tissue and bone. The toxic effects of lead are due to oxidative stress caused by inactivation of anti-oxidant enzymes, which damages DNA, cell membranes and impairs DNA transcription. Common symptoms are microcytic anemia, abdominal colic, nausea, vomiting and neuropathy. Basic workup includes free erythrocyte protoporphyrin or zinc protoporphyrin, blood urea nitrogen, serum creatinine, and urinalysis for 5-Amino-laevulin acid. In this case elevated BLL and classic blood smear lead to the diagnosis of lead poisoning.