bluuebunny/crossref_metadata_2025_split huggingface dataset:
3058 An Unusual Case of Ischemic Colitis
Authors: Bofill Aliana , Medina Rafael , Estremera Rodolfo , Martin Jose 
Published: October 2019

INTRODUCTION:
48-year-old obese (BMI: 40) female, G0P0A0 LMP 1 year ago, with hypertension and hypercholesterolemia who presented with sudden left lower abdominal cramping pain associated with bloody diarrhea of one day duration. Denied associated systemic symptoms. She was using aspirin, simvastatin, metoprolol and had a progestin-only intrauterine device (IUD) placed 2 years ago. Physical examination with tenderness at the left lower quadrant. Digital rectal examination unremarkable. Laboratories with leukocytosis, lactatemia and positive fecal leukocytes. Abdominopelvic CT with IV contrast revealed left-sided peri-colonic and colonic inflammatory changes.

CASE DESCRIPTION/METHODS:
Gastroenterology service consulted due to non-specific colitis and there was concern for ischemic colitis as CT revealed inflammation in a watershed area. Colonoscopy showed edematous mucosa from the splenic flexure to the sigmoid colon associated with multiple large longitudinal ulcers. Biopsies revealed mucosal hemorrhage and neutrophil infiltration, suggestive of ischemic injury. Etiology of ischemia not clear given no obvious risk factors. Cardiovascular, myeloproliferative and prothrombotic workups were negative. The last piece of the puzzle rested on the IUD which was removed by the OBGYN service. A few days later, a follow up CT showed marked inflammation improvement.

DISCUSSION:
Ischemic colitis is generally considered a disease of the elderly. The most common causes include low-flow states due to cardiac dysfunction and hypovolemia. However, in younger patients, hypercoagulable states and drugs are the most common etiologies. In our patient, it was hard to initially find a reasonable cause of ischemia but, after excluding all etiologies, patient's IUD was the most likely cause of bowel ischemia. Combination contraceptives are a well-known risk factor for venous thromboembolism (VTE). However, few data have been published regarding whether the risk of VTE increases with progestin-only contraceptives (1). Mechanism is unclear, although it is hypothesized that protein concentrations influenced by hormones affect coagulation homeostasis (2). This risk appears to increase if additional VTE risk factors are present such in our patient with an elevated BMI (3). This rare case proves the importance of acquiring a detailed medical history including the use of contraceptives. Moreover, awareness of this diagnosis is essential so that early recognition can lead to individualized treatment decision and better patient's outcome.
3060 Octreotide Use in Chronic Diarrhea Post Capecitabine Treatment
Authors: Stewart Sarah , Hobson Erin , Penland-Ismatov Sherry , Demott Chad 
Published: October 2019

INTRODUCTION:
Diarrhea is a known common side effect of chemotherapy, and is commonly associated with Capecitabine which was developed to increase systemic tolerability with tumor-specific conversion to 5-FU. Early onset diarrhea and mild to moderate diarrhea have been noted to occur in colorectal cancer patients on Capecitabine. Chemotherapy induced diarrhea (CID) can be life-threatening in severe cases due to resulting electrolyte imbalances, metabolic acidosis, and renal failure. Loperamide is the first line treatment for CID with octreotide being second-line treatment when patients fail to respond to loperamide within 48 hours. However, in cases of severe CID it is recommended that octreotide be initiated as first line therapy.

CASE DESCRIPTION/METHODS:
A 70 year old male with a history of poorly differentiated mucinous adenocarcinoma of the colon status post capecitabine presented to the ED with complaints of diarrhea. The patient initially presented to the oncology office with reported diarrhea, which was untreated at that time as diarrhea was suspected to be self limiting since he had stopped chemotherapy two days prior. When diarrhea did not abate he was admitted for diarrhea with dehydration. During admission octreotide was initiated since diarrhea did not abate on Imodium and loperamide. One week into admission, the patient developed metabolic acidosis (bicarb 8.6) and minimal resolution of diarrhea while on octreotide. Due to continued soft to loose frequent stools, the patient's octreotide dose was increased to 200 mcg every 8 hours and patient was placed back on scheduled loperamide. He was discharged on 30 mg long acting subcutaneous octreotide and as needed loperamide. He subsequently received 2 additional doses due to continued diarrhea before representing to the ED three months later for worsening diarrhea.

DISCUSSION:
This case demonstrates the complications that can arise from delayed octreotide treatment in diarrhea status post capecitabine treatment for colon cancer. 5-FU based chemotherapy has been known to result in potentially life-threatening mucosal toxicity. Literature review has shown that octreotide has improved overall response when compared to loperamide in resolution of CID diarrhea. This patient's poor inpatient response to anti-diarrheal agents highlights the importance of early CID management.
3064 A Case of a Rectal Xanthoma: A Sessile Polyp in an Uncommon Place
Authors: Urazov Konstantin , Singh Vikram , Mehra Shilpa 
Published: October 2019

INTRODUCTION:
Xanthomas are benign collections of lipid bearing histiocytes that form a localized mass. While they are usually found in the soft tissue, they may also be found in the gastrointestinal (GI) tract. Within the GI tract, they are most commonly located in the stomach, and rarely within the rectosigmoid colon. These polyps are found within the mucosa and while usually asymptomatic, can rarely cause obstructive symptoms or pain if large enough. This case presents a rare finding of a rectal xanthoma.

CASE DESCRIPTION/METHODS:
A 55-year-old woman without any significant PMH presented for an initial screening colonoscopy. Physical exam and basic laboratory evaluation were unremarkable. Colonoscopy showed pan-diverticulosis, internal hemorrhoids, and a rectal polyp. The polyp was 4 mm, sessile, and yellow-white in color. It was removed with cold biopsy forceps. Pathology identified the polyp as a xanthoma. Given the benign nature of the polyp, patient was instructed to undergo screening colonoscopy in 10 years.

DISCUSSION:
During endoscopy, xanthomas are often overlooked as a differential diagnosis for a polypoid lesion, especially when found in an unlikely location. The exact incidence of rectal xanthomas is unknown and mostly limited to case reports alone. They can be seen in any age group, but tend to be more frequent with age. Colorectal xanthomas can present as flat, sessile, or pedunculated lesions. They are usually solitary and yellow-white in color. Xanthomas are typically confined to the lamina propria mucosa with pathology showing the characteristic foamy histiocytes in this location. Unlike cutaneous and tendinous xanthomas that often have a relation to hyperlipidemia, gastrointestinal xanthomas are usually not associated with an underlying disease (though this remains under investigation). The etiology of gastrointestinal xanthomas are poorly understood but it is believed that they arise in areas of damage, especially when they are found in the stomach. As xanthomas are benign and typically do not cause symptoms, there is no treatment necessary. Xanthomas continue to remain an important and rare finding within the GI tract that may eventually be found to have associations with certain systemic conditions.
3067 Colon Mass From an Unusual Etiology
Authors: Aurand William , Wayde Melinda , Back Gregory 
Published: October 2019

INTRODUCTION:
There is a high level of suspicion for colon cancer in an adult patient with hematochezia and endoscopic evidence of a mass. However, it is important to biopsy the mass for definitive diagnosis as other etiologies may be responsible. This case reports on the surprising finding of an ulcerated colon mass found to be due to CMV infection.

CASE DESCRIPTION/METHODS:
A 71-year-old female with past medical history significant for end stage renal disease, hypertension, diabetes mellitus type 2, atrial fibrillation, and peripheral vascular disease was admitted for chest pain and generalized weakness. Gastroenterology was consulted after the patient complained of rectal bleeding in the setting of anemia. A colonoscopy was performed, which showed an ulcerated-appearing 5 × 4 cm mass extending into the ileocecal valve with biopsies taken with concern for malignancy. However, the biopsies showed evidence of a sessile-serrated adenoma that was negative for malignancy and positive for CMV. Ganciclovir was started for treatment of the CMV, and a colonoscopy was scheduled to be done after completion of the antiviral course.

DISCUSSION:
CMV is a member of the Herpesviridae family and has a high prevalence, with 50-80% of adults in the United States being seropositive at 40 years of age or older. It often reactivates in people who are immunosuppressed, with the GI tract being a common area for reactivation. CMV in the colon has a variable presentation, though it usually presents with signs of colitis. Definitive diagnosis of CMV requires biopsy. Treatment is with antiviral medications, such as ganciclovir. This case shows that while a colonic mass in an adult patient presenting with hematochezia places colon cancer high in the differential diagnosis, it is important to consider other etiologies.
3070 A Rare Case of 5-Fluorouracil-Induced Ulcerative Colitis
Authors: Akanbi Olalekan , Perry Courtney , Barrett Terrence 
Published: October 2019

INTRODUCTION:
5-Fluorouracil (5-FU), an antimetabolite used in the management of advanced gastrointestinal cancers, is often complicated by the development of colitis with several reported cases. However, there has been no report of new onset ulcerative colitis (UC) following 5-FU-based chemotherapy. We report a case of 5-FU-induced UC in a patient with no previous personal or family history of inflammatory bowel disease (IBD).

CASE DESCRIPTION/METHODS:
A 60-year-old Caucasian female presented to the emergency department with 1-month history of diarrhea, abdominal pain, nausea and vomiting. Her past medical history is notable for hypertension, gastroesophageal reflux disease and recently diagnosed stage III invasive cecal adenocarcinoma for which she had right-sided hemicolectomy 3 months prior. She also received 3 cycles of adjuvant chemotherapy (folinic acid, fluorouracil and oxaliplatin) with the last cycle being five weeks ago. She had no previous history of colitis or IBD and had been asymptomatic prior to receiving chemotherapy. She was afebrile, mildly tachycardic with moderate tenderness in bilateral lower abdominal quadrants. Apart from anemia, her labs including stool studies and dihydropyrimidine dehydrogenase test were normal. She had little response to conservative management with fluids, antidiarrheals and antibiotics. Colonoscopy showed diffuse severe mucosa inflammation and ulceration with histology suggestive of an emerging IBD and negative for CMV. Fecal calprotectin was significantly elevated. Following minimal improvement with mesalamine and confirmation of UC by serology, she was started on steroids, azathioprine and infliximab with subsequent abatement of symptoms.

DISCUSSION:
Colitis is a significant gastrointestinal complication of chemotherapy. The four most common chemotherapy-induced colitis subtypes in the literature are neutropenic enterocolitis, pseudomembranous colitis, ischemic colitis and anti-CTLA4 antibody enterocolitis. 5-FU is a potent cause of colitis and majority of cases resolve with cessation of chemotherapy and supportive treatment. UC may be considered as a complication of 5-FU especially in the presence of corroborative laboratory, imaging and endoscopic features as well as poor response to conventional management. In addition to withdrawal of chemotherapy, treatment should be initiated per standard management of UC. Benefits and risks of biologic therapy should be thoroughly assessed. This case illustrates the rare potential for UC following 5-FU-based chemotherapy.
3071 A Rare Case of Colonic Mucosal Schwann Cell Hammartoma That Mimics a Regular Polyp
Authors: Shahbazi Shandiz , Higley Cory , Choden Tenzin , Pang Maoyin 
Published: October 2019

INTRODUCTION:
Mucosal Schwann cell hammartomas are considered benign and were rarely reported as an incidental finding during colonoscopies. There is a lack of data on outcomes and surveillance guidelines due to the rarity of these unusual polyps. Here we report a case of colonic mucosal Schwann cell hammartoma incidentally found in a patient with intermittent diarrhea to enhance recognition of this rare lesion.

CASE DESCRIPTION/METHODS:
A 70-year-old-male with history of venous thromboembolism in setting of Factor V Leiden mutation on rivaroxaban had presented to our gastroenterology clinic complaining of chronic intermittent diarrhea without pain, hematochezia, melena, upper GI symptoms, or weight loss. To further evaluate ongoing diarrhea, the patient had a colonoscopy that showed patchy erythematous mucosa of the sigmoid colon with a single polyp measuring 4 mm at the descending colon, which was removed with a cold snare. The polyp showed focal expansion of the lamina propria by a bland spindle cell proliferation (Schwann cells) with no evidence of atypia or mitotic figures. No ganglion cells were noted and by immunostaining the spindle cells were strongly immunoreactive for S100 (Figure 1). Neuron-specific enolase (NSE) and synaptophysin were negative supporting the absence of ganglion cells. The immunoprofile and morphology was consistent with a diagnosis of mucosal Schwann cell hamartoma. Random colon biopsies ruled out microscopic colitis. Follow up visits were suggestive that food intolerances were the likely cause of his intermittent diarrhea.

DISCUSSION:
Benign nerve sheath tumors are mostly seen in the stomach and are rare in the rest of the gastrointestinal tract. The differential diagnosis is wide including neurofibromas, perineuromas, ganglioneuromas, granular cell tumors, gastrointestinal stromal tumors, carcinoid, and leiomyoma. Although there are common histological features of neural tumors, the immunostaining pattern is necessary to differentiate them from one another. Due to its rare occurrence, the exact incidence and prevalence of mucosal Schwann cell hammartoma is unknown. This distinction is important as this lesion has no association with any inherited polyposis syndrome and has a benign clinical course.
3075 Initial Presentation of Advanced Colorectal Cancer in the Cecum Presenting With Mild Tenesmus
Authors: Pacha Faris , Skrove Jamie L. , Sobrado Javier 
Published: October 2019

INTRODUCTION:
Colorectal cancer (CRC) is a lethal disease. 140,250 new cases of large bowel cancer are diagnosed annually in the USA including 97,220 colon and 43,030 rectal cancers. 50,630 Americans are expected to die of large bowel cancer each year. CRC is the third most common cause of cancer death in the USA in women, and the second leading cause of death in men. Common symptomology include change in bowel habits (74%), rectal bleeding with change in bowel habits (71%), iron deficiency anemia (21%). Appendicitis as the initial symptom of CRC is less than 1% for individuals over 40.

CASE DESCRIPTION/METHODS:
Patient is a 52 year old man who presents to our facility for general abdominal pain and tenesmus for three months. The patient has no family history of CRC nor colonoscopy. In the ED routine labs negative Imaging revealed acute appendicitis. Laparoscopic appendectomy was performed and the patient was discharged the following day. Patient returned two months later with complaints of tenesmus and abdominal pain. In the ED acute microcytic anemia was discovered. CT Abdomen and pelvis demonstrated diverticulosis without diverticulitis and FOBT positive. Colonoscopy performed and findings consisted of: large 6 cm cecal mass, biopsies taken, 8 mm polyp in transverse colon removed with cold snare, two 5-7 mm polyps in the ascending colon removed by cold snare, and 4 cm polyp removed via the hot snare in the descending colon. The patient then underwent colonic resection of the mass by general surgery.

DISCUSSION:
What is learned from this case is the importance of CRC screening and rare initial symptom of CRC of appendicitis in a male over the age of 40. The patient is 52 years old with without having CRC screening and acute appendicitis. Had the patient had his diagnostic colonoscopy at the age of 50 the cecal mass would have been discovered sooner and treatment could have been initiated. Another aspect of this case that makes it unusual was the patient did not have any of the more common symptoms of CRC. Our patient presented with general abdominal pain and tenesmus and the latter accounts for less than 1% of all symptomatology along with acute appendicitis. The patient did not have any of the “alarm” symptoms and if not for the appendicitis diagnosed in the hospital the patient “had no intentions” of doing CRC screening. The patient explains he had no family history of gastric or colon cancers, “So why bother?” The acute appendicitis from the cecal mass proved to be critical in the initiation of treatment.
3085 Delayed Diagnosis of Cecal Adenocarcinoma in a Premenopausal Female
Authors: Saliaj Merjona , Ahmad Jan Sayed Tauseef , Saeed Mariam , Khan Zinobia 
Published: October 2019

INTRODUCTION:
Cecal adenocarcinomas can present with anemia and non-specific abdominal symptoms. It is a rare colon cancer associated with aggressive course and poor outcomes. In premenopausal women it can be masked by other gynecological pathologies, resulting in delayed diagnosis and poor outcomes.

CASE DESCRIPTION/METHODS:
A 48 yo Hispanic female presented with acute onset nausea, vomiting and epigastric pain radiating to the right lower abdominal quadrant (RLQ). Her past medical history included active smoking, overactive bladder syndrome, sickle cell trait, hirsutism, uterine fibroids with chronic menorrhagia, constipation, and chronic iron deficiency anemia (IDA). In addition, she had multiple visits to the emergency room with similar symptoms. Prior work up was remarkable for microcytic hypochromic anemia with Hgb of 7.4, Hct of 24 and MCV of 62, severe iron IDA with ferritin 6, total iron 26, TIBC 358, iron saturation 7.3, normal LDH and reticulocyte count. Stool occult was negative. Her usual symptoms were attributed to either gynecological etiologies or her chronic constipation. During this admission her CT abdomen was consistent with acute appendicitis. However, laparoscopy revealed a right colon mass requiring hemicolectomy. Pathology report confirmed grade II cecal adenocarcinoma stage pT3, pN2a.

DISCUSSION:
IDA in men prompts extensive workup for colon cancer. In contrast in women it is normally attributed to gynecological/benign gastrointestinal (GI) conditions resulting in delayed diagnosis. Most of the times IDA can be the only manifestation of right sided colon cancer. In the last years, our patient had persistent abdominal discomfort which were attributed to either uterine fibroids or iron supplement induced constipation. Stool occult test was negative correlating with its low sensitivity, especially in small amounts of bleeding. Many pelvic ultrasounds were done but no advanced investigation was considered to evaluate her GI symptoms. Her anemia was always assumed to be secondary to menorrhagia, which confounded the clinical judgment and underestimated the diagnosis of colorectal cancer. This case illustrates the need for low threshold in screening for colorectal malignancies especially in premenopausal women in which anemia can be overlooked as caused mainly by gynecological conditions.
3092 A Clinically Confounding Presentation of Dysphagia With Multiple Valid Etiologies
Authors: Harriss Patrick B. , Roussel Jordan , Chiu Yiu-Ting , Pandit Sudha , Morris James D. , Jordan Paul 
Published: October 2019

INTRODUCTION:
Dysphagia may result from a variety of different disease processes, including inflammation, infection, motility disorders, mechanical causes, or even functional. The etiology is less clear when a patient presents with multiple individual causes of dysphagia, each alone which may account for their symptoms. Our case report describes the coexistence of dysphagia due to several factors in a single patient, and a puzzling presentation warranting further evaluation to ultimately alleviate the underlying complaint.

CASE DESCRIPTION/METHODS:
We present a case of a 62-year-old female with a past medical history of hypertension that presented to her PCP with 6 months of weakness and limited oral intake. She endorsed issues swallowing and sensation of food stuck in her throat. Dysphagia to solids progressed to include liquids, and with nausea, vomiting, and 40 lbs unintended weight loss. The patient was admitted and failed bedside swallow study. Upper GI series and CT thorax showed hiatal and paraesophageal hernias. EGD revealed GE junction angulation from hernias, as well as esophagitis and gastritis. Manometry demonstrated weak swallows and sparse motility representative of a motility disorder. A gastric tube was placed for continued poor oral intake. She did not tolerate tube feeds, and gastric emptying study showed decreased emptying with marked GERD. EGD biopsies resulted and were consistent with eosinophilic esophagitis and H. pylori. She was prescribed triple therapy and started on PPI. She then had good symptom improvement and was discharged. At 6 week follow-up, the patient was able to tolerate oral intake and plans were initiated for gastric tube removal.

DISCUSSION:
Our patient exhibited numerous clinical findings that could account for her symptoms: esophageal herniations, eosinophilic esophagitis, H. pylori, an intrinsic motility disorder, and GERD. Though dysphagia has various etiologies, it is exceedingly rare for a single patient to display multiple simultaneous findings that might each individually explain their symptoms. Our case is unique in that the patient demonstrated sources from many different levels, yet given resolution with medication, likely originated from the primary eosinophilic esophagitis. Further investigation revealed the complexities of her case, and culminated in the eventual diagnosis, treatment, and symptomatic improvement. Our case also emphasizes the importance of thorough evaluation, as initial findings may be more complex than first realized.