bluuebunny/crossref_metadata_2025_split huggingface dataset:
1660 Malakoplakia of the Rectum Masquerading as a Tumor: A Case Report
Authors: Mashiana Simran , Ambelil Manju , Nair Varsha , Ko Huaibin Mabel , Harpaz Noam 
Published: October 2019

INTRODUCTION:
Malakoplakia is a rare inflammatory disorder that occurs in the clinical setting of persistent infections, immunosuppression and tumors. The most common sites of involvement are the urinary, gastrointestinal and respiratory tracts, skin, brain and lymph nodes where they can mimic malignancies.

CASE DESCRIPTION/METHODS:
A 60-year-old woman with myasthenia gravis and stage IV metastatic thymoma (status-post resection and chemo-radiation) presented with persistent weight loss, bloating, nausea, tenesmus and hematochezia. Her recent history included treatment-resistant Giardia lambia infection for one year as well as recently diagnosed Norovirus and Enteroaggregative Escherichia coli, diagnosed by stool pathogen PCR testing. On colonoscopy, the rectum contained a 7 cm region of polypoid, non-circumferential, non-obstructing nodules (Figure 1) which were highly suspicious for tumor. Microscopically, biopsies revealed rectal lamina propria infiltration by epithelioid cells with small central nuclei, eosinophilic cytoplasm (Figure 2) and lamellated cytoplasmic calcifications (Figure 3). The cells expressed cytoplasmic CD68 (Figure 2) and Von Kossa stain highlighted the calcifications, consistent with Michaelis-Gutmann bodies (Figure 3). Immunostain for pancytokeratin and Ziehl-Neelsen and Gomori's methenamine silver stains were negative. The final diagnosis was malakoplakia. A re-biopsy of the lesion showed positivity for Cytomegalovirus (CMV) immunostain and high levels of CMV viremia (1010IU/mL), for which she was treated with Gancyclovir.

DISCUSSION:
Malakoplakia is a rare gastrointestinal disorder without specific symptoms, endoscopic features or gross findings and tends to masquerade as a tumor. As illustrated herein, it is often an unexpected diagnosis that depends on pathological recognition of characteristic microscopic features. The correct diagnosis is critical to avoid inappropriate radical treatment. Various micro-organisms have been implicated in its development including bacteria, most commonly E. coli, viruses, fungi and even protozoa such as Taeniaspecies and it is characterized by defective bactericidal activity of the macrophages. Pathologists should be aware that malakoplakia can coexist with malignancy and tuberculosis, therefore, thorough sampling of mass lesions and appropriate adjunctive stains are advisable. Risk factors in our case included an immunocompromised state, multiple concurrent infections, and advanced malignancy, although no malignancy was identified in the biopsies.
1661 Colo-Colic Intussusception Secondary to a Large Submucosal Colonic Lipoma
Authors: Fazeli Cameron , Patel Harsh D. , Camero Alfredo , Gonzalez Lisandro , Campi Haisar Dao , Rosenkranz Laura 
Published: October 2019

INTRODUCTION:
Intussusception is telescoping of a proximal segment of bowel into the lumen of the adjacent distal segment of bowel. This condition is usually seen in the pediatric population and is most often due to a benign pathologic lead point. Intussusception remains a rare condition in adults, representing approximately 1–5% of mechanical bowel obstructions typically due to malignancy. We present a rare case of Colo-colic intussusception secondary to a sub-mucosal benign lipoma.

CASE DESCRIPTION/METHODS:
A 33-year-old Caucasian woman with no past medical or surgical history, presented with one month of intermittent left-sided and mid-abdominal cramping, which intensified the week prior to presentation. She reported increasing post-prandial pain with associated nausea and bloating. Physical exam revealed stable hemodynamics, and diffuse abdominal tenderness to palpation. Laboratory testing was unremarkable, including a serum pregnancy test. Contrasted CT Abdomen/Pelvis revealed intussusception of the mesenteric tissues and transverse colon into the descending colon with a discrete mass lesion as the lead point (Figure 1). A colonoscopy revealed a large, non-obstructing, hard, negative pillow sign, subepithelial mass, with a short stalk at the hepatic flexure was encountered (Figure 2). The patient underwent laparotomy by colorectal surgeon. A proximal transverse colon intussusception was identified and a right hemicolectomy with ileocolonic anastomosis was completed. Surgical pathology results revealed a 6.5 cm submucosal lipoma without evidence of dysplasia or malignancy (Figure 3). The patient recovered well post-operatively and was discharged.

DISCUSSION:
In adults, the diagnosis of intussusception can be difficult to make based on clinical presentation alone due to the rarity and non-specific complaints. The condition is commonly related to malignancy. Generally, colo-colic intussusceptions are the least common. Cross sectional imaging, such as CT scans with IV contrast are the most sensitive diagnostic tests. Our case identifies an uncommon cause of abdominal pain in an adult patient with the CT scan and diagnostic laparotomy revealing a colo-colic intussusception. In this fortunate case, pathology revealed a benign lesion as the lead point. Although colonic lipomas are common this patient has low risk factors such as age and no metabolic syndrome, they are often asymptomatic and have been rarely reported to cause similar presentations as they increase in size ( >4 cm).
1665 A Baffling Case of Gastrocolitis
Authors: Penninti Pranav , Lewis Megan , Diallo Souleymane Y. , Malakouti Mazyar , Echavarria Juan , Brady Charles 
Published: October 2019

INTRODUCTION:
Chronic mesenteric ischemia often has a subtle presentation requiring a high index of suspicion. Average time to diagnosis is 10.7 months, often delayed due to the vague nature of complaints. We present a challenging case of severe chronic mesenteric ischemia in a young woman.

CASE DESCRIPTION/METHODS:
A 42-year-old female smoker presented with abdominal pain, constipation, and >70-lb weight loss. She had developed black, watery stools one week prior. Vital signs were normal, BMI was 12.6. She was cachectic, had abdominal distention and tenderness worse in the right lower quadrant. A contrasted CT scan revealed a distended colon and large stool burden. She failed conservative management. Endoscopy revealed multiple Forrest III gastric ulcers (Figure 1) and deep cecal ulcerations (Figure 2) with normal TI. Biopsies showed inflammation with granulation tissue. Work up was negative for vasculitis and infection. She failed a steroid trial for a presumptive diagnosis of Crohn’s disease. CT enterography was normal. Repeat endoscopy showed persistent gastric ulcers. Biopsies revealed ischemic gastritis with associated ulceration and submucosal blood vessels with fibrin thrombi. A CT angiogram showed severe stenosis of the celiac artery and chronic occlusion of the superior mesenteric artery (Figure 3.) Endovascular celiac and SMA stenting failed requiring surgically-placed retrograde celiac and SMA stents. Her symptoms recurred due to celiac stent thrombosis and SMA stent migration to the left iliac artery. Finally, an antegrade supraceliac to celiac and SMA bypass was performed with excellent results.

DISCUSSION:
A high index of suspicion is required to diagnose chronic mesenteric ischemia. Risk factors include age > 60, female gender, history of PAD, CVD, or CAD. Typical symptoms include weight loss, postprandial pain, and diarrhea though most people are asymptomatic or present with atypical symptoms including nausea, vomiting, early satiety, or bleeding which often lead to misdiagnosis or delayed diagnosis. Management is aimed at preventing further bowel infarction via endovascular or open revascularization. Patients who fail stenting or angioplasty have a much higher risk of perioperative mortality during open repair (15% vs. 2%.) Our patient’s young age, normal initial CT abdomen, gastric and cecal ulcerations with lack of vascular disease history blurred the clinical picture. A high index of suspicion is required in patients with an initial negative work up.
1669 Cancer Within the Family Tree: The Risks, Diagnosis, and Treatment of Juvenile Polyposis Syndrome
Authors: Kozacek Kyler , Abdo Michael , Hudspath Caleb , Oroian Tudor , Manibusan Pedro , Goldwire Franklin 
Published: October 2019

INTRODUCTION:
Juvenile Polyposis Syndrome (JPS) is characterized by the development of numerous hamartomatous polyps in the GI tract, increasing individuals’ risk of colorectal and gastric cancer by as much as 68% by age 60. These odds are further compounded by the syndrome’s autosomal dominant (AD) mode of inheritance, placing children at a 50% risk of transmission from an affected parent. Bone Morphogenic Protein Receptor type-1A (BMPR1A) genes located on chromosome 10q22-23 are strongly associated with JPS, with nearly 60% of cases testing positive for the mutation. Effects of this anomaly cascade down the transforming growth factor-beta (TGF-beta) pathway, resulting in patients developing tens to hundreds of polyps within their lifetime, often by the first decade. Mutations in SMAD4 proteins can also lead to JPS and Hereditary Hemorrhagic Telangiectasia (HHT) as they are also vital in TGF-beta signaling. JPS is clinically diagnosed by the absence of other hamartomatous polyposis syndromes (eg, Peutz-Jeghers or Cowden) and the presence of either >5 juvenile polyps in the colorectum, multiple juvenile polyps elsewhere in GI tract, or any polyps with a family history of juvenile polyps.

CASE DESCRIPTION/METHODS:
A 41-year-old female with intermittent IBS symptoms presented for colon cancer screening. Two years earlier, the patient’s mother had been diagnosed at age 64 with multiple juvenile colon polyps and colon cancer testing positive for BMPR1A gene mutation. Patient’s initial colonoscopy revealed multiple 3–4 cm irregularly shaped pedunculated polyps, many less than 1cm and an irregularly shaped mass in the mid-ascending colon. The mass was circumferential, broad-based at 4–5 cm and nearly completely obstructing. Polyps removed revealed tubular adenomas and tubular villous adenomas. Though none of these were documented as juvenile polyps, the patient did test positive for BMPR1A mutation suggestive of JPS. The patient was referred to general surgery for resection of the mass and upper endoscopy.

DISCUSSION:
JPS is a rare polyposis syndrome with AD inheritance. In at-risk patients, it is imperative that genetic testing be performed to determine appropriate cancer screening. Testing should include both SMAD4 and BMPR1A gene mutations, with positive SMAD4 mutations undergoing evaluation for HHT. Current guidelines recommend screening the stomach and colon early, as the length of time to diagnosis remains the single most influenceable and impacting factor in the outcomes of patients and their families.
1672 Appearances Are Glimpse of the Unseen
Authors: Bhandari Sawina , Iqbal Sara , Hosseini-Carroll Pegah 
Published: October 2019

INTRODUCTION:
Breast cancer metastasis is seen in nearly 30% of cases. It most commonly spreads to the liver, brain, bones and lungs1,2. Gastrointestinal tract (GI) especially large bowel involvement is rare3,4. Usually diagnosed because of obstructive symptoms or bleeding. Endoscopic evaluation usually demonstrates obvious ulcerations, masses or stenosis. Finding a normal looking colon infiltrated by metastatic breast cancer cells is unique with incidence unknown5.

CASE DESCRIPTION/METHODS:
We report a case of a 69-year-old African American female with Stage 4 Invasive lobular left breast carcinoma with metastasis to bone and chronic disseminated intravascular coagulation who was admitted for GI bleeding. She underwent upper and lower endoscopies which were unrevealing for the cause of bleeding. Her upper scope revealed erythema in the stomach and duodenal villous blunting both of which were biopsied. Colonic mucosa looked congested and ulcerations were found in the terminal ileum which were also biopsied. These findings are not per literature review typical of metastatic breast cancer. To our surprise biopsies revealed metastatic lobular breast cancer infiltration in all samples collected from stomach, duodenum, terminal ileum and colon.

DISCUSSION:
Lobular breast carcinoma more commonly metastasizes to the gastrointestinal tract6 as compared to infiltrating ductal breast cancer. In instances that it does metastasize to the colon it shows obvious endoscopic findings which was not the case in our patient. Hence we purpose that vigilant sampling of tissue be performed in patients inflicted with this disease even with subtle findings on endoscopy.
1673 Multitarget Stool DNA Test (Cologuard™): A Double-Edged Sword
Authors: Mulat Baruh , Boroda Konstantin , Hertan Hilary 
Published: October 2019

INTRODUCTION:
Colorectal cancer (CRC) is the third most common cancer diagnosed in both men and women in the United States. Fortunately, early, precancerous lesions, can be caught early with proper screening, however, only approximately 60% of the US population gets screened. The multitarget stool DNA test (Cologuard™) is an alternative to colonoscopy that might help reach more patients. We present two cases of patients with positive Cologuard tests and unexpected outcomes which posed clinical challenges.

CASE DESCRIPTION/METHODS:
Case 1: A 63-year-old male who declined colonoscopy in the past opted for Cologuard, which was positive. Subsequent colonoscopy revealed several polyps including one measuring 3.5 cm in the proximal transverse colon, which was thought to be cancerous, so it was only biopsied and not removed (Figure 1). Biopsy of this polyp revealed hyperplastic changes necessitating another colonoscopy. However the patient remains lost to follow up. Case 2: A 75-year-old male, with history of stroke, ischemic heart disease, chronic constipation and no family history of CRC presented to gastroenterology clinic after he had a positive Cologuard test. Colonoscopy was performed revealing a normal colon without mass or polyps.

DISCUSSION:
The multitarget stool DNA (Cologuard™) is highly sensitive for detecting CRC at 92%. It is a convenient alternative for patients who do not want to undergo colonoscopy, however it can sometimes create clinical dilemmas as exhibited by our cases. In our first case Cologuard™ was able to detect a large right-sided polyp, the sensitivity for such polyps is 42%. This patient was very reluctant to undergo colonoscopy in the first place. He agreed to a noninvasive test, but it has proven difficult to get him back for another colonoscopy. This illustrates the potential ethical and medicolegal dilemmas that can arise when patients with positive stool-based tests are lost to follow up. These patients may be prone to defer colonoscopy due their initial reservations about the procedure. In our second case, the positive Cologuard™ with normal colonoscopy raises concern for a neoplasm elsewhere in the GI tract. Some gastroenterologists perform an EGD in this situation, while others do not. The reported false positive rate for Cologuard™ is 45%, however there are no guidelines for what should be done after a false-positive result. This is an area where further research is needed.
1674 Primary Anal Melanoma
Authors: Elfiky Ahmed , Krzyzak Michael , Mukherjee Indraneil , Holmes Nathaniel 
Published: October 2019

INTRODUCTION:
Primary anal melanoma is a rare and aggressive form of neoplasm account <2 % of all melanomas and <2 % of all anal tumors. Metastatic lesions from primary skin tumor are more common. In either case, diagnosis is challenging because often misdiagnosed as hemorrhoid. Surgical excision is the treatment of choice. We present a case of primary anal melanoma that treated with wide local excision and chemotherapy.

CASE DESCRIPTION/METHODS:
A 71-year-old Caucasian smoker male with history of hypertension, and bladder cancer in remission presented with anal discharge and tenesmus of two-month duration, not related to bowel movement. Pt denies pain, bleeding, change in bowel habits or diet. Physical exam including anoscopy revealed grade 2 internal hemorrhoid, external hemorrhoid, with 2 × 6 cm pedunculated freely mobile black rectal mass. Last colonoscopy was 8 years prior to the presentation within normal limits. Patient underwent a wide local excision of the mass. Pathology revealed invasive nodular melanoma. Patient underwent colonoscopy with endoscopic ultrasound that revealed no regional lymphadenopathy. patient was started on chemo therapy and adjuvant immunotherapy by oncologist. Patient was seen in follow up visit after eight months with negative metastatic work up.

DISCUSSION:
Malignant melanomas are the fifth leading cancer in men and the sixth in women in the United States. They are mostly cutaneous with non-cutaneous tumors being rare. Melanoma constitute 1% to 3% of all GI malignancies. It remains controversial as to whether these tumors are true primary tumor or they are metastases from unrevealed or regressed primary cutaneous melanomas. It is important to differentiate primary malignant melanoma from secondary lesions because of the worse prognosis of the first one; they are more aggressive and are usually diagnosed late. due to non specific presenting symptoms, more than 50% of patients have metastatic disease upon presentation. Surgical treatment remains the standard of care with controversy regarding the approach (wide local excision Vs. Abdominoperitoneal excision) depending on the stage of the disease.
1676 EFTR as a Means for Complete Resection for Adenomas
Authors: Yarra Pradeep , Kudaravalli Praneeth , Gabr Moamen 
Published: October 2019

INTRODUCTION:
Endoscopic full thickness resection (EFTR) is an alternative to Endoscopic Mucosal Resection (EMR) and Endoscopic Sub-mucosal Dissection (ESD) for non-lifting lesions or flat lesions and residual adenomas. The current guidelines dictate that any patient able to undergo endoscopic curative treatment should consider it as the first line it is safer and less costly while being equally effacious. Here we describe a case of a non-lifting lesion in the ascending colon at 22 millimeters (mm) of size whose resection was previously attempted by EMR.

CASE DESCRIPTION/METHODS:
66-year-old male with a past medical history of CAD s/p CABG, hypertension, hyperlipidemia, liver cirrhosis and diabetes mellitus presented for surveillance colonoscopy. Three months prior to this he had a piece meal EMR of a 22 mm flat Tubulo-villous Adenoma in the proximal ascending colon. After this a Colonscope was passed under direct vision. EFTR device was passed and when it reached the proximal ascending colon, the previously placed tattoo was seen. A post-polypectomy scar was found between the tattoos. This was a non-lifting lesion and was granular lateral spreading and 22 mm in size. Thermal marking was placed and an Ovesco clip was now passed. Ovesco clip was deployed and using a snare within cap technique a full thickness resection of 22 mm was performed.

DISCUSSION:
ESD and EMR have enabled en bloc R0 curative interventions. FTRD is useful in situations where ESD and ESR fail to achieve a R0 resection. Recent study published by Kuellmer et al showed a technical success rate of 90% and a R0 resection rate of 77%. The limitation in terms of size is the most important one where the snare cannot be used as effectively for lesions more than 20 mm of size. Improvements in FTRD technology in regards to the snare size in the future will allow clinicians to pursue FTRD in these cases. We suggest close follow up for any patient who has a lesion resected on scar tissue due to the reoccurrence at sites where FTRD was done as was seen in the study published by Kuellmer et al.
1695 Removal of a Retained Biliary Stent in a Liver Transplant Patient Secondary to Biliary Cast Syndrome Using Digital Cholangioscopy and Electrohydraulic Lithotripsy
Authors: Koneru Gopala K. , Shah Ishani , Kantamaneni Vamsi , Gavini Hemanth , Peck Joshua R. 
Published: October 2019

INTRODUCTION:
We describe the use of electrohydraulic lithotripsy(EHL) in conjunction with digital cholangioscopy which was used effectively to treat a retained intraoperative biliary stent in a liver transplant patient due to biliary cast which spared the patient from surgery.

CASE DESCRIPTION/METHODS:
A 72-year-old male who received an orthotopic liver transplant for end stage liver failure secondary to cirrhosis due to nonalcoholic steatohepatitis and hepatocellular carcinoma which was complicated by hepatic artery thrombus that ultimately required a second liver transplant with a pediatric feeding tube placed intraoperatively as an internal stent to prevent anastomotic stricture of the bile duct. Approximately eight years later, the patient presented to an ER with altered mental status and elevated liver enzymes. A computed tomography of abdomen and later a magnetic resonance cholangiopancreatography was done which showed an intra and extrahepatic biliary ductal dilation of the common hepatic and duct debris indicative of obstruction (Figure 1a,b). Endoscopy showed an enlarged prominent major duodenal papilla with a biliary stent which was visibly occluded (Figure 2). Attempted removal of stent was unsuccessful and a new plastic biliary stent was placed beside the impacted stent to relieve the obstruction. One month later, the new plastic biliary stent was removed and digital cholangioscopy was used to visualize the the bile duct which showed the endobiliary stent was embedded in stony material that was adherent the duct walls. Cholangioscope was slowly advanced from distally to proximally along the encased stent with the use of EHL which sequentially broke up the surrounding stony material. One half of the stent was stripped and the process was repeated on the other side until the stent was free floating. The stent was then successfully removed using rat-toothed forceps (Figure 3).

DISCUSSION:
This case demonstrated that cholangioscopy with lithotripsy can be used to treat an impacted stent in a liver transplant patient due to biliary cast. This is an unusual case as the intraoperative stent was found to be retained and the timeline of 8 years since liver transplant till presentation of biliary cast syndrome is one of the longest reported in the literature. We demonstrated a novel technique by fragmenting the cast of the encased stent from distally to proximally in order to disimpact the stent and this technique used may be applied to other challenging cases where standard methods have failed.
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