bluuebunny/crossref_metadata_2025_split huggingface dataset:
1823 Esophagitis in Immunocompromised Patient From Strongyloides Reactivation
Authors: Zivari Kaveh , Yunina Daria , Grunwald Matthew , Azar Omar , Tin Kevin , Rahmani Rabin 
Published: October 2019

INTRODUCTION:
Strongyloides Stercoralis infection affects as many as 30 million people in 70 countries worldwide. It also can undergo cycles of autoinfection leading to chronic disease. This infection is usually asymptomatic and may remain undetected for decades. However, in patients who are immunocompromised, such as patient’s undergoing chemotherapy, receiving long-term corticosteroids, transplant patient, or patient with HIV; severe infection can occur and result in mortality rates as high as 87%. Strongyloidiasis is difficult to diagnose as the parasite load is low and the larval output is irregular.

CASE DESCRIPTION/METHODS:
79-year-old Chinese migrant man with metastatic lung adenocarcinoma who was recently started on Erlotinib, presented with nausea, vomiting, diarrhea, generalized weakness, and epigastric pain. He had White Blood Cell count of 7.6 with 6.6% Eosinophils. X-ray and Computed Tomography imaging did not show any changes from prior studies. Esophagogastroduodenoscopy was performed afterwards which showed esophagitis, gastritis, duodenal ulcer and duodenitis. Subsequently, biopsies of the duodenal and esophageal mucosa revealed parasitic larvae consistent with Strongyloides Stercoralis (Figure 1). The patient was started on Ivermectin and had resolution of his symptoms on follow up. Erlotinib was resumed after discharge.

DISCUSSION:
Although differential diagnosis for esophagitis in immunocompromised patients is broad, our patient was interestingly diagnosed with Strongyloides induced esophagitis via biopsy. The larvae of Strongyloides have potential ability to invade and survive for extended periods in human tissue. They have obligatory tissue phase in which the larvae follows from the portal of entry and eventually to trachea and lung. Depressed cell-mediated immunity secondary to malignant tumor, combined with protein-calorie malnutrition, led to lack of granulomatous immune response to larvae in our patient. Several immunodiagnostic assays have been found ineffective in detecting disseminated infection. Although it is important to detect latent S. Stercoralis infections before administering chemotherapy or before the onset of immunosuppression in patients at risk, a specific and sensitive diagnostic test is lacking. When acute esophagitis does present, it may be severe and disabling, and could result in hospitalization, placement of a feeding tube in the stomach or parenteral nutrition, and steady supportive care. Biopsy, cytology, and culture are recommended for suspected cases.
1826 74-Year-Old Man With Esophageal Adenocarcinoma and Right Sided Weakness: Is Brain Involved?
Authors: Omar Abelardo Escriba , Bashashati Mohammad , Moreno Jorge , Deoker Abhizith , Corral Javier 
Published: October 2019

INTRODUCTION:
Esophageal cancer with an incidence of 4.3 per 100,000 per year and a death rate of 4.0 per 100,000 per year accounts for about 1% of all cancers diagnosed in the US. Within the past four decades, while the incidence of esophageal cancer has remained stable in the US, an increasing trend for the adenocarcinoma form has been observed in men mainly due to increased obesity and gastroesophageal reflux disorders. Remarkably, Hispanic-Americans have a lower rate of esophageal cancer. Brain metastasis from esophageal cancer is an extremely rare condition with an incidence of 0.6-1.5%. Here we report a Hispanic-American white patient with brain metastasis from esophageal adenocarcinoma.

CASE DESCRIPTION/METHODS:
74-year-old Hispanic man with history of esophageal adenocarcinoma status post chemo-radiation with resection and gastric pull-through was referred to our hospital 4 years after surgery due to progressive left upper and lower extremity weakness, left facial droop and slurred speech for almost a month. He denied any prior history of headache, trauma, weakness or falls. Brain MRI showed a 61.6 x 47.3 x 45.0 mm heterogeneous/enhancing/intra-axial tumor projected at the level of the right supramarginal gyrus, and another smaller 9 mm intra-axial enhancing lesion in the medial aspect of the right superior temporal gyrus associated with perilesional vasogenic edema and 12 mm right to left midline shift (Figure 1). CT thorax, abdomen and pelvis did not reveal any mass or lymphadenopathy. The patient underwent a right-sided temporal craniotomy for resection of the temporal hemorrhagic tumor with a moderately hard capsule and significant fibrous adhesions invading the M2 branch of the middle cerebral artery with a small rim of tumor left along the back of the middle cerebral artery. He was scheduled for Whole Brain Radiation Therapy (WBRT) showing an improvement in his muscular strength. Pathology report demonstrated metastatic brain adenocarcinoma from the esophagus (Figure 1).

DISCUSSION:
Brain metastasis is a rare condition which should be suspected in patients with esophageal cancer and neurological manifestations. Routine preoperative neuroimaging is not recommended for identification of occult brain metastasis in esophageal cancer rather than in those with a primary esophageal tumor of >8 cm in diameter. Prognosis of this condition is overall poor and treatment should be personalized based on the patient’ general condition. When brain mass is resectable, surgery followed by WBRT is recommended.
1827 Concurrent Barret’s Esophagus and Esophageal Varix With Resolution After Banding
Authors: Rivera Arturo Suplee , Rapoport Grigoriy , Castano Juan J. , Zamir Asif , Nathani Muhammed 
Published: October 2019

INTRODUCTION:
Barret’s esophagus with dysplasia is a premalignant condition frequently treated with radiofrequency ablation. However, the management of concurrent dysplasia with esophageal varices (EV) is not defined. Medical literature on this topic is scant and consists of a few case reports. The following is a case of Barret's esophagus with low grade dysplasia and concurrent esophageal varices, successfully treated with band ligation.

CASE DESCRIPTION/METHODS:
The patient is a 50-year-old man with a history of liver cirrhosis, who presented to our gastroenterology clinic for routine evaluation. His only complaint was chronic heartburn. EGD was significant for grade I esophageal varices and a small segment of columnar epithelium on a variceal segment. Biopsy results were positive for BE with low grade dysplasia. The patient was started on a proton pump inhibitor and scheduled for follow-up. Patient was placed under surveillance with annual EGD. Frequent discussions were held regarding the risks vs benefits of the different treatment options. Next endoscopy revealed progression of his EV to grade II and a persistent area of columnar epithelium on one of the varices. A decision was made to band 2 varices, including the one with Barrett’s epithelium. Repeat endoscopy one year later demonstrated complete resolution of both, the varix and the columnar epithelium. Biopsy was negative for dysplasia and metaplasia. Ten years later, with yearly follow-up, endoscopy continues to be unremarkable in the banded segment.

DISCUSSION:
Epidemiology of BE and its relationship with adenocarcinoma has been extensively described in literature, however it is unknown what percentage of these patients have underlying liver cirrhosis with complications such as EV. This maybe be due to decreased life expectancy of these patients and the lack of routine endoscopic screening.We expect to face more of these challenging cases due to improved life expectancy of cirrhotic patients and the more readily available screening, such as endoscopic procedures for esophageal varices. Our case presents a novel method of treating this unique and difficult clinical scenario. However, we need more cases to validate our work.
1829 A Case of Poorly Differentiated Neuroendocrine Neoplasm of the Esophagus
Authors: Gala Khushboo , Hassan Syed , Parajuli Dipendra 
Published: October 2019

INTRODUCTION:
Esophageal cancer is a growing public health concern, with its prevalence expected to increase by 140% in the next 10 years. The most common types of esophageal tumors include squamous cell carcinoma and adenocarcinoma, which account for more than 95% of cases, however there are some rarer types of esophageal tumors. We describe a case of poorly differentiated neuroendocrine cancer of the esophagus.

CASE DESCRIPTION/METHODS:
A 51-year-old Caucasian male with past medical history of hypertension presented with upper abdominal pain for a month. CT abdomen revealed a large 4.5 x 3.5 cm mass in the gastrohepatic region, which prompted endoscopy. He was found to have an ulcerated, cratered 3.5 cm lesion at the mid esophagus on a background of salmon colored mucosa. Pathology showed a poorly-differentiated neuroendocrine carcinoma on a background of Barrett's esophagus, with positive CAM5.2 cytokeratin and CD56 markers and a Ki67 index of 90%. Staging PET-CT showed metastatic lymph nodes in mediastinum and abdomen, as well as metastatic involvement of liver. He was started on systemic chemotherapy with etoposide and cisplatin, and is following with outpatient oncology for further management.

DISCUSSION:
Neuroendocrine neoplasms (NEN) of the esophagus are very rare, representing only 1% of esophageal malignancies. As in our case, NENs usually occur in older individuals and more commonly in men. Like most esophageal malignancies, they present with dysphagia, abdominal pain, systemic symptoms and at late stages, obstruction; notably, they rarely secrete hormones. On endoscopy, they are usually seen as a subepithelial lesion: a polypoid, nodular elevated lesion with smooth and glistening overlying surface. Diagnosis is made on biopsy, showing the characteristic neuroendocrine cells with abundant neurosecretory granules, which have positive immunohistochemical expression of neuroendocrine markers like synaptophysin and chromogranin. Prognosis depends on the extent of metastasis, determined by cross-sectional imaging and PET-CTs. In general, small superficial NENs < 1 cm can be managed by endoscopic mucosal resection/dissection and NENs >2 cm are treated with surgical resection. For metastatic disease, like in our case, chemotherapy is administered with a combination of platin salts and etoposide. The prognosis for these large tumors remains poor; however rising prevalence of these pathologies warrants a high level of awareness of the condition with treatment options.
1831 Pericardioesophageal Fistula Formation Following Ventricular Tachycardia Ablation: Case Presentation With Discussion of Incidence and Treatment
Authors: Shams Christienne , Patwardhan Soumil , Kulesza Gregory 
Published: October 2019

INTRODUCTION:
Cardioesophageal fistulas following radiofrequency ablation (RFA) for atrial fibrillation is a rare but increasingly recognized complication of the procedure with an estimated annual incidence rate of 0.03-0.04%. While atrioesophageal fistulas require surgical management, pericardialesophageal fistulas can often be conservatively managed. The fistula formation is believed to be due to the inflammatory cascade initiated from thermal injury and subsequent degradation of tissue boundaries. Though reported following atrial ablation, it has not been reported with ventricular ablation. Here, we present a case of pericardioesophageal fistula following RFA for ventricular tachycardia.

CASE DESCRIPTION/METHODS:
61-year-old male presented to the emergency department complaining of fever, chest pain and dyspnea following inferolateral wall ablation and scar homogenization two weeks prior. He had a history of cardiomyopathy with AICD placement and refractory ventricular tachycardia due to ischemic heart disease. CT angiogram ruled out PE but demonstrated a pneumopericardium, later confirmed by echocardiogram. He subsequently developed signs of sepsis with profound hypotension requiring pressor support and underwent a pericardial window and indwelling pericardial drain placement. Due to fibrinous septations, tPA was infused to facilitate the purulent drainage. Fluid cultured from the pericardial window grew Staphylococcus epidermis and gram-negative bacilli. EGD was preformed with a 2 cm diameter pericardioesophageal fistula 4 cm above the GE junction and 36 cm distal to the incisors. He had a fully covered esophageal stent placed given poor nutritional status and poor surgical candidacy. His hospital course was further complicated by vent dependent respiratory failure, acute renal failure, recurrent DVTs with an upper GI bleed due to a contained rupture of an esophageal hematoma necessitating the placement of an IVC filter. Follow-up endoscopy two months following placement demonstrated stent migration but a healed pericardioesophageal fistula.

DISCUSSION:
This case demonstrates the importance of considering pericardioesophageal fistula as a complication of ventricular ablation. Treatment options are variable and they are often managed endoscopically as a temporizing measure until surgery can be safely performed. Here, we report the first case, to our knowledge, of pericardioesophageal fistula following ventricular ablation successfully managed with supportive measures.
1836 The Bougie Cap: A Novel Device for Treatment of Esophageal Strictures
Authors: Ramrakhiani Hannah , Triadafilopoulos George 
Published: October 2019

INTRODUCTION:
Treatment of high cervical esophageal strictures can be technically challenging. Placement of endoscopic balloons across the stricture may not be feasible due to their proximal location. Serial dilation with the use of Savary-Gilliard dilators is a well-established method for treatment of these strictures. However, this technique does not allow for direct optical feedback during dilation. We present a case of benign cervical esophageal stricture treated with a novel method utilizing the BougieCap (Ovesco Endoscopy AG).

CASE DESCRIPTION/METHODS:
A 62-year-old male presented with dysphagia. He had a prior history of peptic stricture at the gastroesophageal junction, treated with multiple balloon dilations that was complicated by an esophageal perforation. Patient underwent an emergent thoracotomy, esophagectomy, and gastric pull-up with placement of a feeding jejunostomy. Four months after surgery, he noted recurrence of dysphagia, with food getting lodged in the area below his throat and upper chest. Barium swallow revealed a tight stricture at the anastomosis that narrowed the lumen down to 5 mm in size. Upper endoscopy confirmed a stricture located 18 cm from the incisors. Using an endoscopic BougieCap the stricture was dilated serially from 7 to 12 mm in size with good results. Expected mucosal disruption was identified at the end of the procedure. On follow up, patient reported significant improvement in his symptoms without any complications.

DISCUSSION:
Use of Savary-Gilliard Dilators for stricture dilation provides only haptic control and often requires the use of fluoroscopic guidance. Our case highlights the use of a novel device - the BougieCap - for treatment of esophageal strictures which allows for direct visual control and optical feedback during the procedure. Ability to visualize the tension on the tissue while passing the stricture with the cap avoids overstretching and may help reduce the risk of complications, allowing for a more effective procedure. Moreover, by eliminating the need to switch instruments, the use of BougieCap can reduce procedure times. Additional prospective studies with a larger number of patients and long-term follow-up are necessary to determine its safety and long-term efficacy.
1837 Potassium-Binding Resin Induced Esophageal Pseudo-Tumor
Authors: Chavez Luis O. , Bustamante Marco A. , Padilla Osvaldo , Gavito-Higuera Jose , Zuckerman Marc J. 
Published: October 2019

INTRODUCTION:
Sodium Polystyrene Sulfonate (SPS) is a resin used to treat patients with hyperkalemia. It has been associated with several gastrointestinal complications, most commonly colonic necrosis. Patients with certain comorbidities are at risk for gastric and esophageal lesions. We describe a case with unusual endoscopic findings secondary to SPS-induced mucosal injury.

CASE DESCRIPTION/METHODS:
An 83-year-old male with a medical history of coronary artery disease presented with a 1-month history of progressive dysphagia, vomiting, cough, melena and a 25 pound weight loss. He denied any home medications, but in a recent hospitalization patient received antibiotics for pneumonia and prolonged treatment with SPS for hyperkalemia. Physical examination was remarkable for tachycardia (110 bpm), and a cachectic appearance. Laboratory results showed a white blood cell count of 8080/mm3, hemoglobin of 9.3 g/dl, mean corpuscular volume 92.8 fl, platelets 432,000/mm3, and a potassium of 5.7 mEq/L. A chest CT without contrast revealed a dilated esophagus with an achalasia-like appearance and a focal region of wall thickening adjacent to the gastroesophageal junction. (Figure 1) An esophagogastroduodenoscopy (Figure 2) was performed showing diffuse severe congestion, erythema, and deep ulcerations in the esophagus. A partially obstructing mass in the lower third of the esophagus was identified. Biopsies were obtained and a nasogastric tube (NGT) was placed for nutrition support. Histopathology showed esophageal squamous mucosa with foci of mixed acute/chronic inflammation and basophilic rhomboid crystals forming a mosaic pattern (consistent with SPS crystals). (Figure 3) Patient was started on omeprazole 40 mg twice a day through the NGT resulting in mild improvement of symptoms.

DISCUSSION:
We present a case of esophageal mucosal injury secondary to SPS mimicking an esophageal carcinoma. The mucosal changes are secondary to prolonged exposure of SPS to the epithelium causing ischemic necrosis. The identification of basophilic crystals in the epithelium with surrounding inflammation is a hallmark of SPS-induced mucosal injury. SPS esophagitis may affect the entire or distal esophagus. Findings of mucosal thickening and cobblestone appearance are usually present. Other endoscopic findings may mimic different conditions such as Candida esophagitis or gastric bezoar. In our case, the deep ulcerations, extensive inflammation and the mass-like thickening of the mucosa imitated an esophageal carcinoma.
1840 Salivary Gland Choristoma: A Rare Finding at Gastroesophageal Junction
Authors: Comba Isin Y. , Henriquez Richard , Kumar Sundeep , Merino-Chavez Hilda , Wallis-Crespo Maria , Cooper Christopher , Bhatia Lakhinder 
Published: October 2019

INTRODUCTION:
Choristoma is tumor-like outgrowth of heterotopic and mature tissue located at anatomically unusual sites. Heterotopic salivary gland tissue (HSGT) has been most commonly described in head and neck region but can rarely involve gastrointestinal (GI) tract with a few cases reported in the literature.

CASE DESCRIPTION/METHODS:
An 87-year-old female with past medical history of gastroesophageal reflux disease (GERD), hypertension, and chronic kidney disease was admitted for an acute DVT. Due to worsening anemia, she underwent an upper endoscopy that showed a small nodularity at the GE junction (Figure 1a), a large hiatal hernia, and reflux esophagitis in the lower one-third of the esophagus (Figure 1b). Biopsy of the nodule demonstrated an esophagogastric junction-type mucosa with mild to moderate chronic inflammation, mild acute inflammation and focal glandular tissue consistent with heterotopic salivary gland tissue (Figure 1c, d). No intestinal metaplasia or dysplasia were noted.

DISCUSSION:
Salivary gland choristoma at the gastroesophageal junction (GEJ) is an extremely rare entity, with only one case reported in the English literature. Additionally, two other cases of HSGT at GEJ not in the form of choristoma were described in the same report. All of the cases had a medical history of GERD. One of the HSGT cases had reflux esophagitis while the other had Barret’s esophagus with high-grade dysplasia. Similarly, our patient had a history of GERD with reflux esophagitis. She was diagnosed incidentally, through an EGD-guided biopsy of the nodule to exclude malignancy. It is well-known that intestinal columnar metaplasia at the GEJ can occur secondary to chronic acid exposure and inflammation in the setting of GERD. The origin of these intestinal glandular cells remains unknown. Furthermore, pancreatic acinar metaplasia at the GEJ is a relatively common finding, but the causative relationship between GERD and pancreatic acinar metaplasia is obscure. Salivary gland choristoma of the GEJ could be a metaplastic change in the setting chronic inflammation as a result of reflux esophagitis. However, the biological and clinical significance of this finding is yet to be investigated.
1842 Retroperitoneal Fibrosis: A Presenting Symptom of Esophageal Adenocarcinoma
Authors: Dhanani Zehra , Madanchi Nima , Dia Sunita , Distajo Ronald 
Published: October 2019

INTRODUCTION:
Retroperitoneal fibrosis can be idiopathic or secondary to drugs, infections, radiotherapy, surgery, trauma, amyloidosis, or malignancies. There are very few reported cases of retroperitoneal fibrosis related to esophageal cancer and none of them have reported retroperitoneal fibrosis as the presenting feature of esophageal adenocarcinoma.

CASE DESCRIPTION/METHODS:
A 68-year-old female with a past medical history of psoriasis and type-one Chiari malformation presented with one month of progressive abdominal and lower back pain. CT abdomen pelvis revealed inflammatory changes around the aorta, celiac artery, SMA and renal artery with severe narrowing of both renal veins and near obliteration of the IVC. Infectious work-up including TB, Syphilis, Hepatitis B and C, and rheumatologic work-up including ANA, ENA, RF, CCP and IgG4 were negative. Patient continued to have worsening symptoms and worsening kidney failure despite bilateral nephrostomy, high-dose steroid and empiric antibiotics. Eventually, patient underwent upper endoscopy for episodes of bilious vomiting which revealed esophagitis and nodularity in lower third esophagus. Esophageal biopsy showed poorly differentiated adenocarcinoma. Retroperitoneal biopsy also demonstrated the same morphological features consistent with an esophageal source.

DISCUSSION:
To the best of our knowledge, this is the first report of an esophageal adenocarcinoma presenting with retroperitoneal fibrosis with complete absence of dysphasia, odynophagia and weight loss. Patient did not experience any GI symptoms until late in the disease course. Malignancy-related retroperitoneal fibrosis can be secondary to either metastasis/invasion from a solid tumor or due to release of fibroblast-stimulating cytokines. Cytokine release is most commonly seen in carcinoid tumors. It is associated with poor prognosis. The nonspecific presenting symptoms, as witnessed in our patient, make it difficult to reach a diagnosis. By the time the patient has more clear symptoms of malignancy, it is often too late for curative treatment. There is currently a lack of effective therapies to treat retroperitoneal fibrosis. Corticosteroids are commonly employed in idiopathic cases however their use in malignancy-related cases has not been effective. Palliative chemotherapy or surgery might be effective for symptomatic management. In conclusion, we recommend considering esophageal cancer as a differential diagnosis in unexplained retroperitoneal fibrosis.