bluuebunny/crossref_metadata_2025_split huggingface dataset:
2537 Case of an Incidental Small Bowel Adenocarcinoma Upon Surgical Evacuation of a Retained Video Capsule Endoscopy in a Patient With Crohn's Disease
Authors: Moon Nabeel 
Published: October 2019

INTRODUCTION:
Here we report the case of a patient with Crohn's disease in whom a video capsule got lodged in a small bowel stricture and upon surgical evacuation of the capsule small bowel adenocarcinoma was incidentally found. This case emphasizes that it is important to consider small bowel adenocarcinoma in Crohn's disease patients with obstructive signs. This case also demonstrates the management of a retained capsule in Crohn's patients.

CASE DESCRIPTION/METHODS:
A 28 year old male with history of Crohn's disease presented for an evaluation of bright red blood per rectum and severe anemia. Initial evaluation with a colonoscopy and EGD revealed no source of bleeding and thus a video capsule was placed. Two days after placement of the capsule the patient began having severe abdominal pain. A KUB revealed that the capsule was still at the ileocecal valve, indicating that it was possibly stuck in a stricture. The patient was started on IV methylprednisolone in order to reduce inflammation to allow for passage of the capsule. Upon further evaluation, surgical intervention was necessary to remove the capsule. In the operating room the surgeons visualized a tumor in the jejunum arising from a Crohn's stricture. Despite multiple inspections of the resected small bowel the capsule could not be located. An intraoperative x-ray revealed the capsule to be in the splenic flexure of the colon indicating that the capsule passed through the stricture prior to resection. The final pathology revealed metastatic poorly differentiated adenocarcinoma.

DISCUSSION:
Small bowel adenocarcinoma is a recognized however overlooked complication of Crohn's disease. In patients with non-concerning colonoscopies with signs of obstruction (such as a retained capsule) and severe anemia, small bowel adenocarcinoma should be strongly considered. Capsule retention is often diagnosed via abdominal x-ray such as in our case. A retained capsule often remains asymptomatic however carries the risk of perforation, secondary obstruction, or ulceration. Double-balloon enteroscopy is considered the primary method for capsule retrieval however surgical exploration is often done. The concern for the capsule being lodged in a stricture in our patient made surgery the best option. We did first attempt IV methylprednisolone and within the five day interval prior to surgery the capsule had passed into the colon. In Crohn's disease patients, immunosuppressive medications such as steroids and infliximab have been shown to facilitate capsule passage.
2539 Case of a Young Man With Small Bowel Obstruction After Trauma
Authors: Lysek Michael , Stibbe Jason R. , Raines Daniel 
Published: October 2019

INTRODUCTION:
In few reports, trauma has been associated with small bowel obstruction. These cases typically happen in children; however, in adults this is a rare phenomenon. We present a case in a young male with a history of MVA 5 years prior, who presented for small bowel obstruction related to his prior trauma.

CASE DESCRIPTION/METHODS:
A 27 yo male presented with recurrent abdominal pain for six months. He had intermittent diarrhea, abdominal bloating, and a 15 lb weight loss over that time. Physical examination was normal. Basic laboratory studies were significant for T bili of 1.4 mg/dl (normal 0.1 - 1.0). Diagnostic EGD, colonoscopy, and CT scan of the abdomen/pelvis were normal. Due to concern for a potential diagnosis of small bowel Crohn's disease, a video capsule study was performed, which showed a hold-up in the mid small bowel for over 2 hours, without any other abnormalities. Due to this, an upper double balloon enteroscopy was performed, which was revealing for a stenosis in the distal jejunum. The stenosis was marked with submucosal india ink injection. Biopsies of the stenosis were unrevealing. Previous medical history was negative with the exception of a motor vehicle accident complicated by intra-peritoneal bleeding five years ago, which was managed conservatively without surgery. Review of this patient's medications was negative for any NSAID use. He had no history of radiation exposure or abdominal surgery. He had never experienced any symptoms of abdominal pain or bloating prior to the onset of symptoms 6 months ago. Family history is negative for celiac disease or inflammatory bowel disease. Surgical resection of the stenotic segment was performed. The patient recovered from surgery without complication. Histopathology from the resected segment was consistent with benign small bowel without inflammation or other pathologic features. The conclusion of the medical providers was that this patient developed a symptomatic stricture as the result of previous MVA with hematoma.

DISCUSSION:
Small bowel obstruction from trauma has been highlighted in few cases in children; however, trauma-causing small bowel obstruction (SBO) in adults is more rare. Throughout the cases we reviewed, the timeline of this trauma causing SBO ranged from thirteen weeks to eight years after the initial event.2,3,4 In this case, the man presented five years after his MVA with symptoms of bowel obstruction, with a prior hematoma being the cause of this obstruction. This case highlights MVA as a cause of SBO in adults.
2550 Henoch-Schönlein Purpura Mimicking Crohn's Disease in a 65-Year-Old Male
Authors: Lee Edwin J. , Kang Sohyun , Miller John W. , Marino Danielle E. 
Published: October 2019

INTRODUCTION:
Henoch-Schönlein purpura (HSP) is a small vessel vasculitis typically seen in children, often presenting with abdominal pain, purpuric rash, arthritis, and hematuria. Also known as immunoglobulin A (IgA) vasculitis, it is mediated by the deposition of immune-complexes containing IgA in the skin, gut and kidneys. Although rarely seen in adults, adult cases are associated with a more severe course than in pediatric patients. We present the case of adult-onset HSP with GI involvement.

CASE DESCRIPTION/METHODS:
A 65-year-old retired male dairy farmer with recent travel to Southwest US presented with a 6-week history of abdominal pain in the setting of a subacute, diffuse, purpuric rash. After admission, computed tomography (CT) imaging revealed ileitis with fat stranding and mesenteric vascular engorgement, concerning for Crohn's disease (Figure 1). Patient was also found to have proteinuria and arthralgia. Stool infectious work-up was unrevealing. Skin biopsy of the rash identified leukocytoclastic vasculitis and IgA deposition. Patient then underwent colonoscopy with ileoscopy, which scattered areas of congested appearing mucosa with deep purplish discoloration surrounded by normal mucosa (Figure 2). Scattered, nonspecific, rare small erosions and focal erythema were also seen throughout colon and rectum (Figure 3). Biopsies indicated mildly active ileitis and focal areas of active colitis with foci of hemorrhage in the right and transverse colon; there was no evidence of chronicity. Though non-specific, histologic findings were consistent with IgA vasculitis, rather than Crohn's. Patient was started on intravenous (IV) steroids and azathioprine. His rash and abdominal pain improved considerably after 48 hours of treatment.

DISCUSSION:
HSP, although more common in children, can be seen in adults, and should be included on the differential diagnosis when abdominal pain and/or GI bleeding is seen with concurrent skin, renal, & musculoskeletal findings. HSP is associated with significant morbidity and mortality due to the rapid progression of the disease and recognition can be delayed, particularly in adults. This case of adult-onset HSP was quickly diagnosed and treated with appropriate anti-inflammatory therapy. HSP can mimic Crohn's disease, by history and imaging, but the endoscopic findings are very different. The case illustrates some of the endoscopic and radiographic findings of HSP, promoting awareness among adult gastroenterologists.
2555 Immune Check Point Inhibitor Enteritis: A Case of Severe Duodenitis From Nivolumab Therapy
Authors: Keyes Erin , Hammami Muhammad B. , Beck Kendall R. 
Published: October 2019

INTRODUCTION:
Nivolumab, an immune checkpoint inhibitor, is an immunotherapy that has shown remarkable benefit in treating a wide range of cancers. However, by activating the immune system, these agents can cause immune-related adverse events (irAE). The gastrointestinal (GI) system is commonly affected, and typically presents with lower GI inflammation, such as colitis. Upper GI involvement is rarely reported. We present a case of nivolumab-associated duodenitis refractory to systemic corticosteroids but resolved after treatment with infliximab.

CASE DESCRIPTION/METHODS:
A 61-year-old man with a history of squamous cell carcinoma of the head and neck presented with intense cramping abdominal pain several weeks after nivolumab initiation. Given concerns for an irAE, he was initially treated with prednisone for 2 weeks, with minimal improvement in symptoms. He underwent esophagogastroduodenoscopy (EGD), which showed granularity and erythema of the duodenum with pathology consistent with duodenitis. He was referred to our institution, and treated with a course of IV solumedrol, which resulted in worsening abdominal pain and severe (grade 3) watery diarrhea. He was admitted to the hospital, and infliximab 5 mg/kg was initiated for suspected steroid-resistant immune checkpoint inhibitor-associated duodenitis/enterocolitis. He was noted to have rapid improvement in diarrhea and abdominal pain within 24 hours, with total resolution within nine days. After a second infusion of infliximab, he underwent a small bowel enteroscopy, which was unremarkable. His rapid improvement following infliximab further confirmed suspicion for an immune-checkpoint inhibitor medicated duodenitis/enterocolitis.

DISCUSSION:
As the use of checkpoint inhibitor immunotherapy grows, it is imperative that gastroenterologists be able to recognize and promptly treat GI immune-related adverse events, especially less common presentations involving the upper GI tract. Our case of nivolumab-associated duodenitis is an example of a rare immune-related adverse event that was refractory to steroids but responded to infliximab. Given no clear guidelines for duration of infliximab treatment, recommendations were extrapolated from IBD literature, with subsequent infusions recommended at two and six weeks. It has been reported that one-third to two-thirds of patients with immune-related GI toxicities do not respond to high dose systemic steroids or experience a relapse of symptoms. These are the patients that should be considered for infliximab.
2558 Mesenteric Panniculitis in a Young Adult: Case Report and Literature Review
Authors: Then Eric O. , Cercio Oleandro , Ofosu Andrew , Are Vijay S. , Culliford Andrea , Gaduputi Vinaya 
Published: October 2019

INTRODUCTION:
Mesenteric Panniculitis (MP) is an inflammatory condition of adipose tissue located in the small bowel mesentery. The exact cause is unknown although current literature has described some associations that may lead to its development. These include infection, paraneoplasic syndrome, history of multiple abdominal surgeries and lymphoma among others. Here we present a rare case of mesenteric panniculitis accompanied by retroperitoneal fibrosis.

CASE DESCRIPTION/METHODS:
The patient is a 31 year-old female with a medical history of cholecystectomy, appendectomy and Roux-en-Y gastric bypass surgery who presented to our emergency department complaining of diffuse abdominal pain, lower back pain and non-bloody vomiting for one day. Physical exam was remarkable for a scar over her right lumbar area and splenomegaly. Notable laboratory workup included an alanine transaminase of 54 IU/L, aspartate transaminase of 192 IU/L, alkaline phosphatase of 154 IU/L, total bilirubin of 0.5 mg/dL and hemoglobin of 10 gm/dL. While in the emergency department the patient underwent computed tomography of the abdomen which showed retroperitoneal fibrosis with lymphadenopathy, left sided hydronephrosis and mesenteric panniculitis (Figures 1 and 2). The patient was then admitted for further management. During her admission the gastroenterology service was consulted and their impression was mesenteric paniculitis secondary to multiple abdominal surgeries. The rheumatology service was also consulted and recommended obtaining serologies for IgG-4; ANA; ANCA; ACE; and SPEP all of which returned within normal limits. During her course the patient underwent left nephrostomy tube placement to relieve the left hydronephrosis and was otherwise treated consertivately. She was then discharged home with pain medications and follow up appointments.

DISCUSSION:
Mesenteric Panniculitis is characterized by inflammation of the small bowel mesentery, specifically the adipose tissue that surrounds it. Current data suggests that MP is a male predominant syndrome with a ratio of 3:1 when compared to females. Symptoms of MP are non-specific and include abdominal pain, diarrhea, weight loss, and fever. Biopsy is the gold standard for diagnosis, but imaging such as CT scan may also aid in its identification. There is no consensus regarding treatment, but many cases have been successfully treated with prednisone. Prognosis of MP is usually favorable with no follow up required if it is not associated with malignancy.
2559 Adenosquamous Carcinoma of the Ileum: A Rare Entity Found Incidentally
Authors: Yacyshyn Sara , Chen Patrick , Krishnamurthy Padmini 
Published: October 2019

INTRODUCTION:
Primary small bowel malignancy accounts for 0.6% of all new cancer cases in the U.S. and 1-3% of gastrointestinal tract neoplasms. The common subtypes of malignant small bowel tumors include carcinoid (44%), adenocarcinoma (33%), lymphoma, (15%) and sarcoma (8%). Adenosquamous carcinoma (ASC) is even more rare with only a few cases reported in the literature. The infrequency with which this malignancy is diagnosed and it's late and nonspecific clinical presentation contribute to delayed diagnosis and consequently worse prognosis.

CASE DESCRIPTION/METHODS:
A 58-year-old African American male presented for a surveillance colonoscopy. His initial screening colonoscopy at 53 years of age showed six polyps, of which, one was a 1 cm sized tubular adenoma. He had no history of gastrointestinal symptoms. During the colonoscopy and routine terminal ileum (TI) intubation, a 4 cm sized mass with central ulceration was visualized. The rest of the colonoscopy was significant only for two small hyperplastic polyps in the rectum. Endoscopic biopsies of the mass showed atypical epithelium. Further, abdominal computed tomography (CT) scan showed no lymphadenopathy or evidence of metastatic disease. He underwent exploratory laparotomy with ileocecectomy and pathology of the mass revealed poorly differentiated, high grade adenocarcinoma with areas of squamous differentiation, arising from a villous adenoma and extending into the muscularis propria (pT2).

DISCUSSION:
ASC can involve any organ including lungs, pancreas, liver, gallbladder and the gastrointestinal (GI) tract. ASC of ileum is an extremely rare diagnosis. Published case reports show that metastases of small intestinal ASC is common at the time of diagnosis. Our patient was fortuitous enough to have been diagnosed with ileal ASC in an early stage without evidence of metastasis, due to TI intubation during a routine colonoscopy. Surgical resection was likely curative for this patient. To our knowledge, no study has been published to evaluate the prevalence of TI malignant tumors during routine colonoscopy. In addition, intubation of the TI is currently not required during routine colonoscopy. This raises the question if there is utility in measuring TI intubation rates as a potential quality indicator for colonoscopists in the future.
2561 Not All That Ulcerates Is Crohn's: A Malignant Mimic of Small Bowel Crohn's Disease
Authors: Witt Danielle , Spenney Jerry G. , Peter Shajan , Edwards Adam L. 
Published: October 2019

INTRODUCTION:
Capsule endoscopy (CE) is indicated in the evaluation of suspected Crohn's disease (CD) when ileocolonoscopy and radiographic studies are negative or inconclusive. However, it should be recognized that mucosal breaks or ulcers alone are not always diagnostic of CD.

CASE DESCRIPTION/METHODS:
A 55 year-old man from India who immigrated to the US as a child was admitted to an outside hospital with 6 months of bilateral lower quadrant abdominal pain and iron-deficiency anemia. After normal upper endoscopy and colonoscopy, CE showed an ulcer and inflamed mucosa in the ileum. On this basis he was diagnosed with CD and treated with prednisone. The next month he was admitted to our institution with ongoing abdominal pain and unintentional weight loss but no diarrhea or hematochezia. On exam his vital signs and body mass index were normal. His abdomen was soft without organomegaly or palpable mass. He was tender to palpation in the bilateral lower quadrants. Stool was brown. Laboratory results were Hgb 8.3 g/dL, iron studies consistent with iron-deficiency, albumin 2.8 g/dL, C-reactive protein 150 mg/L, and erythrocyte sedimentation rate 45 mm/hr. CT enterography showed wall thickening of the mid-ileum with mucosal enhancement and mesenteric root adenopathy. Retrograde double balloon enteroscopy 90 cm into the ileum revealed a 15 mm shallow ulcer 80 cm proximal to the ileocecal (IC) valve and a similar ulcer 15 cm proximal to the IC valve. Biopsies showed ulcerated mucosa with infiltrating atypical cells that stained positive for ERG, a highly specific endothelial marker, and negative for other immunostains, leading to a diagnosis of primary intestinal angiosarcoma.

DISCUSSION:
Primary intestinal angiosarcoma is a rare soft tissue sarcoma that may present with abdominal pain, GI bleeding, obstruction, or weight loss. Tumors, detected on 2-4% of CEs, are in the differential diagnosis for small bowel CD along with infection, ischemia, vasculitis, lymphoma, Behcet disease, radiation enteritis, and drug-induced enteritis. In suspected CD, there is no reference standard or uniform criteria for diagnosis by CE. And, many of the lesions that lead to a diagnosis of CD are non-specific with the specificity of CE for CD as low as 53% and the positive predictive value <60% in some studies. Thus, findings of CE should be interpreted with an adequate degree of skepticism and a broad differential diagnosis considered to minimize mimics being mistaken for CD.
2566 Essential Thrombocythemia and AVM-Related Gastrointestinal Bleeding: A Rare Paradoxical Phenomenon
Authors: Mulat Baruh , Nawaz Waqas , Hertan Hilary 
Published: October 2019

INTRODUCTION:
Essential thrombocythemia (ET) is a myeloproliferative neoplasm characterized by excessive platelet production. It usually presents with thrombotic events. However, rarely, essential thrombocythemia may present with gastrointestinal (GI) bleeding. This phenomenon is seen paradoxically at very high platelet counts. We present a case of GI bleeding secondary to arteriovenous malformation (AVM) in a patient with platelet counts >1 million/uL.

CASE DESCRIPTION/METHODS:
A 74 year old male with history of hypertension, myeloproliferative disease, on hydroxyurea therapy, complicated by deep vein thrombosis requiring inferior vena cava filter placement, ischemic stroke, was admitted to inpatient rehabilitation after suffering from acute ischemic stroke 2 weeks ago. The patient was started on clopidogrel for acute stroke. He was found to have melena and gradual drop in hemoglobin (11.5 g/dL down to 6.5 g/dL). Complete blood count showed progressive rise in his platelet count (from 937 k/uL to 2.4 million/uL). Upper endoscopy revealed one small AVM in the fourth portion of the duodenum, treated successfully with hemostatic spray. Clopidogrel was switched to aspirin and hydroxyurea dose was increased for cytoreductive therapy as suggested by hematology. Subsequent colonoscopy revealed two non-bleeding AVMs in the cecum, treated with argon plasma coagulation (APC).

DISCUSSION:
ET is known to increase the risk of thrombotic events, including cardiovascular events, deep vein thrombosis, pulmonary embolism, retinal artery occlusion, digit ischemia and hepatic or portal vein thrombosis. However, ET also increases the risk for bleeding paradoxically with incidence rates ranging from 5-30 percent at the time of diagnosis. In GI tract, the bleeding is mostly from AVMs in ET. This phenomenon has been associated with qualitative defects and alteration in the platelets aggregation due to depletion of high-molecular weight von Willebrand factor multimers and development of an acquired von Willebrand disease. Interestingly, incidence of bleeding in ET correlates with the severity of thrombocytosis, mostly seen with extreme thrombocytosis (platelet counts >1 million/microL) [2-3]. Previous bleeding episode and use of antiplatelet drugs may further increases the risk of bleeding. Hydroxyurea is used for cytoreduction with platelet apheresis reserved for extreme cases where platelets exceed 1.5 Million/μl.
2567 A Rare Manifestation of a Bleeding Tubulovillous Duodenal Polyp Presenting as an Upper Gastrointestinal Hemorrhage
Authors: Dasu Neethi R. , Khalid Yaser , Itidiare Michael , Walters Richard , Suga Herman 
Published: October 2019

INTRODUCTION:
Duodenal polyps are rare findings, they have been reported in only 0.3-1.5% of individuals who undergo upper endoscopy (EGD). They are histologically classified by mucin phenotype into intestinal (89.1%), morphologically tubular or tubulovillous adenomas, and gastric type (10.9%); grossly as sessile or pedunculated polyps, nodules, excrescences. They can be located either in the duodenal bulb, ampullary region, or distal duodenum. Duodenal polyps carry a low probability for malignant transformation, around 90% are non-neoplastic. We present a case of a 76-yr-old male who presented with hematemesis, an atypical and unusual manifestation.

CASE DESCRIPTION/METHODS:
A 76-year-old male presented for feeling “off” and increased respiratory secretions. Gastroenterology was consulted following an episode of coffee-ground hematemesis which was noticed while checking residuals after tube feeding. The patient's hemoglobin was 9.9 g/dL and he was hemodynamically stable thus EGD was not done. His hematemesis was thought to be secondary to apixaban and aspirin so both were stopped. However, his hemoglobin decreased to 6.6 g/dL and orogastric lavage revealed 1 liter of coffee-ground emesis. Subsequently, the patient underwent an emergent EGD which revealed a 10 mm pedunculated polyp in the proximal duodenum with active bleeding. The polyp was resected with hot snare and clipped twice with a resolution of bleeding and stabilization of his hemoglobin. The biopsy of the polyp tissue revealed a pedunculated, intestinal-type tubulovillous adenoma with minute foci of high-grade dysplasia (HGD).

DISCUSSION:
The isolated occurrence of such adenomas is rare and presentation as an upper gastrointestinal hemorrhage is even rarer. Our patient presented with a malignant subtype although around 90% are benign. His neoplastic pedunculated polyp was identified in the second portion of the duodenum, which is another atypical occurrence. His polyp was 10 mm, but with HGD, the odds of being malignant are higher as was seen on biopsy. There are currently no definitive guidelines on how a duodenal polyp should be resected; further studies are needed to assess techniques that can decrease mortality and prevent a recurrence. EGD techniques that are currently used include endoscopic snare and electrocautery, which was successful in this case. EGD surveillance within 1-6 months is recommended due to an increased risk of colorectal neoplasia. It is also important for practitioners to keep in mind rarer causes of upper GI bleeding.