bluuebunny/crossref_metadata_2025_split huggingface dataset:
1581 Sequential Fecal Microbiota Transplantation for Severe Acute Refractory Clostridium difficile Colitis: A Life-Saving Treatment Approach
Authors: Kilakkathi Sindhu , Shah Rushikesh , LeVert Francis Edward 
Published: October 2019

INTRODUCTION:
Fecal microbiota transplantation (FMT) is now a commonly used mode of treatment for recurrent Clostridium difficile infection (rCDI) refractory to antibiotics. We report a unique case where two sessions of sequential FMT were used to treat acute rCDI refractory to antibiotics with endoscopically documented marked improvement in disease process.

CASE DESCRIPTION/METHODS:
A 69 year-old female presented with 4 days of fever, large volume non-bloody diarrhea and poor appetite. She denied abdominal pain, nausea or vomiting. She reported two months before this admission, she was treated for hospital-acquired CDI, but could not recall what she was treated with. Physical examination revealed a non-tender abdomen without guarding or rigidity. Laboratory tests revealed hemoglobin 11.3 g/dL and white blood cell (WBC) count 18,700/mcL. Stool testing was positive for C. difficile toxin assay. Computed tomography of the abdomen showed diffuse pancolitis, compatible with CDI, no evidence of bowel perforation or obstruction. Despite treatment with oral vancomycin (500 mg every 6 hours), intravenous metronidazole and probiotics for 5 days, her leukocytosis increased to 32,000/mcL, hemoglobin dropped to 6 g/dL and her symptoms persisted. The decision was made to try FMT and antibiotics were stopped for 48 hours as per FMT protocol. Colonoscopy showed severe pancolitis (Figure 1) and pseudomembranes consistent with severe C. difficile colitis with distal ascending colonic mucosa concerning for ischemia. 250 mL of donor stool was delivered at the proximal transverse colon. After the first FMT, mild improvement was noted in her symptoms and leukocytosis but she persisted to have severe diarrhea. A second FMT was performed 4 days later. Repeat colonoscopy (Figure 2) showed marked improvement in the appearance of pancolonic erythema, inflammation and pseudomembranes compared to prior. 250 mL of donor stool was infused through the colonoscope into the cecum. The following day after the second FMT, the patient began having formed stool and improved leukocytosis. She was discharged from the hospital 3 days after the second FMT with normal stool consistency and normal WBC count.

DISCUSSION:
There have been no clear data regarding directing severe rCDI treatment with regards to the length of time in between FMTs. Clinicians should be aware that patients may need multiple FMTs to treat rCDI. A shorter duration in between FMTs may rapidly improve severe rCDI, reduce the duration of hospitalization, and improve outcomes.
1633 Extensive Colonic Ischemia Due to Sumatriptan: An Unusual Adverse Effect
Authors: Mazumder Mohammed , Thorpe Candy , Horenstein Frances , Mazumder Jubaida 
Published: October 2019

INTRODUCTION:
Ischemic colitis (IC) is attributed to variety of etiologies including hypo-perforation due to dehydration, sepsis; thrombosis and embolic/thrombotic arterial occlusion. Pharmacological agents like 5Hydroxytryptamine1 (5HT 1) receptor agonists including Sumatriptan, widely used for refractory headaches, have also been known to be a cause of IC in rare circumstances. There are approximately 12 cases of IC reported which are related to 5 HT1 use. We are reporting a case of IC, which is likely related to long-term use of Sumatriptan.

CASE DESCRIPTION/METHODS:
A 39-year-old female with no significant past medical history was admitted to medical floor due to diffuse crampy abdominal pain and bloody diarrhea. Laboratory workup shows WBC 11500 cell/ml and negative IBD serology. CT of the abdomen and pelvis revealed pan-colitis. Stool culture and C. Difficile DNA were negative. Colonoscopy performed during admission revealed severe colitis involving entire colon except the rectum and distal sigmoid colon, biopsy featured ischemic colitis. A mesenteric Doppler ultrasound was ordered which was not conclusive, subsequently CTA performed which showed no mesenteric vascular stenosis. She was not on oral contraceptive pills and through careful questioning she mentioned that she had been taking Sumatriptan for a while. Due to the presumed association between Sumatriptan and IC, Sumatriptan was discontinued. She was emperically started on mesalamine and steroid, which were discontinued. Her symptoms improved with conservative management. A repeat colonoscopy in a few months after her hospital discharge did not show any colitis or ileitis; random colonic biopsies were unremarkable while she was off sumatriptan.

DISCUSSION:
Although rare, Sumatriptan use can be associated with IC, therefore we should be vigilant in reviewing medication lists in situations where there is no obvious etiology. Incidence of drug-related ischemia might be more than reported. It is imperative to counsel about meidcation adverse effect and reporting adverse effects.
1689 Managing Bouveret Syndrome in the Setting of Complex Foregut Anatomy: Impossible Is Nothing!
Authors: Hughes Michelle L. , Cheong Janice , Enslin Sarah , Kaul Vivek , Kothari Truptesh , Kothari Shivangi 
Published: October 2019

INTRODUCTION:
Bouveret syndrome is a rare complication of cholelithiasis. Traditional treatment has been surgical, but endoscopic therapy has emerged as an attractive option, especially in surgically unfit patients.

CASE DESCRIPTION/METHODS:
An 80-year-old female with history of coronary artery disease/CABG on Clopidogrel and COPD on home oxygen presented with severe right upper-quadrant abdominal pain and nausea for 3 days. WBC was 14,400 μ/L, afebrile, with stable vital signs. Liver tests were normal. Abdominal ultrasound showed cholelithiasis and an obstructive calcified shadow at the pylorus. CT abdomen revealed a dilated stomach, gallstones and a 3 cm gallstone in the duodenal bulb with entero-biliary fistula. Endoscopic treatment of Bouveret was planned. At endoscopy, an unexpected high-grade mid-esophageal stricture prevented passage of standard and ultra-thin gastroscopes. A 8 mm balloon dilation was performed causing a modest-sized mucosal rent. An ultrathin gastroscope (5.9 mm) was then passed through the esophageal stricture and to the duodenum. A large pigmented gallstone was encountered in the duodenal bulb with luminal occlusion. Saline solution was infused and electrohydraulic lithotripsy (EHL) was performed at escalating settings up to 100W/ 20 shots per activation. The stone was ultimately fragmented and luminal patency restored. An ulcer with a visible vessel was seen at anterior wall of duodenal bulb; brisk bleeding was noted and hemostasis was achieved with epinephrine spray and 18 W cautery using pediatric snare tip, due to limitations of a 2.0 mm endoscope channel. The entero-biliary fistula was cannulated with the ultrathin endoscope and an additional large pigmented stone was seen in the gallbladder. This was left undisturbed. The patient had an uneventful recovery and was discharged home on regular diet after 2 days.

DISCUSSION:
Endoscopic management of Bouveret syndrome is an effective intervention and should be preferred in patients with severe comorbidities. This case demonstrates how anatomic and device related challenges were overcome using an ultrathin gastroscope to manage Bouveret syndrome and luminal bleeding. An ultrathin endoscope successfully permitted performance of EHL, evaluation of cholecystoduodenal fistula and hemostasis to save the day in this complex clinical scenario.
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1705 Esophageal Food Impaction: Novel Use of Water Flushes and Esophageal Overtube as a Safety Indicator and Facilitator to Push Food Bolus Into the Stomach
Authors: Shao Paul , Grewal Jasleen , Leung Felix 
Published: October 2019

INTRODUCTION:
Esophageal food impaction requires urgent intervention. A food bolus is removed endoscopically by extraction or push into the stomach. Due to risks of perforation, controversy exists between when to extract verses to push. There are no clear guidelines on when it is safe to push on a food bolus; endoscopists rely on their subjective experiences and judgments. We present a case of the novel use of water flushes and an esophageal overtube to determine the safety of pushing on a food bolus to facilitate its passage into the stomach.

CASE DESCRIPTION/METHODS:
A 69 year-old man presented to the ED 12 hours after ingesting a piece of steak and a sensation of food stuck in his throat. The patient underwent esophagogastroduodenoscopy (EGD), which showed a large meat bolus firmly fixed in the upper esophagus. An overtube was placed to protect the airway. Extraction was attempted in piecemeal fashion. Because the food bolus was soft, only tiny pieces were retrieved with each attempt. We used water flushes to help determine when it would be safe to push the bolus. Initially, water retained proximal to the bolus (refluxed back into the overtube), suggesting that there was a complete luminal obstruction and that pushing would be ineffective and unsafe. Later, after more of the bolus was extracted, water passed beyond the bolus distally (no longer refluxed back into the overtube), indicating partial luminal obstruction and that it may be safe to push the food bolus. With a gentle push, the food bolus passed into the stomach easily.

DISCUSSION:
In esophageal food impaction, there are no clear guidelines on when it is safe to attempt the push method. We demonstrate a novel way of using water flushes and esophageal overtube to help objectively decide when it might be safe to push the food bolus. If water is retained and refluxed into the overtube, there may be a complete luminal obstruction and push is not recommended. If water does not accumulate or refluxed into the overtube, there is an opening in the lumen allowing the water travel distal to the bolus and pushing the food bolus may be considered. The use of water flushes and an esophageal overtube is safe, easy and cost-effective. It may serve as an additional safety indicator to help decide when to push the food bolus. In addition, water may moisturize the food bolus and help loosen the impaction to facilitate its passage into the stomach.
1721 Black Esophagus: A Case of Acute Esophageal Necrosis
Authors: Aujla Amreet K. , Elkhattib Ismail , Siddappa Pradeep , Pratt Perry , Bath Roopjeet , Hoffman Martin 
Published: October 2019

INTRODUCTION:
Acute esophageal necrosis (AEN) is a rare clinical entity characterized by diffuse, circumferential, black-appearing distal esophageal mucosa on EGD typically limited to the gastroesophageal junction. In this case, we discuss AEN in a chronically ill female precipitated by an acute low perfusion state in the setting of her preexisting vasculopathy.

CASE DESCRIPTION/METHODS:
A 76-year-old female with past medical history of severe coronary artery disease, high-grade distal aortic stenosis, gastroesophageal reflux disease, history of ischemic colitis presents with two-day history of melena. Patient initially presented at an outside hospital for symptomatic anemia and was transfused packed red blood cells. She was transferred to our institution and was found to have a systolic blood pressure in the 80s. Physical exam was notable for pallor and a delayed capillary refill time. Labs revealed a hemoglobin of 10.8 g/dL, white blood count of 17 uL, procalcitonin of 1.8 ng/mL, creatinine of 1.2 mg/dL, INR of 2.7, and albumin of 2.5 g/dL. CT of the chest and abdomen revealed a right lower lobe lung consolidation and a very decompressed IVC concerning for a low volume state. Patient was adequately fluid resuscitated, kept NPO and was placed on a pantoprazole (PPI) infusion. An EGD was performed which revealed diffuse severe mucosal changes characterized by ulceration with necrotizing black mucosa in the lower third of the esophagus, and non-bleeding cratered and superficial duodenal ulcers. One week later, a repeat EGD demonstrated significant esophageal mucosal healing with esophagitis and distal esophageal ulcerations. Esophageal biopsies revealed denuded submucosa, marked acute inflammation with negative HSV, CMV and fungal cultures. Given the significant improvement in symptoms and findings, her diet was advanced. She was discharged on oral PPI and sucralfate with a plan for repeat EGD in three months.

DISCUSSION:
The incidence of AEN ranges from 0.2% to 0.28%, however, true prevalence is underestimated given the transient nature of the insult and early tissue healing. Distal esophagus and duodenal injury are common given their similar supply from the celiac artery. This case highlights a rare disease entity with increasing prevalence owing to the increased number of comorbid conditions attributed to the disease process. It emphasizes the potential causes of the disease and timely diagnosis warranting physicians to have an understanding and awareness on potentially fatal but reversible clinical syndrome.
1757 Melanoma Metastatic to the Esophagus
Authors: Yarze Joseph C. 
Published: October 2019

INTRODUCTION:
To describe a case of melanoma metastatic to the esophagus.

CASE DESCRIPTION/METHODS:
A 65 yo male with a prior history of hypertension and melanoma of the scalp treated with MOHS in 2011 presented in 1/19 for direct-access EGD to evaluate chronic reflux symptoms (which were responsive, but PPI-dependent). The EGD was normal aside from revealing an 8 mm, deeply pigmented, raised nodule in the upper esophagus at 30 cm from the incisors (Figure 1). Biopsies revealed malignant melanoma (lesional cells positive for SOX10 and MiTF; negative for MN116). The patient was referred to medical oncology. PET-CT staging of the chest and abdomen were negative and brain MRI was normal. After multidisciplinary consideration, the patient underwent esophageal EUS and ESD of the esophageal lesion. The resected melanoma lesion was confined to the mucosa. After further consideration, the patient opted to undergo adjuvant therapy with nivolimumab.

DISCUSSION:
While malignant melanoma has a known propensity to metastasize to the GI tract, esophageal metastases are uncommon. Our patient was found to have an asymptomatic esophageal metastatic lesion, which was found incidentally when he underwent EGD to evaluate chronic reflux symptoms. He was successfully treated with ESD of the localized metastatic lesion followed by adjuvant nivolimumab therapy.
1759 Dysphagia in Extra-Pyramidal Syndrome: A Reversible and Uncommon Presentation
Authors: Sun Haozhe , Abbas Hafsa , Jyala Abhilasha , Badipatla Kanthi Rekha , Nayudu Suresh Kumar 
Published: October 2019

INTRODUCTION:
Neuroleptic medications are known to cause extrapyramidal syndrome (EPS) in individuals taking antipsychotic medications. However, dysphagia is an uncommon clinical entity presenting as EPS. We present a case of dysphagia in an individual taking Haloperidol confirmed by swallowing studies, which resolved entirely on discontinuation of Haloperidol and appropriate medical management.

CASE DESCRIPTION/METHODS:
A 22-year-old male with a history of bipolar disorder was admitted to the inpatient psychiatric unit for an episode of psychosis. He was started on oral valproic acid, oral haloperidol as well as scheduled monthly injections of Haloperidol Decanoate. One week after his discharge, he was seen in the clinic for coarse tremors and stiffness in all his extremities. It was decided to taper haloperidol and start benztropine. In two weeks, he presented to the emergency room with difficulty in swallowing (both liquids and solids) as well as worsening stiffness of all four extremities. Physical examination was significant for masked facies, bradykinesia with decreased active range of motion of both the upper and lower extremities. A computed tomography (CT) of his head, neck, and soft tissues showed no acute abnormalities. A functional swallow evaluation was performed which revealed oral decompensation for regular solid texture, marked by excessive chewing and delayed anterior to posterior transit. There was no remarkable oral residue, symptoms or signs of airway protection deficits were appreciated on assessment. Esophagogastroduodenoscopy did not reveal any structural etiology for his dysphagia. He was admitted to hospital; haloperidol was discontinued and Benztropine dose was increased. Also, he was started on diphenhydramine His symptoms were completely resolved in four days. He was discharged home in stable condition.

DISCUSSION:
Extrapyramidal symptoms (EPS) are a well-known adverse reaction from antipsychotic medications, that can range from acute dystonia, akathisia, parkinsonism to tardive dyskinesia. Dysphagia is a known but rare side effect of antipsychotic medications. Our case stresses the importance of suspecting drug-induced dysphagia in individuals on neuroleptics. Early diagnosis can decrease morbidity and hospital stay as the main stay of management of these patients is to discontinue precipitating agent and reversing physiological effects by medical management that can result in shortening disease course and better outcomes.
1771 Eosinophilic Esophagitis Presenting With Esophageal Wall Dissection
Authors: McCarron Joshua D. , Lawson Robert D. 
Published: October 2019

INTRODUCTION:
Eosinophilic esophagitis (EoE) is a chronic immune/antigen-mediated, inflammatory disease with a wide spectrum of presentation from mild dysphagia to food impaction. We describe the presentation and management of a patient whose initial presentation of EoE included the rare complication of esophageal dissection.

CASE DESCRIPTION/METHODS:
A 30-year old Caucasian male presented to the emergency department after 10 days of dysphagia and odynophagia. His physical exam was normal. Initial laboratory evaluation revealed mildly elevated troponin I and leukocytosis. CT imaging with IV contrast showed an air-fluid level within the distal esophagus. EGD could only be completed with a pediatric gastroscope (5.4-mm) due to severe, diffuse narrowing of the esophagus. The entire esophagus had findings of EoE including edema, furrowing, and circumferential rings. The lumen of the proximal esophagus was 12-15 mm with acute narrowing to 7mm at 27-cm. Most notable was a 1-cm x 2-cm hole at 25-cm which communicated with a fluid-filled, granulation tissue lined space that paralleled the distal esophagus (Figure 1). Biopsies showed >50 Eos/hpf consistent with EoE. The patient was started on broad-spectrum antibiotics, IV proton pump inhibitor therapy, topical steroid and kept NPO. CT imaging with IV and gastrograffin contrast demonstrated a long segment intramural dissection with a double-barreled esophageal lumen (Figure 2). Following consultation with cardiothoracic surgery, endoscopic management was pursued. Endoscopic suturing was not attempted given severe luminal narrowing. The tissue proved too fibrotic for hemostasis clips. A through-the-scope, fully-covered self-expanding esophageal stent (FCSEMS) was deployed across the defect and a feeding tube was inserted. An elemental diet was started. Follow-up imaging showed obliteration of the false lumen by post-procedure day 9 (Figure 3). Repeat EGD one month later showed an intact lumen but with delicate-appearing granulation tissue at the location of the previous hole (Figure 4), thus another FCSEMS was placed and elemental diet was resumed with plans for repeat EGD in 4 weeks.

DISCUSSION:
Intramural esophageal dissection is a rare, potentially life-threatening complication of EoE which can be medically and endoscopically managed. “The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the United States Air Force, the Department of the Navy, Department of Defense, or the U.S. Government.”
1772 Novel Use of Low Dose Amitriptyline in the Prevention of Deglutition Syncope: A Case Report
Authors: Shah Ravi , Mayuga Kenneth A. , Gabbard Scott 
Published: October 2019

INTRODUCTION:
Deglutition syncope is a rare entity with approximately 100 reported cases. It is a subtype of neurocardiogenic syncope triggered by deglutition secondary to organic and functional esophageal pathology. There are limited treatment options, and here we report a case of using low-dose amitriptyline (10 mg) for deglutition syncope.

CASE DESCRIPTION/METHODS:
A 58 year old male with hypertension, diabetes mellitus, and peripheral neuropathy presented to gastroenterology clinic with a diagnosis of deglutition syncope. Over the preceding year, he experienced four syncopal episodes while eating, described as lightheadedness before losing consciousness for a minute. Electroencephalogram, electrocardiogram, and echocardiography were unremarkable. Tile-table test showed reflex vasovagal syncope with systolic vasodepression (63 mm Hg) without cardioinhibition. Continuous telemetry showed sinus bradycardia (50 bpm) followed by three sinus pauses up to 4 seconds and return to normal sinus rhythm during episodes of dysphagia and lightheadedness. Evaluation for dysphagia with esophagogastroduodenoscopy (EGD) was unremarkable. Esophagram showed tertiary contractions in the mid-distal esophagus. Esophageal manometry was unremarkable for dry swallows with premature contractions possibly suggestive of distal esophageal spasm (Figure 1). Patient refused repeat EGD. A diagnosis of deglutition syncope with combined cardioinhibition and vasodepression secondary to esophageal spasm was made. Pacemaker implantation was recommended for syncopal symptoms from cardioinhibition; however, the patient declined due to potential persistence of symptoms from vasodepression. Initial recommendations of dietary changes and avoidance of triggering medications were made. Calcium channel blockers and nitrates were limited by bradycardia and hypotension. Hyoscyamine provided partial relief, but pre-syncopal symptoms persisted. Low-dose amitriptyline was initiated for the potential underling etiology of esophageal spasm. After a year, the patient reported resolution syncopal symptoms and dysphagia.

DISCUSSION:
Deglutition syncope due to cardioinhibition and vasodepression secondary to underlying esophageal spasm was diagnosed with tilt-table testing, continuous telemetry, and esophageal manometry. Amitriptyline was chosen for its anticholinergic effects and esophageal neuromodulator properties. Low-dose amitriptyline may be considered as a preventative treatment for resistant deglutition syncope.