bluuebunny/crossref_metadata_2025_split huggingface dataset:
2773 Gastric Small Cell Cancer: An Extremely Rare and Lethal Type of Stomach Cancer
Authors: Aamar Ali , Barakat Mohamed , Aloreidi Khalil , Tsipotis Evangelos , Reddy Madhavi 
Published: October 2019

INTRODUCTION:
Small cell carcinoma commonly originates in the lung, but it can also arise from many extrapulmonary sites including the stomach. Gastric small cell carcinomas (GSCC) are extremely rare and comprise less than 0.1% of all gastric cancers. GSCC has aggressive clinical course with early metastases. The median survival time for localized disease is 1.4 to 3.5 years. We report a rare case of metastatic gastric small cell cancer in an elderly female.

CASE DESCRIPTION/METHODS:
A 79-year-old African American female with past medical history of hypertension presented with vomiting and 15-pound weight loss over 2 months. She also reported solid food dysphagia for 2 weeks. CT abdomen showed innumerable hypodense lesions throughout the liver, compatible with metastases and several necrotic appearing enlarged lymph nodes in the gastrohepatic ligament. EGD revealed a single cratered and linear ulcer on the lesser curvature of body of the stomach 3 cm below the gastroesophageal junction (Figure 1). It measured 8 × 1.5 cm in size. Multiple biopsies were taken. EUS showed multiple discrete hyperechoic lesions in the left lobe of the liver consistent with liver metastases (Figure 2). Liver biopsy was performed. Biopsy suggested invasive small cell carcinoma with necrosis. CT chest was negative for lung cancer. Bone scan showed multiple focal bony lesions consistent with bone metastases. Patient was started on chemotherapy by oncology for stage IV small cell gastric cancer. Unfortunately, the patient died within few months of initial diagnosis.

DISCUSSION:
GSCC is very rare and it was first reported in 1976. It has poor prognosis even in patients with localized disease. Epigastric pain, dysphagia and melena are common clinical presentations of GSCC. GSCC frequently metastasize to the liver, followed by lymph nodes and bones. Surgical resection is considered standard therapy for localized disease. Chemotherapy can increase median survival from 6 to 12 months for advanced disease. Early recognition and treatment of small cell gastric cancer in very important as advanced disease has dismal prognosis and it is universally fatal.
2788 Double Pylorus in a Patient With Alcoholic Cirrhosis and Intractable Vomiting
Authors: Deshmukh Farah , Francisco Peter , Merrell Nancy 
Published: October 2019

INTRODUCTION:
Gastroduodenal fistula (GDF) or double pylorus is a rare, often asymptomatic, condition with a prevalence of approximately 0.02-0.08%. The majority of previously reported cases have been in Asian countries and it has been found to be more prevalent in males than females. Although Helicobacter pylori and NSAID use has been associated with the formation of gastroduodenal fistulae, the actual mechanism of the condition is unknown.

CASE DESCRIPTION/METHODS:
We present the case of a 65-year old female with alcoholic cirrhosis and a long history of intractable vomiting due to unknown etiology. She was found to have a pre-pyloric gastric antral ulcer during an emergent endoscopy for an episode of hematemesis seven years ago. Follow up endoscopies over a course of three years found the antral ulcer to be healing. Seven years from the discovery of the initial lesion, a gastroduodenal fistula was found. The pre-pyloric antral ulcer in the process of healing fistulized into the duodenal bulb creating the appearance of a double pylorus.

DISCUSSION:
Gastroduodenal fistula or double pylorus can be acquired or congenital. Acquired GDF is a very rare complication of peptic ulcer disease. They can be a result of healing due to bridging fibrosis within the pylorus or, as in this case, fistulization from the gastric antral ulcer. Most GDF are found incidentally during endoscopy that was done for another reason. This case report follows the serial endoscopic examination of a cirrhotic patient with a pre-pyloric antral ulcer that developed into GDF. We propose that the GDF was caused by fistulization of a pre-pyloric antral ulcer with no other predisposing factors and gastrointestinal fistulization processes.
2789 Abdominal Pain Unveils a Gastric Psammoma Fascinoma
Authors: Harris Patrick , Winters Jennifer , Al Diffalha Sameer , Weber Frederick H. 
Published: October 2019

INTRODUCTION:
Carney Complex (CNC) is a rare multiple neoplasia syndrome of autosomal dominant inheritance characterized by skin pigment abnormalities, myxomas, endocrine tumors or hormonal hypersecretion, and schwannomas. The clinical presentation varies and median age at detection is age 20.

CASE DESCRIPTION/METHODS:
A 22-yr-old African American male presented with 3-months of intermittent left-sided abdominal pain. He had a large cell calcifying Sertoli cell testicular tumor (LCCSCT) removed by right orchiectomy at age 12. CT showed a 12.9 × 11.8 cm well circumscribed retroperitoneal mass involving the left adrenal gland with mass effect on adjacent organs and a 4.0 × 3.0 cm well-defined mass in the gastric body. EUS revealed a cystic gastric body sub-epithelial mass measuring 3.5 cm × 2 cm. The patient underwent partial gastrectomy, orchiectomy, and adrenalectomy revealing pathology consistent with a gastric psammomatous melanotic schwannoma (PMS), adrenocortical carcinoma, and a second LCCSCT. H&E stained sections of the gastric lesion show a well-demarcated subepithelial lesion with multiple psammomatous calcifications. Marked accumulation of melanin in tumor cells and melanophages were identified. Histological and immunophentypic features were consistent with a gastric melanotic schwannoma with psammomatous calcifications. These findings are diagnostic of CNC.

DISCUSSION:
CNC is caused by a harmful mutation in the PRKAR1A gene, which this patient was found to have upon genetic testing. Many individuals with CNC will have distinctive skin pigmentation and an increased risk for development of cutaneous and cardiac myxomas. As a result of this patient’s diagnosis, his mother was evaluated and was found to also have a PRKAR1A mutation; imaging led to discovery of a cardiac myxoma requiring surgical removal. CNC is also associated with multiple endocrine tumors with or without hormonal hypersecretion. LCCSCT occur in almost all adult males with CNC and are typically bilateral and benign. PMS, tumors of the nerve sheath, occur in approximately 8% of individuals with CNC. These can occur anywhere in the central and peripheral nervous system but most frequently occur in the GI tract (stomach/esophagus) or in the paraspinal sympathetic chain. PMS have distinct pathology including heavy pigmentation (melanin), frequent calcifications, and the presence of psammoma bodies. The importance of recognizing these pathological features is emphasized by the fact that approximately half of patients with PMS have CNC.
2795 The Effect of an Invasive Approach for Infected Necrotizing Pancreatitis on Mortality: A Retrospective Large Multi-Center Cohort Study
Authors: Horibe Masayasu , Minami Kazuhiro , Sanui Masamitsu , Sasaki Mitsuhito , Iwasaki Eisuke , Mayumi Toshihiko , Kanai Takanori 
Published: October 2019

INTRODUCTION:
Infection of acute pancreatic necrosis is associated with a high mortality rate. The relative merits of invasive therapies for preventing death among patients with this condition are unclear.

METHODS:
This retrospective multicenter cohort study was conducted from 2009 to 2013 at 44 treatment centers in Japan. Patients who underwent invasive treatment for suspected infection of pancreatic necrosis were enrolled into three treatments groups: the primary open necrosectomy before drainage, secondary open necrosectomy after drainage, and minimally invasive treatment (laparoscopic, percutaneous, and endoscopic) groups. The association of each treatment with mortality was assessed using multivariate analysis after adjusting for age, severity according to the revised Atlanta criteria, and the Charlson index.

RESULTS:
Of 1159 patients with acute pancreatitis, 118 patients underwent invasive treatment for infected pancreatic necrosis. Of these, nine, 20, and 89 patients underwent a primary open necrosectomy, secondary open necrosectomy, and minimally invasive treatment (three laparoscopies, 49 percutaneous treatments, 37 endoscopies), respectively. The mortality rate was 33.9% (40/118). Multivariate analysis showed no significant association between the type of intervention or Charlson index and mortality (P = 0.35 and P = 0.12, respectively). The mortality odds ratio (OR) for the secondary open necrosectomy versus minimally invasive treatment was 1.25 (95% confidence interval [CI]: 0.40–3.84, P = 0.69) while that for the primary open necrosectomy versus minimally invasive treatment was 3.13 (95% CI 0.66–17.5, P = 0.15). However, age (OR 1.04, 95% CI [1.01–1.08], P = 0.0067) and severity (OR 7.57, 95%CI [2.27–25.2], P = 0.0002) were significantly associated with mortality.

CONCLUSION:
In patients with infection of acute pancreatic necrosis, age and severity based on the revised Atlanta criteria, but not intervention type, were significantly associated with mortality. For patients undergoing an open necrosectomy, performing drainage after rather than before the procedure may produce better outcomes.
2797 Fenofibrate and PSC: A Case Series From a Single Center Liver Registry
Authors: Shah Shivani , Silveira Marina , Assis David , Cusack Laura 
Published: October 2019

INTRODUCTION:
Background: Primary sclerosing cholangitis (PSC) is a cholestatic liver disease with no current effective therapy. Ursodeoxycholic acid (UDCA) is often used, however it does not slow disease progression despite improvement in serum alkaline phosphatase (ALP). Fenofibrate (FF) improves cholestasis in patients with primary biliary cholangitis (PBC). We present a retrospective single-center case series of Fenofibrate in PSC patients.

METHODS:
Methods: Patients were identified within a Liver Registry with large-duct PSC on FF. Overlap cases with PBC or autoimmune hepatitis were excluded. The mean age at diagnosis was 39.7 ± 19.2 years; 4 were males, 5 Caucasian and 2 Hispanic. Five had inflammatory bowel disease, five had intra/extrahepatic disease and two had intrahepatic disease. All patients received UDCA. FF was added 5-396 months post diagnosis.

RESULTS:
Mean ALP pre-FF was 654 U/L ± 646 and after 4-6 months improved by a mean of 176 ± 263.4 U/L; 4/7 patients had ALP reduction with FF and 3 achieved a normal ALP level (Figure 1). MRI post FF was available in five patients; 3 had worsening of strictures after 6-12 months of FF while 2/5 were stable). ERCP was performed for stricture management on 4 patients and 2 required repeat ERCP. One patient developed cirrhosis; no patients developed ascites, encephalopathy, cholangiocarcinoma or hepatocellular carcinoma. One patient had a transplant evaluation for refractory pruritus. Of four with pruritus pre-FF, 1; one had moderate improvement. Of 6 patients with fatigue, 3 had persistence post-FF and 1 had new fatigue. Of 3 patients who had cholangitis pre-FF, 2 had recurrent episodes post-FF. No patients developed myopathy or acute kidney injury. FF was discontinued in one patient due to lack of ALP improvement at 6 months. Amsterdam-Oxford Risk Score (Figure 2) was calculated at time of FF, 4-6 months after FF, and at 1- and 2- years for those with data beyond 6 months. Among the 4 patients with ALP improvement, there was mild improvement in the risk score (not sustained beyond 2 years in 3 patients).

CONCLUSION:
Conclusion: This case series suggests a potential use for FF in the treatment of PSC. However, despite reduction in ALP, fatigue, pruritus, and recurrent cholangitis persisted and FF did not improve strictures, similar to UDCA studies in PSC. Future aims of this study involve examining elastography data pre- and post-FF. The role of FF in PSC treatment should be examined in larger, longitudinal studies.
2801 Does Rapid On-Site Evaluation by a Cytopathologist During Endoscopic Ultrasound-Guided Fine-Needle Aspiration (EUS FNA) of Pancreatic Masses Improve Diagnostic Yield and Accuracy? A Systematic Review and Meta-Analysis
Authors: Kamal Faisal , Khan Muhammad Ali , Tariq Raseen , Bayoumi Mahmoud , Marella Hemnishil K. , Reddy Yala , Ismail Mohammad , Tombazzi Caludio 
Published: October 2019

INTRODUCTION:
EUS FNA plays an important role in the diagnostic evaluation of pancreatic masses. Studies comparing the diagnostic yield of EUS FNA of pancreatic masses when performed with rapid onsite evaluation (ROSE) by a cytopathologist vs. without ROSE have reported conflicting results. By systematic review and meta-analysis, we aim to compare the diagnostic yield and diagnostic accuracy of EUS FNA when performed with and without ROSE in the evaluation of pancreatic masses.

METHODS:
We reviewed Pubmed, Scopus and Web of Science from inception to November 15, 2018 to identify studies comparing EUS FNA with and without ROSE for evaluation of pancreatic masses. The primary outcome of interest was diagnostic yield for malignancy. Secondary outcomes were diagnostic accuracy and sample inadequacy. A random effects model was used to analyze the data. Pooled odds ratios (ORs) with 95% confidence interval (CI) were used to summarize the data. Heterogeneity was assessed by I2statistic.

RESULTS:
We included 7 studies (6 publications and 1 abstract) comprising 1327 patients. EUS FNA was performed with and without ROSE in 641 and 686 patients, respectively. 5 studies were retrospective and 2 were randomized controlled trials. Diagnostic yield and accuracy were similar between the two groups. Seven studies reported data on diagnostic yield for malignancy; pooled OR was 0.96 (0.71, 1.31) with low heterogeneity (I2 = 26%; Figure 1). 4 studies reported data on diagnostic accuracy; pooled OR was 0.73 (0.39, 1.36) with low heterogeneity (I2 = 42%; Figure 2). 4 studies reported data on inadequate samples; no difference was observed between groups (OR 1.99; 95% CI 0.82, 4.85; I2 = 36%).

CONCLUSION:
This meta-analysis found that ROSE by a cytopathologist during EUS FNA of pancreatic masses does not improve diagnostic yield or diagnostic accuracy.
2808 Gastrointestinal Bleeding After Pancreatic Transplant, Beyond the Usual Suspects: A Systematic Review
Authors: Pena Polanco Nathalie A. , Keihanian Tara , Barkin Jodie A. , Barkin Jamie S. 
Published: October 2019

INTRODUCTION:
Pancreatic transplant represents the ultimate treatment for certain patients with diabetes mellitus & end-stage renal disease. Despite good outcomes, it carries a high rate of vascular complications, & with increased numbers of enterically-drained grafts, obscure gastrointestinal bleeding (GIB) can be the initial presentation. Delayed diagnosis & treatment of life-threatening hemorrhage can ensue if clinicians are not aware of this association. Therefore, we aimed to perform a systematic review of the literature, evaluating the presentation, diagnosis & treatment of patients with GIB caused by complications from enterically-drained pancreatic transplants.

METHODS:
We performed a systematic search of published data, regarding GIB due to complications from pancreatic transplant. Specific keywords including pancreatic transplant & gastrointestinal bleeding, with all possible permutations & associated MeSH terms were used, from inception of PubMed database to 04/30/2019. 107 results matched initial search criteria. After assessment to determine appropriateness, 26 publications with complications resulting in GIB at presentation were included. A recursive search was performed from bibliographies, yielding the remaining results.

RESULTS:
36 publications met final inclusion criteria (25 case reports & 11 case series) dating from 1989 to 2019, for a total of 69 patients, (47.8% men, mean age 41.4 years). Of these, 67 (97%) presented with overt bleeding, with lower GIB as the most common presentation (59.4%), followed by cases of both upper & lower GIB (8.7%), & occult GIB the least common (2.9%). Sentinel GIB was reported in 49.3% of cases. GIB etiologies included formation of fistulas (52.2%), anastomotic ulcer & donor duodenal bleed (11.6% each) & pseudoaneurysms (8.7%), with other rare causes (mucosal rejection, cytomegalovirus-related ulcers) also identified. Diagnosis was made by angiography in 31.9% & by surgery in 21.7% of cases, respectively. Endoscopic diagnosis was only successful in 7 patients. Surgery (n = 42) & interventional radiology procedures (n = 19) were the mainstays for treatment. Overall, 50.7% of patients had pancreatic graft loss prior to GIB.

CONCLUSION:
GIB after pancreatic transplant can be devastating. In our review, failed grafts were found in half the cases, with lower GIB due to arterial-enteric fistulas being the most common presentation. Angiography & surgery were the most common diagnostic & therapeutic modalities.
2817 Efficacy of Fecal Microbial Transplant in Treatment of Recurrent Clostridioides difficileInfection in Community Hospitals in Las Vegas
Authors: Brumand Azadeh , Hoang Lynda , Akbar Azaan , Carlson Brian 
Published: October 2019

INTRODUCTION:
Fecal microbial transplant (FMT) has been established as an effective treatment for recurrent Clostridioides difficile infection (CDI); however, current treatment guidelines for recurrent CDI in the community hospital setting remain unclear. Recurrence is defined as resolution followed by recurrence of CDI symptoms within 2-8 weeks after discontinuing antibiotic treatment. Recurrent CDI is seen in 10-25% of patients most commonly within 30 days but up to 2 months after completion of antibiotic therapy. In 2013, a randomized control trial demonstrated 81% response rate to FMT therapy for recurrent CDI versus 31% with vancomycin alone. The goal of our study was to evaluate the efficacy of FMT as a treatment modality for recurrent CDI in the community hospital setting.

METHODS:
In a retrospective data collection study, 27 patients diagnosed with 2 or more recurrences of CDI were selected for cecal infusion of FMT at 3 different community hospitals in Las Vegas between March 2017 and December 2018. Donor feces were obtained from OpenBiome and prepared according to the manufacturer’s instructions. Patients were screened for HIV, HAV, HBV, HCV and enteric bacterial pathogens. Antibiotics were discontinued 24-48 hours prior to FMT. All patients underwent bowel preparation with 4 liters polyethylene glycol. 250 cc of donor feces was delivered into the cecum via colonoscopy. Patients were re-evaluated at 8-weeks follow-up visits.

RESULTS:
Of the 27 patients treated with cecal infusion of FMT, 18 were available for 8-weeks follow-up evaluations. 14 of these patients reported complete resolution of CDI symptoms without recurrence. 3 patients had refractory CDI. 1 patient had persistent diarrhea due to Crohn’s disease. 1 patient died of septic shock during a hospital readmission. 8 patients were lost to follow-up.

CONCLUSION:
This study demonstrated FMT was effective in 78% of patients with recurrent CDI in community hospitals. Of the 3 patients with refractory CDI, 1 responded to a second FMT, 1 failed two additional FMTs but ultimately responded to an extended course of vancomycin and 1 remains on an extended course of vancomycin. Our study was limited by missing data; 30% of our patients were lost to follow-up. Although high rates of inadequate bowel prep were observed, further studies are needed to explore the significance of poor prep on FMT outcomes. Overall, the response rate supports the use of FMT for recurrent CDI in community hospitals.
2831 Altering Perceptions of In-Hospital Stool Testing for Clostridioides difficile Infection Reduces Inappropriate Prescribing of Antibiotics and Length of Hospital Stay
Authors: Malik Fahad , Patel Bhavin , Kim Marina , Dunn Kelsey , Gonzalez Manuel O. , Muhammad Wafa , Saverimuttu Jessie 
Published: October 2019

INTRODUCTION:
Clostridium Difficile Infection (CDI) occurs predominantly in the intestinal tract due to alteration of normal gut flora often due to antibiotics. Testing for CDI is common on the inpatient setting. However, we recognized that over 95% of ordered stool tests are negative for CDI which indirectly was associated with an increased length of hospital stay, the unnecessary use of antibiotics and placing patients on isolation precautions. A hospital initiative led by our team that included provider education and a special electronic order set increased the accuracy of testing for CDI at our institution.

METHODS:
A one-year retrospective study was done evaluating the number of symptomatic and asymptomatic patients that were tested by the toxin A/B EIA and PCR assays. Similar data was obtained from the following year after the initiation of our hospital initiative. The hospital initiative included education for all hospital prescribers as well as the creation of a special electronic order set including alerts and special restrictions implementing the Infectious Disease Society of American (IDSA) guidelines. CDI cases were reported and compared between the two groups.

RESULTS:
During the first study period, there were a total of 877 CDI Antigen & Toxin tests ordered for inpatients. This resulted in 712 or 81% negative results for both antigen & toxin. Out of 877 tests, 120 were found to have antigen positivity but negative for CD toxin (indeterminate results). These 120 patients were further analyzed by polymerase chain reaction (PCR). Only 45 out of 877 were truly positive for CDI antigen & toxin (5% of total ordered tests). During the second study period, post intervention a total of 828 total CDI tests were ordered. This result showed 678 CDI tests or 82% ordered tests were negative for CDI antigen & toxin. Out of 828, 101 tests were antigen positive but negative for toxin which were further analyzed by PCR. Only 49 resulted positive for CDI antigen & toxin (6% of total tests ordered with positive for CDI).

CONCLUSION:
Our hospital initiative that included guideline-based education for ordering physicians as well as implanting an electronic order set enforcing testing criteria was effective at identifying more true positive results of CDI. We can infer that the underlying cause for the majority of symptomatic patients resulted from an etiology other than CDI. Further practitioner education with stricter measures must be enforced to reduce excessive testing.