bluuebunny/crossref_metadata_2025_split huggingface dataset:
1508 A Rare Case of Lobular Breast Cancer With Metastasis to the Colon
Authors: Shah Kinnari , Chuang Keng-Yu , Srinivasan Indu 
Published: October 2019

INTRODUCTION:
Metastasis from infiltrating lobular cancer (ILC) preferentially involves bones, peritoneum and liver. Metastatic involvement of the gastrointestinal (GI) tract is very rare and if present usually involves the stomach and small intestine. Colorectal involvement is extremely rare. We present a rare case of an elderly female with a history of ILC who presented with GI symptoms that led to subsequent diagnosis of colon metastasis.

CASE DESCRIPTION/METHODS:
This is a 68 years old female diagnosed with ILC of the right breast six years ago treated with lumpectomy and chemotherapy. She also had peritoneal carcinomatosis. Six years later, she presented with abdominal pain and dark stools mixed with blood. CT scan of the abdomen showed ascites, peritoneal thickening and normal appearing bowel. Colonoscopy showed internal hemorrhoids, melanosis coli and erythema in the transverse colon (Figure 1). Biopsy from transverse colon revealed atypical cells in the lamina propria in “Indian file pattern” with Immunohistochemistry (IHC) positive for CK-7, mammaglobin and negative for CDX2. A positive CK7 and mammaglobin in the colon suggest ILC metastasis (Figures 2 and 3) whereas a negative CDX2 excludes primary colon cancer. She was started on palliative chemotherapy.

DISCUSSION:
Metastasis of ILC to the colon can manifest with a wide range of clinical and radiological features resembling various GI disorders. Further incidence of benign GI disorders in these patients is higher than metastasis, making the diagnosis a challenge. The presentation can range from asymptomatic abdominal mass to perforation, GI bleeding and obstruction. Radiology findings include normal appearing colon to diffuse or multifocal involvement, micro nodularity, tethering and stenosis. Colonoscopy with biopsy has moderate diagnostic yield especially in the absence of intraluminal lesion, and therefore in suspicious cases, a deep biopsy is indicated. Diagnosis is based on establishing similarities in the histology between a colon and breast tissue in terms of cellularity, growth pattern, hormonal status and IHC. ILC involves the layers of the colon in a “single file pattern” causing very subtle changes that can be missed on endoscopy. Treatment involves a multi-disciplinary approach including surgery, radiation and systemic therapy. Despite treatment colorectal metastasis from ILC has a poor prognosis with a median survival of 1-2 years.
1515 Portal Vein Thrombosis After Laparoscopic Sigmoid Colon Resection for Recurrent Diverticulitis
Authors: Bommena Shoma , Mehta Shivang 
Published: October 2019

INTRODUCTION:
Portal vein thrombosis (PVT) following laparoscopic surgery is a rare complication. PVT after laparoscopic colorectal surgery is usually associated with inflammatory conditions like IBD and is more likely to occur after total proctocolectomy and in presence of postoperative intra-abdominal infection. We report a case of PVT in a patient with no identifiable hypercoagulable disorder who underwent laparoscopic sigmoid colectomy for recurrent diverticulitis.

CASE DESCRIPTION/METHODS:
A 54 year old male with a past medical history of gout and no known history of thrombosis had recurrent diverticulitis. He also had Clostridium difficile infection secondary to antibiotic use. CT showed diverticulosis, but no portal vein thrombosis. He underwent robotic sigmoid colon resection with an uneventful postoperative course. Six months later he started noticing right upper quadrant abdomen pain and diarrhea that went on for five weeks. He denied confusion, ascites and GI bleed. His PCP ordered a CT abdomen in that showed right hepatic lobe atrophy and non-opacification of branches of right portal vein consistent with prior intrahepatic portal vein thrombosis. Lab work revealed normal CBC, negative stool studies, slightly elevated alkaline phosphatase of 137, AST of 31, ALT of 28, total bilirubin of 1. He was referred to our hepatology clinic. We repeated MR abdomen with and without contrast that confirmed chronic non-occlusive thrombus in the right portal vein, left portal vein and main portal vein were widely patent. Further lab work by hematology showed no evidence of thrombophilic condition. Repeat labs after three months showed normal LFTS and intact liver function.

DISCUSSION:
PVT as a complication of laparoscopic surgery is uncommon. Local and systemic factors contribute to development of post-op PVT. Thrombosis related to CO2pneumoperitoneum may be caused by hemodynamic changes like decrease in superior mesenteric arterial and portal venous blood flow. Issues with PVT have been seen related to splenectomy, bariatric procedures, and right hemicolectomy. Pneumoperitoneum induced hemodynamic changes and local inflammation due to diverticulitis might have contributed to PVT in our case.
1526 Abdominal Tuberculoma in a Cirrhotic Patient With Disseminated Tuberculosis
Authors: Rezaie Aida , Ahmed Shifat , Mann Saba , Shaughnessy Richard 
Published: October 2019

INTRODUCTION:
Disseminated tuberculosis (TB) is defined as two or more noncontiguous sites due to lymphohematogenous spread by Mycobacterium tuberculosis. Diagnosis is made through isolation of the organism from blood, bone marrow, or from two or more non-contiguous organs. Lymphocytopenia is a risk factor for dissemination. The incidence of disseminated TB is unclear, but of the cases reported in the United States in 2016, both pulmonary and extrapulmonary sites were reported in less than 10% of cases. We present a rare case of an abdominal tuberculoma in cirrhotic patient with disseminated tuberculosis.

CASE DESCRIPTION/METHODS:
72 year old Vietnamese female with a history of hepatitis C cirrhosis who presents with altered mentation concerning for stroke. CT head without contrast was negative. She subsequently developed melena with an associated hemoglobin of 6.2 overnight. She underwent upper endoscopy without significant findings. CT chest without contrast showed numerous noncalcified nodules bilaterally as well as the apices concerning for military tuberculosis. BAL positive with AFB stain. Lumbar puncture did not show significant pleocytosis, normal glucose and protein. CSF culture was negative for AFB, cocci, Cryptococcus. Blood cultures, HIV 1/2 Ag/Ab screen 4th generation and serum cocci were negative. CEA was 2.7. MRI head with and without contrast showed multiple enhancing lesions concerning for infection versus malignancy. CT abdomen/pelvis showed a colonic mass in the cecum and ascending colon with thickening in the ileum. Colonoscopy showed a non-obstructing large mas in the cecum. Biopsies of the ileum and cecum were consistent with granuloma formation with necrosis, acid-fast bacilli with confirmation on AFB stain. The patient was started on RIPE therapy. Unfortunately, her encephalopathy did not improve despite 2 weeks of treatment and she was placed on hospice.

DISCUSSION:
Abdominal tuberculosis (TB) is reported in less than 5% of all cases of TB worldwide. It can present with non-specific symptoms such as fever, weight loss and abdominal pain. Endoscopic findings of intestinal TB vary from ulcers, strictures, nodules to deformed ileocecal valves and fistulas. Patients typically improve within weeks of initiating antituberculous therapy. One case report demonstrated correlation with carcinoembryonic antigen (CEA) pre -and post antituberculous therapy in a patient with multivisceral tuberculosis suggesting it could be a marker to trend response to therapy.
1528 No Drama: Cap-Assisted Endoscopic Mucosal Resection of an Incidental Colonic Traumatic Neuroma
Authors: Estifan Elias , Patel Varun , Grossman Matthew 
Published: October 2019

INTRODUCTION:
A traumatic neuroma is a well-known complication after acute trauma to a peripheral nerve; the nerve tries to re-establish continuity by an orderly growth of axons from the peripheral to distal stump through the proliferation of Schwann cells. However, this process is not always perfect, and aberrant repair gives rise to a neuroma.

CASE DESCRIPTION/METHODS:
We present a 50-year-old female who underwent an initial colonoscopy for change in bowel habits and was found to have a 7 mm submucosal lesion in the proximal rectum (Figure 1). She denied any complaints of rectal pain or previous rectal manipulation. Endoscopic ultrasound was done which showed a hypoechoic lesion in the submucosal layer without muscularis propria invasion. The patient underwent successful cap-assisted endoscopic mucosal resection of the lesion without complication (Figure 2). Pathology of the specimen revealed a traumatic rectal neuroma with immunostaining positive for S100 (Figure 3).

DISCUSSION:
The usual presentation of a traumatic neuroma is of pain, however, our patient presented asymptomatically which can possibly be attributed to the lack of somatic innervation as opposed to neuromas located in an extremity. Interestingly, our patient never had a previous colonoscopy, rectal trauma/manipulation, or rectal intercourse, which could have precipitated a neuroma. In the only other case of a traumatic rectal neuroma, the lesion likely arose as a result of trauma to the submucosal Meissner's plexus fibers or Auerbach's plexus fibers during the polypectomy. To our knowledge, this is the second case of a traumatic rectal neuroma reported in the English literature.
1530 Colo Low Flow: A Case of Exercise-Induced Colon Ischemia
Authors: Marcuard Maurice , Oldfield Edward C. , Kulla Bakri , Chen Ian 
Published: October 2019

INTRODUCTION:
Colon ischemia is the most common type of mesenteric ischemia and is responsible for 15% of hospitalizations for acute lower gastrointestinal bleeding.1 While it predominately affects the elderly, colonic ischemia can occur in younger individuals during periods of intense exercise, typically long-distance or marathon runners.2,3

CASE DESCRIPTION/METHODS:
A 28 year-old male with a past medical history of type 2 diabetes mellitus and obesity presented to the hospital with two days of generalized abdominal pain associated with fevers, fatigue, and general malaise. The patient denied any diarrhea, blood in his stool, or vomiting. The patient did report an intentional 60 lb weight loss in the last 6 weeks through a diet and exercise regimen including up to 60 minutes of exercise per day. Physical examination demonstrated mild right sided abdominal tenderness but was otherwise unremarkable. Initial imaging with CT abdomen showed thickening and inflammation in the cecum and terminal ileum (Figure 1). Laboratory studies were normal apart from mild elevations of lactic acid 1.0, CRP 14.4, and ESR 31. Subsequently, a colonoscopy was performed which showed mild to moderate colon ischemia at the ileocecal valve and in the proximal right colon (Figures 2a and b). Sources of potential ischemia were further investigated with a CT angiography of the abdomen and echocardiography, both of which were normal. Given that no source of ischemia could be identified, the patient was diagnosed with colon ischemia secondary to exercise and managed with supportive care and close follow-up.

DISCUSSION:
Our case highlights an episode of nonocclusive colon ischemia triggered by shunting of blood away from the colon during periods of exercise. Importantly, our patient's presentation was non-specific and not characteristic for colon ischemia, which is classically a disease of elderly patients with risk factors for atherosclerotic disease; furthermore, when colon ischemia is induced by physical activity, most case reports have shown it is due to prolong intense exercise in long-distance and marathon runners.2,3 The occurrence of colon ischemia with only a moderate level of activity may be a reflection of the significant increase in our patient's activity from baseline without complete physiological adaptation. As such, it is important that clinicians are cognizant of the possibility for colon ischemia in any patient with regular exercise patterns, in particular if this represents a recent behavior change.
1538 An Unusual Presentation of Ischemic Colitis
Authors: Davis Nathan , Govil Yogesh 
Published: October 2019

INTRODUCTION:
We present an unusual physical exam finding in ischemic colitis.

CASE DESCRIPTION/METHODS:
A 44 year old male with no known medical history presented to emergency department with complaint of abdominal pain and flu-like symptoms for 10 days. He had associated bloating and constipation which was minimally relieved with over the counter laxatives. There was no report of hematochezia or melena. Computed tomography of the abdomen and pelvis was notable for severe contiguous wall thickening and pericolonic fat stranding in the descending colon, sigmoid colon, and rectum. These findings were suspicious for either infectious or inflammatory colitis. There were no abnormalities in the mesenteric vasculature. The patient was discharged on an empiric course of ciprofloxacin and metronidazole, and was seen in the office two days later for follow up. On physical examination, there was an unusual finding of a tender, non-pulsating palpable mass over the left hemi-abdomen without rebound, guarding or rigidity. The patient's antibiotics were discontinued due to low suspicion for an infection. Given the finding of abdominal mass on exam, he was referred for urgent colonoscopy out of concern for colon cancer or lymphoma. On colonoscopic examination, findings were notable for altered vascularity, edema, erythema and linear erosions throughout the rectum, sigmoid colon and descending colon which were consistent with colitis. Biopsies from these sites showed edema and superficial prominence of capillary-sized vessels. The patient was given a diagnosis of colonic ischemia and he was provided with appropriate treatment. One week later on telephonic follow up, the patient reported resolution of his symptoms with plan for repeat computed tomography of the abdomen.

DISCUSSION:
This patient presented with an unusual finding of a palpable mass to his left hemi-abdomen in the setting of colonic ischemia. Abdominal masses on exam are most frequently due to hernias, neoplasms, infectious collections and hematomas. However, the diagnosis of colonic ischemia generally relies on history, imaging and colonoscopy. The available literature on physical exam is generally non-specific and limited to abdominal tenderness. This patient had the characteristic findings of colonic ischemia including edema, linear erosions and segmental erythema to support a diagnosis of colonic ischemia. It is suspected that his abdominal mass represented the affected colonic segments which makes this a rather unique finding for this disease.
1540 Colorectal Cancer: An Uncommon Cause for Restrictive Lung Disease
Authors: Mizrahi Joseph , Namn Yunseok , Buscaglia Jonathan M. 
Published: October 2019

INTRODUCTION:
Colorectal cancer (CRC) often presents with gastrointestinal complaints such as changes in bowel habits or rectal bleeding. We present here an unusual case of CRC diagnosed in the setting of respiratory distress.

CASE DESCRIPTION/METHODS:
A 78-year-old female with no prior history of lung disease but a long smoking history presented with acute dyspnea, with an oxygen saturation of 86%. The physical exam revealed bilateral wheezing and a soft non-distended abdomen. There were no biochemical lab abnormalities and her chest radiograph demonstrated an elevated right hemidiaphragm, a chronic finding for the patient (Figure 1). Given her longstanding smoking history, she was started on steroids and nebulizers for a suspected COPD exacerbation. However, her respiratory status worsened and she was upgraded to the medical intensive care unit. A pulmonary function test was subsequently performed which showed a reduced FEV1 (0.48) and FVC (0.63), but a normal FEV1/FVC ratio (77%) – denoting a restrictive lung disease pattern, inconsistent with the original diagnosis of a COPD exacerbation. This prompted further imaging which revealed a severely dilated colon (maximum dilation of 8.4 cm) with a transition point at the proximal sigmoid colon (Figure 2). As the patient previously never had a colonoscopy, one was performed which revealed a 3 cm, circumferential, fungating, nearly lumen obstructing mass 30 cm from the anal verge, concerning for adenocarcinoma (Figure 3). A colonic stent was therefore placed with improvement in the patient's work of breathing. Biopsies later confirmed adenocarcinoma for which she underwent a left hemicolectomy.

DISCUSSION:
CRC is rarely diagnosed as a result of non-gastrointestinal related symptoms. In this case, the patient presented with wheezing and dyspnea as a result of a large colonic mass causing upstream dilation and severe compressive atelectasis. Based on the patient's smoking history and wheezing on exam, the physicians anchored on the diagnosis of a COPD exacerbation despite the lack of a COPD history or radiographic findings to suggest an obstructive pulmonary pathology. Anchoring bias is a common source of diagnostic error among physicians and it is important to always establish a broad differential diagnosis – especially when patients fail the first line of treatment. In addition, this case underscores the importance of CRC screening in patients, as she herself had no prior screening and unfortunately developed CRC.
1544 Klippel-Trenaunay-Weber: Rare Congenital Syndrome Causing Persistent Rectal Bleeding
Authors: Kataria Archish , Patel Harsh D. , Wright Randy P. 
Published: October 2019

INTRODUCTION:
Klippel-Trenaunay Weber syndrome (KTS) is a rare congenital disorder characterized by a triad of cutaneous capillary malformation (port-wine stain), venous malformations and limb hypertrophy. Diffuse vascular malformations of the gut in KTS can lead to gastrointestinal (GI) bleeding ranging from minor to life threatening hemorrhage necessitating surgical intervention. We describe a case of persistent rectal bleeding and iron dependent anemia in a patient with KTS.

CASE DESCRIPTION/METHODS:
A 32-year-old female with previous diagnosis of KTS was seen for recurrent hematochezia and iron deficiency anemia. A recent colonoscopy demonstrated non-bleeding arteriovenous malformations (Figure 1), presumed to be the source for the recurrent rectal bleeding episodes. On exam, she appeared pale, had a right hip deep purple telangiectasia, right posterior thigh palpable mass without visible varicosities and no limb hypertrophy. Her laboratory tests revealed: Hb: 9 g/dl, mean corpuscular volume: 75.0 fl, ferritin: 3 ng/ml and serum iron: 22 mcg/dl. CT abdomen/pelvis showed diffuse thickening of the rectum and sigmoid colon with scattered mural calcifications. A repeat colonoscopy demonstrated non-bleeding large circumferential vascular malformation extending from the dentate line to about 20 cm in the rectum (Figure 2) and multiple soft, pale lymphatic blebs in the colon and rectum (Figure 3). Her iron deficiency anemia from chronic blood loss was treated with oral and IV iron therapy. Despite conservative therapy, patient continues to bleed intermittently but has decided against surgical intervention at this time.

DISCUSSION:
GI hemorrhage occurring in association with KTS is an uncommon cause of rectal bleeding but is the most common symptom and potentially life-threatening emergency of KTS involving the gut. Investigation should begin with visualization of the entire GI tract for localization and extension of the disease. Angiography remains the gold standard and carries the advantage of allowing therapeutic interventions to control bleeding. The management of GI vascular malformations in KTS depends on the frequency and severity of blood loss requiring transfusions. Conservative management and iron supplements may be sufficient in the patient who presents with occasional non-debilitating bleeding. Transfusion dependency and life-threatening bleeding episodes necessitate definitive surgical therapy which involves resection of the diseased bowel.
1555 Intestinal Spirochetosis: A Call to Unravel the “Spiral” of Undetermined Significance
Authors: Cancio Anthony T. , Cruz Crystale J. 
Published: October 2019

INTRODUCTION:
Intestinal Spirochetosis (IS) is a rare incidental finding on routine biopsies of the colon, thought to be a commensal organism more prevalent among those with HIV, immunocompromised, or those in developing countries. Anecdotally, it does not seem to be widely known among practicing gastroenterologists, and in those who have encountered it, their management has varied widely. The classic histologic finding is a fringe-like attachment of densely packed filamentous spirochetes on the surface epithelium of the large intestine. Identification can be done with H&E staining, but confirmation requires Warthin-Starry staining. Although clinical presentation varies, often patients are asymptomatic and have an endoscopically normal appearance.

CASE DESCRIPTION/METHODS:
In this case report, we present a 37 year old otherwise healthy homosexual female with intermittent hematochezia and RLQ pain and a family history remarkable for polyps in her sister (36), and father who was diagnosed with colon cancer in his 50s. Colonoscopy was remarkable for punctate ulcers on her IC valve and cecum, with biopsy findings of “chronic inflammation and architectural distortion” suspicious for Crohn's. She was started on Apriso BID, and on second read, the pathologist stated, ‘of note, we also identify organisms morphologically consistent with intestinal spirochetosis (Brachyspira), confirmed with a Warthin Starry stain, with an appropriately positive control. Intestinal spirochetosis usually is an incidental finding and the organisms are generally not considered pathogenic'. Consideration was given to treat the patient with a course of Flagyl, however, the patient was no longer symptomatic and on repeat colonoscopy the ulcers had resolved. Biopsies taken of the involved area again demonstrated Spirochetosis.

DISCUSSION:
While often regarded as a clinically insignificant finding, not enough is known about IS to make firm conclusions about the relevance of this organism. IS has been associated with IBS in a general population in Sweden1, and a retrospective case-control study in Japan demonstrated a strong association between IS and Sessile Serrated Adenomas/Polyps2. This case sheds light on the fact there is a lack of awareness and understanding of this organism among all involved sub-specialties. Further studies on this potentially pathogenic organism need to be carried out.