bluuebunny/crossref_metadata_2025_split huggingface dataset:
2726 Dilemma of Hypercalcemia and Persistent Peptic Ulcer Disease: Case Report and Literature Review
Authors: Bella Saif , Najar Hatem , Shumeyko Mark 
Published: October 2019

INTRODUCTION:
Hypercalcemia has been linked to peptic ulcer disease (PUD), but between the two is not well understood. We are presenting a case of PUD that did not respond to long term twice daily PPI but did improve when the hypercalcemia was corrected with parathyroidectomy.

CASE DESCRIPTION/METHODS:
A 48-year-old male patient underwent one yearlong evaluation for persistent abdominal pain. His evaluation included three CT scans, EGD as well as octreotide and parathyroid scans. Initially, it was believed that his symptoms were related to severe PUD that did not respond to prescribed medical treatment due to poor patient compliance. He presented to the ED complaining of epigastric pain. Abdominal imaging revealed inflammation and narrowing of the entire duodenum as well as non-obstructive nephrolithiasis. His Calcium level was 11 mg/dl. An EGD revealed many non-bleeding cratered duodenal ulcers in the entire duodenum. An acquired non-obstructing, benign-appearing, intrinsic stenosis was found in the third portion of the duodenum. Biopsies were negative for H. pylori infection. He denied NSAID use. He was discharged on oral PPI therapy twice daily. Two months later, he returned with recurrent abdominal pain after running out of his PPI. CT scan showed persistent inflammatory changes involving the entire duodenum to the jejunum. Serum gastrin level was 201 pg/ml. Calcium level was 10.4 mg/dL. He was treated symptomatically with plans for outpatient push enteroscopy. The patient’s clinical course was complicated by obstructive nephrolithiasis requiring bilateral ureteral stents. Almost one year later, he returned with abdominal pain. Another CT scan showed persistent duodenitis. His labs showed evidence of Hypercalcemia 12 mg/dl. Gastrin Level 382 pg/ml. Octreotide scan was performed and was negative for any active neuroendocrine tumor. Parathyroid scan revealed parathyroid adenoma. The patient underwent parathyroidectomy and did well. He was discharged home on PPI twice daily. He was seen in follow-up and denied any PUD symptoms.

DISCUSSION:
This patient with severe non-resolving peptic ulcers. Removal of the parathyroid adenoma resulted in complete resolution of his symptoms. The gastric secretory response to hypercalcemia may be responsible for the occurrence of peptic ulcer disease in patients with hyperparathyroidism. In conclusion, serum calcium level must be considered among the usual tests in patients with rare and/or non-specific abdominal symptoms and part of the workup for persistent PUD.
2729 An Unusual Location of a Mucosal Schwann Cell Hamartoma
Authors: Rojas Patricia Guzman , Gonzaga Ernesto Robalino , Macias Kathlyn Camargo , Parikh Jignesh 
Published: October 2019

INTRODUCTION:
Nerve sheath tumors are rarely found in the gastrointestinal tract andhave been seen only in association with inherited syndromes such as neurofibromatosis type I (NF-1), multiple endocrine neoplasia type 2B (MEN 2B) and Cowden syndrome. Mucosal Schwann cell hamartoma (MSCH) is a new entity described by Gibson et al. in 2009 and has mostly been described in the colorectal area.

CASE DESCRIPTION/METHODS:
A 59-year-old man with no pertinent past medical history visited the gastroenterology clinic as a scheduled appointment for a long-standing history of GERD. He denied any nausea, vomiting, early satiety, abdominal pain or unintentional weight loss. His diagnosis was made on a clinical basis, and for this reason, an EGD was recommended. The EGD showed no abnormalities and esophageal mucosa was not erythematous (Figure 1). Multiple biopsies were taken. Pathology results showed mucosal Schwann cell hamartoma features in the antral biopsies (Figure 2).

DISCUSSION:
The exact incidence of MSCH is not known but it is mostly seen in female patients. MSCH has specific histological characteristics: lack of circumscription, absence of peripheral lymphoid cuff, crypt entrapment and strong positive stain for S-100. It is important to differentiate it from other spindle cell tumors since this will affect the management, prognostication and monitoring of possible associated complications. Differential diagnosis includes gastrointestinal stromal tumors (GISTs), carcinoid tumor, leiomyoma, schwannoma, mucosal neuroma, neurofibroma and ganglioneuroma. GISTs are the most common spindle cell tumors in the GI tract, however they have immunoreactivity to C-KIT and CD 117. GI schwannomas are mostly found in the stomach, but these have peripheral lymphoid cuffs and Antoni-A and Antoni –B regions. MSCH presents as a polypoid lesion in the colon and patients are typically asymptomatic. However, they can also present with rectal bleeding when the tumor is located in the colorectal area. This tumor follows a benign course and there is no need for treatment or extraction. Given its recent discovery and rarity, there is only one case report in the literature describing gastric affectation of the MSCH tumors. We describe this case due its unusual location as this is the 2nd case in the literature describing gastric affectation. Furthermore, a correct histological characterization is recommended since it will be crucial for the management and prognostication of these patients.
2737 An Over-the-Scope Clip Rescue of a Perforation During a Conversion Form ESD to EMR of a Symptomatic Large Bleeding Duodenal Lipoma
Authors: El Douaihy Youssef , Alsheikh Mira , Andrawes Sherif 
Published: October 2019

INTRODUCTION:
Lipomas are the second most common benign GI tumors. Their distribution varies vastly among different sections of the digestive system and their management is dictated by the location, size and whether they cause symptoms or not. Traditionally they were removed surgical but with the advancement of the technology and third space endoscopy, endoscopist are more experienced in endoscopic therapy of such lesions.

CASE DESCRIPTION/METHODS:
53 yo male with PMHx of morbid obesity had a recent admission for acute blood loss upper GI bleeding (UGIB) with profound acute anemia and a hemoglobin of 6.3 requiring several blood transfusions. On gastroscopy he was found to have an ulcerated 6 cm duodenal pedunculated lesion with a recent bleeding described as a pigmented spot (Forrest IIc).

Procedure:
The endoscope with a distal cap attached was advanced into the stomach. In order to prevent possible GI hemorrhage, an endoloop was successfully placed on the base of the stalk. An attempt to snare the pedunculated mass with a large hexagonal snare failed given the size of the mass. Subsequently, submucosal dissection was started. Using the SB knife a alternating coag and cut modes were utilized to perform safe dissection. A shiny layer of fat was exposed in the middle of the polypoid lesion. Then the SB knife was switched to an IT knife to complete the dissection. Coag grasper was used to achieve hemostasis, the mass was captured and taken out with a snare. Ex vivo it measured 5.4 cm. After the dissection a 1 cm partial perforation was noted. The dual grasper was used to approximate the defect and a 12 mm OVESCO type was deployed to succefully close the defect. the scope was then withdrawn. The patient was admitted for monitoring and a contrast small bowel series. A gastrografin small bowel series confirmed a contained leak in the duodenum. The patient was NPO for 24 hours. A repeat study at that point showed resolution of the leak. A clear liquid diet was started and the patient was monitored for another 24 hours then was discharged home.

DISCUSSION:
With the emergence of new tools, technology and technics, third space endoscopy is leading to more invasive resection. This comes at a cost of increased complications. None the less these new advancement are putting at the endoscopist tools to manage these complications independently.
2753 Got the GIST: Multidisciplinary Management of an Acute Bleeding Gastrointestinal Stromal Tumor
Authors: Baliss Michelle , Clark August , Dayah Rawan , Guturu Praveen 
Published: October 2019

INTRODUCTION:
Gastrointestinal stromal tumors (GISTs) account for 1%-3% of all gastrointestinal tumors. They most commonly arise in the stomach followed by the jejunum/ileum. Presentation varies from incidental discovery during autopsy or endoscopy to acute gastrointestinal (GI) bleeding or bowel obstruction. We report a case of this rare neoplasm in a patient with an acute GI bleed, treated endoscopically with hemostatic spray and ultimately with arterial embolization and surgical resection.

CASE DESCRIPTION/METHODS:
A 67-year-old female with a family history of colorectal cancer presented to the emergency department for hematemesis and left lower quadrant abdominal pain for 1 day. Physical examination was notable for left lower quadrant tenderness to palpation. Initial laboratory data showed a hemoglobin of 12.8 g/dL from 14.4 g/dL 8 months prior. A CT scan of the abdomen demonstrated a 3.2 × 4.1 cm well-circumscribed mass along the lesser curvature of the stomach arising from the gastric wall. Overnight, she had an episode of large volume hematemesis and became tachycardic and hypotensive. Her hemoglobin dropped to 7 g/dL. An esophagogastroduodenoscopy (EGD) showed LA Grade D esophagitis and a submucosal ulcerated gastric tumor on the lesser curvature of the stomach to which Hemostatic powder spray was applied. She initially refused surgical intervention and remained hemodynamically stable for ∼12 hours after EGD. She then had multiple episodes of hematemesis with hypotension despite blood transfusions. She underwent embolization to the left gastric artery after which hemostasis was achieved. She then decided to proceed with surgical resection of the gastric mass. Pathology confirmed the diagnosis of GIST, spindle-cell type with strongly positive stains for DOG-1 and CD117.

DISCUSSION:
GISTs are rare tumors that originate from mesenchymal stem cells. Although 40% of gastric GISTs present with GI bleeding, there are no clear guidelines on the management of these lesions. Therapeutic endoscopy and arterial embolization are effective methods used in the management of GISTs with acute bleeding. Hemostatic spray, an inorganic powder that concentrates clotting factors on bleeding surfaces, can be used adjunctively to other methods for the management of bleeding GISTs especially when traditional endoscopic techniques are challenging or when surgery is not an option. This case highlights the importance of a multidisciplinary approach in the management of these rare tumors.
2754 A Gaping Hole in the Stomach - A Rare PEG Tube Complication
Authors: Gupta Nikita , Likhtshteyn Michelle , Kancharla Pragnan , Iqbal Sadat , Al-Ani Firas , Grossman Evan 
Published: October 2019

INTRODUCTION:
Up to 200,000 gastrostomy tubes (PEG) are placed in the United States each year, with a success rate over of 95%. Here we present a patient with complaints of abdominal pain and discharge from the PEG site, who was found to have an interesting EGD finding.

CASE DESCRIPTION/METHODS:
A 52 year old cachectic woman with a history of opioid abuse, roux-en-Y gastric bypass for obesity 14 years prior, and PEG placement due to inadequate oral intake almost 3 months prior to her admission, presents to the ED with worsening abdominal pain, nausea, intermittent vomiting and discharge of fecal like material from PEG site for the last few days. On exam patient appeared cachectic, disheveled, and had diffuse erythema of her abdominal wall. Vital signs were significant for hypothermia to 91.3 F, and bradycardia. Labs were significant for sodium of 152. CT abdomen and pelvis showed the PEG tube in satisfactory position. She was started on IV fluids and antibiotics but soon became hypoxic and tachycardic requiring medical ICU care. Subsequently, bleeding around the PEG tube was noted. Hemoglobin dropped from 9.8 to 7.2 within 9 hours. Lavage of the PEG tube revealed coffee ground material. Due to patient’s tenuous respiratory status, it was decided to perform an upper endoscopy by accessing the stomach via the gastrostomy fistula. The PEG tube balloon was deflated and the endoscope was easily inserted without resistance. The peritoneum was immediately visualized, which contained undigested food (Figure 1). The endoscope was withdrawn and was navigated into the body of the stomach, via a large opening. A significant amount of undigested material was seen in the remnant stomach (Figure 2). There was an opening between the remnant stomach and the gastric pouch (Figure 3), which was traversed with the endoscope. The gastric pouch was severely ulcerated and the gastrojejunal anastomosis could not be identified. The patient was then transferred to the hospital where her previous surgery and PEG tube were placed. There, her hospital course was complicated by ARDS requiring intubation. She eventually underwent replacement of PEG tube and after 50 days of hospitalization, she was discharged home.

DISCUSSION:
Procedure related complications such as perforation can occur anywhere from <0.5-1.8%. In this case, although the PEG tube may have initially been placed in the stomach, the replacement balloon PEG tube may have been inserted into the peritoneum. Complications such as these should always be a consideration.
2755 Metastatic Melanoma of the Stomach
Authors: Leung David , Miles Michelle , Chandradas Sajiv 
Published: October 2019

INTRODUCTION:
The GI tract is rarely affected by secondary tumors. One of the most common primary malignancies is melanoma, however, the stomach is a rare location for metastasis of malignant melanoma. We present a rare case of a patient who developed metastatic melanoma to the stomach.

CASE DESCRIPTION/METHODS:
An 82-year-old male with a prior history of melanoma presented with a chief complaint of hematemesis. Two weeks earlier, the patient had discovered an enlarged left axillary lymph node. His oncologist acquired a PET scan which demonstrated lower lobe pulmonary nodules and left axillary adenopathy. A biopsy of the axillary lymph node revealed metastatic melanoma. On the day of admission, he had several episodes of dark bloody emesis. Initial laboratory workup revealed a hemoglobin of 4.4. The patient was resuscitated and subsequently underwent an endoscopy. Innumerable black nodules were found scattered throughout the duodenum and stomach (Figure 1) along with a large ulcerating nodule with a depressed black center in the body of the stomach (Figure 2). Multiple cold biopsies revealed infiltration of the duodenal and gastric mucosa with discohesive malignant cells, abundant mitotic figures, and focal pigment formation. Immunohistochemical stains showed the cells to be positive for SOX10 and Melan-A (Figure 3). This confirmed metastatic melanoma within the upper GI tract and oncology was consulted for further management.

DISCUSSION:
The most common gastrointestinal metastatic sites from melanoma are the small bowel, followed by the colon, rectum and then stomach. The stomach is a rare location with a reported incidence of only 7%. Patients often present at an advanced stage of disease and prognosis is dismal. Median survival period from diagnosis is 4-6 months. Diagnosis is not commonly made before endoscopy as associated symptoms are non-specific and rarely present. Endoscopically, gastric melanomas are classified into 3 main morphological types: ulcerated melanotic nodules, submucosal masses with ulcerations, and mass lesions with necrosis and melanosis. The classic appearance is multiple, small nodules that can be pigmented or ulcerate to produce a bulls-eye appearance. The mechanisms underlying metastatic melanoma to the stomach are unclear. Four pathways may be involved in the metastatic spread of primary cancers to the stomach which includes peritoneal dissemination, hematogenous dissemination, lymphatic spread, and direct tumor invasion.
2758 Lymphocytic Gastritis With Hypoproteinemia Treated With Helicobacter pyloriEradication
Authors: Murthi Mukunthan , Murali Rangan 
Published: October 2019

INTRODUCTION:
Lymphocytic gastritis with hypoproteinemia is a rare condition and has been associated with Helicobacter pylori infection. We present the case of a 59-year-old female with hypoproteinemia associated with lymphocytic gastritis. The hypoproteinemia resolved after eradication of H. pylori.

CASE DESCRIPTION/METHODS:
The patient is a 59-year-old female who presented with complaints of early satiety. She had lost fifteen pounds over a period of six months. The patient had no other significant past medical history, and her clinical examination was normal except for minimal epigastric tenderness. She had no signs of malnutrition and did not have chronic diarrhea. On routine workup, she was found to have low total protein and normal albumin. Total protein on initial presentation was 5.4 g/dL. Eight weeks later, her total protein was still low (5.5 g/dL) with slightly low albumin (3-4 g/dL) as well. She had normal liver function tests and a negative celiac screening. Upper endoscopy revealed some patchy erosion of the antrum and thick gastric folds in the proximal body. Biopsies from the antrum and body revealed severe lymphocytic gastritis with chronic active inflammation. There were significant surface and foveolar epithelial infiltration by T lymphocytes (more than thirty lymphocytes per 100 epithelial cells). Immunohistochemical staining did not show Helicobacter pylori, but she did have positive H. pylori antibodies in the serum. The patient was treated with triple therapy for two weeks. Six weeks after eradication of H. pylori, her total protein increased to 7.5 g/dL. She also gained six pounds and was asymptomatic.

DISCUSSION:
Very few cases of lymphocytic gastritis-associated hypoproteinemia that resolved after eradication of H. pylori have been described in literature. Previous reports indicate that eradication of H. pylori is associated with prompt and significant improvement of hypoproteinemia as well as eventual disappearance of lymphocytic gastritis. Studies have suggested that lymphocytic gastritis condition is likely a rare and specific immune response to H. pylori. Links have also been described between lymphocytic gastritis and celiac disease as well as between lymphocytic gastritis and varioliform gastritis. This case serves to further establish an etiological link between H. pylori infection and lymphocytic gastritis accompanied by a protein-losing state.
2760 A Case of Collagenous Gastritis: A Rare Entity
Authors: Cortez Nathaly , Mahfouz Mahmoud , Berzosa Manuel , Bloom Michael 
Published: October 2019

INTRODUCTION:
Collagenous gastritis (CG) is a rare histopathologic entity that involves marked subepithelial collagen deposition in the gastric mucosa. Endoscopic findings can be diverse such as mucosal erythema, nodularity and ulceration. The presentation is very diverse such as abdominal pain, weight loss, gastrointestinal bleeding and dyspepsia. Its treatment remains unclear.

CASE DESCRIPTION/METHODS:
71-year-old with long history of dyspepsia was referred to our institution due to a 6-month history of epigastric discomfort, profound weight loss (50 lb) and early satiety. Symptoms were mildly improved with sucralfate and smaller and more frequent meals. Tissue transglutaminase antibody was negative. Endoscopy at other institution suggested collagenous gastritis but biopsies were not conclusive. Endoscopic ultrasound at our institution was done for further characterization of the stomach layers and revealed a tubular J-shape stomach deformity with diffuse atrophic mucosa in the gastric body. Localized submucosal wall thickening was visualized endosonographically in the entire body of the stomach which measure up to 5 mm in thickness in the gastric wall. Random gastric biopsies could not confirm CG diagnosis. Persistent symptoms led to further work up including MRI enterography and gastric emptying study, all negative. Eight months later, “well type” biopsies were taken from the gastric body and antrum. Pathology report revealed antral glands atrophy with pyloric hyperplasia, prominent smooth muscle hyperplasia in the lamina propia, along with gastric corpus and antrum with thickened subepithelial collagen layer on hematoxylin and eosin, confirmed on trichrome stain. These features were consistent with a diagnosis of collagenous gastritis. Although limited evidence on the treatment of this disease, patient was started on budesonide therapy (9 mg/day). Future endoscopic surveillance and clinical follow up is planned to assess symptomatic improvement.

DISCUSSION:
Collagenous gastritis is a rare entity as only 60 cases have been reported in the literature. We need more awareness of this disease for early recognition and reduction of unnecessary work up. Clinical presentation is very diverse and endoscopic findings can be very subtle. High clinical suspicion is necessary to allow proper biopsy techniques. The well technique permits deep tissue sampling by taking multiple samples from the same site and has been advocated for use in subepithelial lesions, avoiding the need for full thickness biopsy or surgery.
2762 Median Arcuate Ligament Syndrome: A Rare but Overlooked Cause of Post-Prandial Abdominal Pain
Authors: Tayel Hussam , Tayel Hesham , Mehta Sagar V. , Duarte-Chavez Rodrigo , Kim Brian , Bahirwani Janak , Martinez-Tapia Ana , Modi Ronak , Chaput Kimberly J. , Martins Noel B. , Geme Berhanu , Matin Ayaz 
Published: October 2019

INTRODUCTION:
Median arcuate ligament syndrome (MALS), also known as celiac artery compression syndrome or Dunbar syndrome, is defined as chronic recurrent abdominal pain related to compression of the celiac artery by the median arcuate ligament. The median arcuate ligament is a fibrous arch that crosses the aorta and links the crura of the diaphragm. This ligament typically passes superior to the origin of the celiac artery, however about 10% of the population (with strong female predominance) has a low-lying ligament that causes compression of the celiac trunk that is usually asymptomatic. We report a case of median arcuate ligament syndrome presenting similar to chronic mesenteric ischemia but without the typically associated cardiovascular risk factors.

CASE DESCRIPTION/METHODS:
A 54-year-old woman with no significant past medical history presented to the emergency department with a 6-month history of post-prandial abdominal pain associated with nausea, nonbilious emesis, sitophobia and a 60lb weight loss in the past 6 months. Vital signs were unremarkable. Her physical exam was entirely benign aside from mild epigastric tenderness to deep palpation. Labs were significant for a WBC 11.4, Hb 19.0 (baseline 13-15), K + 2.9. Gastroenterology was consulted and the patient underwent EGD which showed normal appearance of the esophagus, stomach, and duodenum with negative biopsies. Due to concern for mesenteric ischemia, the patient underwent CT Angiography of the abdomen which demonstrated 70% stenosis of the proximal celiac artery highly suggestive of median arcuate ligament syndrome. All other vessels were patent.

DISCUSSION:
Median arcuate ligament syndrome is a rare cause of post-prandial abdominal pain and weight loss that can often be challenging to diagnosis unless suspected by the clinician. Many patients undergo extensive workups for abdominal pain before being diagnosed. This syndrome presents similar to chronic mesenteric ischemia however many of these patients lack the typical cardiovascular risks factors associated with mesenteric ischemia as the demographic for MALS is typically middle-aged females ranging from age 40-60 years old. Patients are also often misdiagnosed with functional dyspepsia. Patients diagnosed with this disease should undergo laparoscopic celiac artery decompression which cures the majority of the patients with symptom recurrence occurring in approximately 6% of patients.