bluuebunny/crossref_metadata_2025_split huggingface dataset:
1455 Double Trouble: A Rare Case of Colonic Mixed Adenoneuroendocrine Carcinoma (MANEC)
Authors: Averbukh Leon D. , Forouhar Faripour , Vaziri Haleh 
Published: October 2019

INTRODUCTION:
Mixed adenoneuroendocrine carcinoma (MANEC) is a rare malignancy involving both epithelial and neuroendocrine components and accounts for fewer than 2% of all colorectal cancers. We present the case of a 34 yo male whose persistent weight loss and cramping abdominal pain led to the discovery of Stage IV MANEC.

CASE DESCRIPTION/METHODS:
34 yo male with no significant past medical history presented with the chief complaint of diffuse abdominal cramps over the preceding 3 days. He had intermittent, non-bloody diarrhea, and endorsed 25-30 lb unintentional weight loss in the preceding 4 months. Labs were significant for a WBC of 17.3 U/L, CRP 94.4 mg/L, and sedimentation rate of 60 mm/hr. CT abdomen and pelvis was concerning for underlying inflammatory bowel disease. Before further work up, the patient left against medical advice. He returned 2 months later due to persistent symptoms. Gastrografin study and colonoscopy showed a circumferential, partially obstructing, ulcerated mass in the sigmoid colon (Figure 1). Biopsy of the lesion showed moderately differentiated adenocarcinoma. He underwent exploratory laparotomy, sigmoidectomy, and mesenteric lymph node dissection with pathology consistent for mixed adenoneuroendocine carcinoma with a high grade aggressive neuroendocrine component of the sigmoid with involvement of small bowel, bladder serosa, and lymph nodes (Figure 2). The metastatic component was exclusively high-grade neuroendocrine tumor. The patient subsequently underwent complete resection of primary and metastatic lesions and was started on Cisplatin and Etoposide for adjuvant chemotherapy.

DISCUSSION:
MANEC is a mixed tumor containing adenocarcinoma and neuroendocrine components each representing at least 30% of the tumor. It is hypothesized that the tumor arises from multi-potent endodermal progenitor cells with bi-directional differentiation into both epithelial and neuroendocrine neoplasms. Outcomes depend on each malignant component and the type of neuroendocrine cells present. Due to its neuroendocrine component, MANEC is more aggressive and advanced at the time of diagnosis with poorer outcomes as compared to adenocarcinoma. While no standardized treatment regimen has been identified for MANEC, currently accepted therapy involves complete resection of the primary and metastatic lesions with individually tailored adjuvant chemotherapy to help reduce its high recurrence rate.
1457 Cocaine-Induced Colonic Ischemia
Authors: Abdo Michael , Kozacek Kyler S. , Oroian Tudor , Mank Victoria M. , Hudspath Caleb , Manibusan Pedro 
Published: October 2019

INTRODUCTION:
Cocaine use is associated with arterial vasoconstriction and enhanced thrombus formation. Rarely, these effects on the intestinal blood supply result in intestinal ischemia. Cocaine-induced ischemic colitis is a relatively poorly-defined variant of this phenomenon, but some studies suggest it may be associated with higher morbidity and mortality than other etiologies. Therefore, timing is critical in both diagnosis and initiating treatments to prevent poor outcomes. We present a case of a middle-aged patient who had an unusual presentation for ischemic colitis due to cocaine abuse.

CASE DESCRIPTION/METHODS:
A 49-year-old male with a history remarkable only for alcohol and cocaine use disorders presented with a two day history of hematemesis with syncope and severe abdominal pain. Urine drug screen was positive for cocaine on admission, and initial workup with EGD was grossly unremarkable. An abdominal CT scan showed extensive circumferential submucosal fat but without colonic wall thickening or other signs of acute process, and a mesenteric angiography was similarly unrevealing. However, his clinical condition continued to deteriorate over the next 48 hours with worsening abdominal pain, and he began passing large melanic stools with occasional frank red blood. He subsequently became septic; due to concern for ischemic bowel, a colonoscopy was emergently performed. Diffuse severe ischemic changes with deep cratered ulcers in the descending, transverse, and ascending colon were noted. Emergent laparotomy was performed for a near-total colectomy, after which the patient began to stabilize.

DISCUSSION:
Long-term cocaine abuse is associated with multiple vascular morbidities, including bowel ischemia. Our patient presented in extremis due to bowel ischemia of both SMA and IMA territories requiring intensive care and emergent colectomy. Interestingly, despite the widespread vascular compromise, initial symptoms were nonspecific without blood per rectum and imaging was unremarkable, including CT and angiography. This illustrates the importance of maintaining clinical suspicion and the utility of colonoscopy in diagnosis, as his unusually diffuse disease eventually necessitated a colectomy in this middle-aged man with otherwise unremarkable medical history.
1463 Underwater Cap-Assisted Endoscopic Diagnosis and Treatment of Anal Intraepithelial Neoplasia
Authors: Ali Mohammed Fahad , Brennan Gregory T. , El Hage Chehade Nabil , Samarasena Jason 
Published: October 2019

INTRODUCTION:
Anal intraepithelial neoplasia (AIN) is a premalignant lesion which can progress to squamous cell carcinoma of the anus. Although rare, therate of anal canal cancer is rising within the United States and is associated with significant morbidity and mortality. Early detection of premalignant lesions is critical. AIN is frequently missed because detailed examination of the anal canal is difficult. Here we present two cases describing techniques to aid in the diagnosis and resection of AIN including endomicroscopy, distal attachment caps, and underwater endoscopy.

CASE DESCRIPTION/METHODS:
Patient 1 A 78-year-old woman with a history of HPV and AIN presented for follow up. A flexible sigmoidoscopy (FS) with a distal attachment cap was used to examine the anal canal and revealed two verrucous polypoid-appearing lesions just distal to the dentate line. Probe based confocal endomicroscopy of these lesions showed abnormal cellular structure and capillaries. The lesions were completely resected using a combination of biopsy forceps and cold snare. Both lesions were consistent with high-grade squamous AIN II-III. Repeat flexible sigmoidoscopy 6 months later showed no evidence of recurrence. Patient 2 A 63-year-old woman with a history of AIN with high grade dysplasia was referred to our center for resection. FS with a ESD cap attachment and water-immersion revealed a 5 mm villiform lesion (Figure 1). Using water-immersion the lesion appeared to float up off the mucosa. Probe based confocal endomicroscopy showed highly vascularized abnormal cellular architecture. The lesion was removed with cold forceps and pathology was consistent with low grade squamous AIN I. A follow up FS 1 year later showed a lesion consistent with AIN using narrow band imaging and near focus (Figure 2 and 3). The lesion was removed in piecemeal fashion with cold forceps underwater. Pathology again was consistent with low grade squamous AIN 1.

DISCUSSION:
Here we described techniques to improve identification and resection of AIN. Our approach is to use an ESD cap which helps stabilize the scope tip in the anal canal and spread mucosal folds to flatten areas of interest. Confocal probe based endomicroscopy has been described to take “optical biopsies.” Narrow band imaging and near focus of endoscopic images aids in the identification of lesions. Finally, water-immersion technique frequently causes AIN lesions to float up off the mucosa which aids in identification and resection.
1466 Diverticulitis: The Rare and Unanticipated Complication of Colonoscopy
Authors: Khan Zarak H. , Korpole Pranay R. , O'Brien John 
Published: October 2019

INTRODUCTION:
Colonoscopy is a common therapeutic and diagnostic tool used for colon cancer screening and surveillance. Although considered low risk, the most common complications include hemorrhage, bowel perforation and infection with rates of 1%, 0.1% and 1.1% respectively. Other uncommon complications include splenic injury and bowel obstruction. Diverticulitis is defined as inflammation of a diverticulum and is the result of a small tears in the diverticular wall. The reported incidence of colonoscopy induced diverticulitis differs between 0.08 and 1.9 per 1000 colonoscopies.

CASE DESCRIPTION/METHODS:
64-year-old male with past history of CAD, HLD and diverticulitis presented with severe abdominal pain. 6 hours before presentation, patient had undergone a screening colonoscopy with polypectomy. Patient's abdominal pain was sharp and non-radiating. He denied any associated fevers, diarrhea, nausea or vomiting. Patient however did complain of chills. Upon presentation, patient had a temperature of 102.3 °F and HR of 109. Physical exam revealed diffuse abdominal tenderness. Labs were significant for lactic acid of 3.7. WBC count was 7,900. CT scan findings suggested diverticulitis. Repeat CBC few hours later showed an up-trending WBC count (10,800). Patient was managed with IV fluids and antibiotics. He was initially kept n.p.o. and then diet was gradually advanced which he tolerated well. A day after admission, patient was tolerating oral intake well and pain had resolved. He was discharged in stable condition.

DISCUSSION:
A retrospective cohort studied 236,377 colonoscopies with development of acute colonic diverticulitis in 68 patients within 30 days after colonoscopy. The rate of colonoscopy induced diverticulitis in the cohort was estimated to be 10 times less than the reported rates of other complication. Past history of diverticulitis is considered to be a risk factor for development of diverticulitis. No evidence of diverticulitis specifically after polypectomy was found on literature review. In our patient, we suspect that the micro and/or macro perforations induced by polypectomy led to introduction of bacteria into the diverticular wall and subsequently to the blood stream resulting in both local and systemic manifestations. Moreover, our patient's past history of diverticulitis also increased his risk. Our case is intended to shed light on this rare but potentially serious complication of colonoscopy in patients who develop severe abdominal pain and/or fever following colonoscopy.
1467 Are Those Really Xanthomas?
Authors: Khan Zarak H. , Korpole Pranay R. , Singh Tejveer , Jarodiya Vijay , Khan Tahir , Rai Raveen 
Published: October 2019

INTRODUCTION:
GI xanthomas are benign mucosal neoplasms consisting of foamy histiocytes. Xanthomas most frequently involve the stomach and usually spare other parts of the GI tract. Gastric xanthomas are well known as yellow to white well-demarcated plaques generally noted after gastrectomy. There is varying association of hyperlipidemia with GI tract xanthomas. Colorectal xanthomas are a rare entity when compared with gastric and esophageal xanthomas and their true incidence rates are unknown.

CASE DESCRIPTION/METHODS:
An 89-year-old lady with past medical history of short gut syndrome secondary to partial colectomy presented to the hospital with nausea and vomiting. Upon presentation, her vitals were stable. On examination, her abdomen appeared distended. Lab work was notable for sodium of 120. CT scan of the abdomen revealed marked wall thickening of the rectosigmoid colon consistent with colitis. Gastroenterology was consulted for further evaluation. Patient's electrolyte abnormalities were attributed to fluid loss secondary to vomiting. She underwent an EGD which was normal and a sigmoidoscopy which revealed multiple submucosal masses in the rectum and distal sigmoid. Biopsy specimens taken from the rectosigmoid colon revealed xanthomatous mucosal changes without any evidence of malignancy or inflammation. A fasting lipid panel was within normal limits. Patient's vomiting and electrolyte abnormalities resolved with bowel rest and IV fluids. She was able to tolerate advancement in diet and was therefore discharged home with follow up in as an out patient with Gastroenterology. Review of patient's chart revealed four previous visits in the last 3 years to the hospital for nausea, vomiting and abdominal distension. During each visit, imaging was significant for colitis and colonoscopy revealed sigmoid masses proven to be xanthomas on histopathology.

DISCUSSION:
Majority of the cases of colorectal xanthomas are incidental findings on elective colonoscopies and usually don't present with upper or lower GI symptoms. They typically appear as whitish to yellowish plaques or papules. Our case presentation is unusual in that our patient presented with recurrent symptoms and signs of gastrointestinal tract obstruction such as vomiting and abdominal distension and imaging consistent with colitis without other obvious etiologies. Furthermore, colonoscopy revealed submucosal mass-like xanthomas rather than plaques or papules.
1469 Hematochezia in a Young Female: An Early Sign of Serrated Polyposis Syndrome
Authors: Aamar Ali , Aloreidi Khalil , Tsipotis Evangelos , Reddy Madhavi 
Published: October 2019

INTRODUCTION:
Hyperplasic polyposis syndrome is characterized by multiple serrated polyps in the colon. It is also known Serrated Polyposis Syndrome (SPS). Serrated polyps can be divided into hyperplastic polyps, sessile serrated polyps and traditional serrated adenomas. It is associated with up to 50% lifetime risk of colorectal cancer. Serrated polyps can be difficult to diagnose due to their flat and sessile nature making it hard to be visualized by the endoscopist. We report a case of a young Caucasian female who presented with hematochezia and she was found to have SPS.

CASE DESCRIPTION/METHODS:
A 29-year-old female presented to the clinic with hematochezia. She did not have any family history of colon cancer in her first-degree relatives. She underwent a diagnostic colonoscopy and multiple polyps were seen. A 1.5 cm flat polyp (Figure 1) was seen in the ascending colon that was removed with endoscopic mucosal resection (EMR). Biopsy suggested hyperplastic polyp. A 3.5 cm flat polyp (hyperplastic) was seen in the ascending colon (Figure 2) that was removed with EMR and 5 clips were placed to prevent delayed bleeding. A 5 mm flat polyp was seen in the transverse colon and a 1 cm polyp was seen in the descending colon. Patient was rescheduled for colonoscopy in 3 months to remove these polyps. On repeat colonoscopy, a 1 cm polyp (hyperplastic) was seen in the ascending colon at previous EMR site. Repeat EMR was performed to remove the polyp. An 8 mm flat polyp (hyperplastic) was seen in the ascending colon that was removed with cold snare polypectomy. A 6 mm flat polyp (tubular adenoma) was seen at the hepatic flexure that was removed with snare cautery polypectomy. A 6 mm polyp (hyperplastic) was seen in sigmoid colon that was removed with cold biopsy polypectomy.

DISCUSSION:
Sessile polyposis syndrome (SPS) is defined as following: (1) At least 5 serrated lesions proximal to sigmoid colon with at least 2 polyps >1 cm in size; (2) One serrated polyp was family history of SPS; (3) >20 serrated polyps in the entire colon. Based on current studies of SPS, some experts believe that patients should undergo regular endoscopic surveillance to prevent malignant progress of polyps removing only proximally located polyps, while others believe all polyps greater than 5 mm should be removed. First-degree relatives of patients with SPS should be screened starting at age 40 or 10 years earlier than age of presentation of SPS in the family member.
1471 Normal Polypoid Tissue After Endoscopic Full Thickness Resection of Colonic Lesions
Authors: Al-Taee Ahmad M. , Alkaade Samer 
Published: October 2019

INTRODUCTION:
Endoscopic full thickness resection (EFTR) is a novel endoscopic procedure for management of challenging colorectal lesions. Resection site growths after EFTR are usually concerning for incomplete resection or recurrence of the initial lesion. Here we report two patients who underwent EFTR and had polypoid growth of normal tissue at the site of EFTR on surveillance colonoscopy.

CASE DESCRIPTION/METHODS:
Case 1 A 51-year-old Caucasian male was referred for evaluation of residual sigmoid colon tubulovillous adenoma with focal high grade dysplasia. He has a family history of late onset colorectal cancer in his mother and grandmother. He had no abdominal symptoms and examination was unremarkable. Colonoscopy revealed residual polypoid tissue at the site of a prior attempted polypectomy for which he underwent EFTR. Surveillance colonoscopy 6 months later showed a 15-mm polyp-like growth at the site of prior EFTR that was lifted and resected with a hot snare (Figure 1). Pathology showed benign mesenchymal proliferation. Case 2 A 70 year-old Caucasian female was referred to our clinic for evaluation of an incompletely resected 20-mm transverse colon tubular adenoma. Her father developed colon cancer after the age of 60. She had no abdominal symptoms and examination was unremarkable. Colonoscopy showed a 20-mm transverse colon polyp with overlying scarring. She underwent EFTR and pathology showed tubular adenoma with clear margins. Repeat colonoscopy 6 months later showed a 10-mm polyp-like lesion at the site of previous EFTR that was lifted and resected with a hot snare (Figure 2). Pathology showed normal colonic mucosa.

DISCUSSION:
EFTR is a novel procedure for management of lesions that are not amenable to conventional endoscopic resection methods such as non-lifting lesions, lesions with high probability of malignancy, and lesions located in difficult anatomic locations. It is an attractive alternative to surgical resection or endoscopic submucosal dissection for management of such lesions. Resection site growths after EFTR are usually concerning for recurrence. However, polyp-like growths of normal tissue after EFTR were noted in 2 out of 8 patients who underwent EFTR at our institution. Therefore, EFTR site growths may not always represent recurrence of the initial lesion. Awareness of this possibility can alleviate patient anxiety and reduce cost associated with further investigations and resections.
1473 A Vanishing Cecal Mass
Authors: Newman Krista M. , Shmidt Eugenia , Vercellotti Gregory 
Published: October 2019

INTRODUCTION:
Systemic mastocytosis (SM) is a rare disease characterized by infiltration of mast cells in extracutaneous organs. Although gastrointestinal (GI) manifestations such as nausea, vomiting, abdominal pain are observed in up to 60-80% of patients, colon lesions are rarely identified. Here we describe an unusual case of SM that manifested as a colon mass on routine screening colonoscopy.

CASE DESCRIPTION/METHODS:
A 71-year-old, asymptomatic, female with a long history of urticaria pigmentosa was referred to a gastroenterology clinic for evaluation of an eight by twelve centimeter, polypoid mass involving the cecum and ileocecal valve, found on screening colonoscopy. Subsequently, a CT scan noted mucosal hyperenhancement with slight vascular engorgement and colonic wall thickening involving the cecum and proximal ascending colon. Pathology from the initial biopsies revealed dense (>100 per high powered field) infiltration of mast cells that stained positive for CD117 and CD25 cell surface proteins. The initial, large, polypoid, cecal mass was not present on repeat colonoscopy with upper endoscopy. Instead, there was patchy nodular- appearing mucosa in the right colon. Follow-up biopsies of the upper and lower GI tract revealed dense infiltration of mast cells in the duodenum, ileum, ascending colon and transverse colon as well as elevated serum tryptase level (38 ug/L), all findings consistent with GI involvement of SM. Histamine-blocking therapy with ranitidine and cetirizine was commenced.

DISCUSSION:
Systemic mastocytosis results from a sporadic somatic mutation in the KIT gene that encodes a protein implicated in cell growth, division & survival that results in overproduction of mast cells that accumulate in organs. There are four subtypes of SM that range in severity from slow and indolent to rapidly progressive towards organ failure. It is important to recognize and categorize systemic involvement of mastocytosis to aid in prognosis and treatment. Frequently, GI symptoms are mild but can include more serious effects of mast cell infiltration including peptic ulcer disease, malabsorption and non-cirrhotic portal hypertension. Specifically important to gastroenterologists is the recognition of GI involvement of mastocytosis disorders and understanding of appropriate evaluation, including upper and lower endoscopy with random biopsies to identify mast cell infiltration. Although GI symptoms are frequent and result in endoscopic evaluation, there are only rare reports of colon masses.
1474 Cowden and MAP Syndrome: The Untold Story of a Screening Colonoscopy—Case Report
Authors: Fernandez Wilfor Diaz , Tiriveedhi Kiranmaye 
Published: October 2019

INTRODUCTION:
Cowden syndrome is a rare autosomal dominant condition associated with PTEN gene mutation. MUTYH-associated polyposis (MAP) is inherited by autosomal recessive fashion. Cowden syndrome presents with multiple hamartomas in a variety of tissues, oral fibromas, and punctate palmoplantar keratoses, and an increased risk of breast, endometrial, thyroid, kidney and colorectal cancers. MAP syndrome is associated with adenomatous polyps and colon cancer predisposition.

CASE DESCRIPTION/METHODS:
51-year-old female underwent screening colonoscopy and was found to have multiple polyps throughout the colon. Biopsy showed ganglioneuromas and hamartomous polyps. Medical history was significant for hypothyroidism and hypoparathyroidism secondary to thyroidectomy for a goiter, bilateral mastectomy for a ductal carcinoma in situ, hysterectomy for fibroids, palmar keratosis and oral papillomatosis. Family history was relevant for breast cancer in her mother at age 50. Genetic analysis revealed mosaicism for a loss of function variant in PTEN and autosomal recessive pathogenic single MUTYH variant which confirmed Cowden Syndrome and carrier state for MAP syndrome. Appropriate cancer surveillance was arranged for our patient according to the National Cancer Center Network Guidelines through multidisciplinary approach.

DISCUSSION:
PTEN gene is a tumor suppressor responsible for regulating the cell cycle. Because of her mutation, our patient is susceptible for an array of different malignancies. Her genetic profile showed mosaicism for PTEN genetic variant. Adequate cancer surveillance for colon cancer, renal cell carcinoma and recurrence of breast cancer were discussed with our patient. MUTYH variant mutation was found in this patient. However, she inherited only one single copy of this recessive gene expecting not to develop clinical MAP syndrome. Risks associated with a single variant in MUTYH are unclear. There are some reports that suggest an inconsistent increased risk of colon, endometrial, and breast cancer. National Cancer Center Network Guidelines has created surveillance guidelines for individuals with a single MUTYH variant but cautioned that these guidelines are likely to change over time. Uniquely, extracolonic neoplastic complications were detected before the diagnosis of Cowden in our patient. High clinical suspicion and early diagnosis of this condition is crucial for effective prevention of colonic and extracolonic malignancies that these individuals are at high risk for.