bluuebunny/crossref_metadata_2025_split huggingface dataset:
2986 Celiac Disease Among Hispanics Undergoing EGD for Workup of Unexplained Anemia in a Safety Net Population
Authors: Epistola Raisa , Hou Linda A. , Eysselein Viktor E. , Reicher Sofiya , Fleischman Wayne 
Published: October 2019

INTRODUCTION:
Celiac disease (CD) affects roughly 1% of the population globally and 0.75% of the general US population. In individuals with confirmed iron deficiency anemia (IDA), the prevalence of CD is much higher, with nearly 4% of such individuals affected in large cohort studies. The prevalence of CD in Hispanics however remains largely unknown due to over representation of non-Hispanic whites in the studies. We aimed to examine the prevalence of CD in Hispanics with unexplained anemia and in those with confirmed IDA presenting to a large safety net health care system.

METHODS:
Electronic health records of all Hispanic patients (self-identified) referred for workup of unexplained anemia at our institution from 8/2013 to 4/2018 were retrospectively analyzed. Data were collected with regards to comorbidities, pre-procedure hemoglobin, and pre-procedure ferritin. All patients underwent EGD with duodenal biopsies from both the first and second portion of the duodenum as part of routine workup for unexplained anemia. Anemia was defined using the established World Health Organization criteria (hemoglobin <12 g/d for women, <13 g/dL for men). Pathology reports were reviewed for biopsy proven CD utilizing the Marsh classification system. Subgroup analysis of patients with confirmed IDA (ferritin <15 ng/mL) was also performed. Mean hemoglobin and ferritin were calculated in all patients. In those with biopsy confirmed CD, a mean Marsh classification score was also determined. Means and standard deviations were calculated for all continuous variables to better characterize our population cohort.

RESULTS:
96 Hispanic patients with unexplained anemia were identified; 36 were male; average age 53.9. In our patient cohort peptic ulcer disease 14.4% (14/96) and malignancy 6.2% (6/96), were most common identified etiologies of anemia. There were 5 cases of biopsy proven CD with an overall prevalence of 5.2% (5/96). Prevalence of CD among patients with confirmed IDA was 2.4% (1/41) (Table 1). At the time of diagnosis average Marsh score was 3 for all patients and for patients with IDA.

CONCLUSION:
Our data from large safety net health care system shows high rate CD among Hispanics with unexplained anemia suggesting the continued utility of screening for CD in work up of unexplained anemia in Hispanic patient population.
2987 Significance of Small Intestine Search in Dysphagia of Elderly People
Authors: Kurokawa Sei 
Published: October 2019

INTRODUCTION:
Patients suspected of having small bowel disease tend to increase, and even in the elderly, it is often necessary to perform small bowel examination. However, elderly people often have dysphagia and may not be able to perform capsule endoscopy (CE) examination. The use of an advanced capsule endoscope insertion aid and an overtube was used to examine the usefulness of small intestine examination in elderly people with difficult swallowing.

METHODS:
In this study, patients aged 75 years and older who required small-bowel examination were treated as patients with dysphagia who required device as group A and patients who did not use as group B. We compared clinical data and retrospectively examined the usefulness of CE in elderly people with dysphagia. From July 2015 to April 2019, our hospital performed CE were 273 cases, 247 patients, elderly people over the age of 75 were 154 cases, 139 patients. Group A: 21 cases, 21 patients. Group B: 133 cases, 118 patients.

RESULTS:
Gender differences are male/female, A group 9/12, B group 62/71. The average age was 85.8 years for A group and 82.3 years for B group (P = 0.0018). Stomach transit time (min): A group average 64.9, B group average 53.9, small intestine transit time (min): A group average 350.4, B group average 349.9. In blood examination, RBC (× 104/μl): A group average 314.8, B group average 331.2, Hgb (g/dl): A group average 9.24, B group average 9.74, Alb (g/dl): A group average 3.08, B group average 3.43 (P = 0.0156), Cre (mg/dl): A group average 1.77, B group average 1.14 (P = 0.0060). Anticoagulant medications were 14 in A group (66.7%) and 74 in B group (55.6%). Mini-Mental State Examination (MMSE): A group 11.1, B group 22.0 (P < 0.0001). In OGIB for inspection purposes, 17 cases were A group (80.9%) and 100 cases were B group (75.2%). The incidence rate was 11 in A group (52.4%) and 78 in B group (58.6%) (P = 0.5890).

CONCLUSION:
In elderly patients who require small-bowel examination, it was possible to obtain the same finding rate as subjects who can swallow it, using a CE insertion aid together.
2991 Preoperative Imaging of Gastric Neuroendocrine Tumors and Lymph Node Metastases
Authors: Ragheb Jonathan , Bahdi Firas , Mehta Neal , Butler Robert , Chahal Prabhleen , Stevens Tyler , Cruise Michael , McNamara Michael , Walsh R. Matthew , Augustin Toms , Bhatt Amit 
Published: October 2019

INTRODUCTION:
In recent years, detection of gastric neuroendocrine tumor (GNET) lymph node (LN) metastasis has become more apparent with innovative imaging such as endoscopic ultrasound and PET. Currently, the National Comprehensive Cancer Network recommends multiphasic CT or MRI as part of the initial workup for GNETS. We sought to evaluate these recommendations with respect to the detection of LN metastases and compare CT to alternative pre-operative modalities for gastric staging at our institution.

METHODS:
This is a single center retrospective study evaluating consecutive patients who underwent surgical resection or endoscopic submucosal dissection of biopsy proven GNET from April 1988 to January 2019 at a tertiary referral center. LN metastases were defined by positive nodes following resection. Local invasion was characterized by tumor involvement of any gastric layers beyond the mucosa. Regional metastases included perigastric (gastroduodenal, gastrohepatic, gastroepiploic, pyloric, pancreaticoduodenal), celiac, and peripancreatic LN abnormalities. Distant metastases were defined as involving another solid organ, retroperitoneal or distant LN. Imaging modalities included endoscopic ultrasound, CT, MRI, and PET.

RESULTS:
Thirty patients were included in the study with each patient's respective GNET imaging in Table 1. Mean age of diagnosis was 63.9 ± 12.3 years old. There were no type 2 NET's identified based on documented history. Twenty patients underwent CT, and 13 of these patients underwent additional imaging or preop staging (EUS, PET, MRI, Octreotide, pre-op surgical biopsy). Of those undergoing CT, 12.5% of patients were identified as having regional or distant metastases; however, when correlating CT findings in patients with LN pathology, no patients were correctly identified as having positive LN's (Table 2). Conversely, patients with regional LN metastases on biopsy had CT's showing no lymphadenopathy or local metastases.

CONCLUSION:
As in most cancers, successful interventions vary according to presence or absence of LN metastases. Despite a limited number of patients in this study who had true LN metastases resected, CT and alternative modalities appeared comparable in their ability to “rule out” LN metastases for GNET. Of some concern, none of the imaging appeared sensitive for GNET LN metastases. Investigation of imaging modalities more sensitive for GNET LN metastases, such as PET Dotatate, is needed to better inform decisions regarding medical and surgical intervention.
3001 A Rare Location for Signet Ring Cell Carcinoma
Authors: Ousley Joshua , Kumar Manoj , Mando Rufaat , Mizrahi Meir 
Published: October 2019

INTRODUCTION:
Roughly 96% of Signet Ring Cell Carcinoma (SRCC) occurs in the stomach. However, it has also been reported at extra-gastric locations such as the breast, colon, and gallbladder. Although still rare, the incidence of gastric signet ring cell carcinoma has been rising in the past decade and it is now being found in uncommon locations. Only 7 cases have been reported for the presence of a SRCC in pancreas. We report a case of pancreatic signet ring cell carcinoma which was diagnosed with EUS-guided biopsy.

CASE DESCRIPTION/METHODS:
Case A 71-year-old Caucasian male presented with diarrhea and abdominal pain for 1 month as well as a 10 lb weight loss over a 2-month period. Physical examination was positive for jaundice and initial labs showed a bilirubin of 9.8, AST 229, ALT 240, and alkaline phosphatase 420. MRI of the abdomen showed dilation of both the pancreatic duct and common bile duct (CBD), and a distal CBD stricture. The patient underwent an EUS, which showed a 2.8 cm × 2.5 cm hypoechoic ill-defined mass in the head of the pancreas with poorly defined, irregular borders. A 22-gauge needle was used to perform aspiration with four needle passes. ERCP was then performed to place a 10 Fr plastic stent across the CBD stricture. Pathology of the pancreatic mass aspiration revealed moderately to poorly differentiated adenocarcinoma with signet ring cell features. PET CT and abdominal CT were performed without evidence of distant metastasis. CA 19-9 levels were 352. Based on radiographic imaging and endoscopic ultrasound, the patient was staged IIA (T3N0M0) but was found not to be a surgical candidate due to multiple cardiopulmonary comorbidities and was started on neoadjuvant chemotherapy.

DISCUSSION:
The histopathology of SRCC in pancreas appears similar to that of the gastric variant in that the tumor is characterized by intra-cytoplasmic mucin vacuoles that expand the nucleus of the cell to the periphery. Little is known about the differences in prognosis and treatment. However, there is an overall poorer prognosis in patients with SRCC regardless of location. EUS guided biopsy provides a safe technique in the setting of co-morbidities which preclude surgery. Our case demonstrates the need for more research in SRCC on any location as well as targeted modalities for extra-gastric locations while also highlighting the usefulness of EUS as a tool for diagnosis.
3004 Recurrent Painful Pancreatitis After Puestow Procedure
Authors: Arroyo-Mercado Fray Martin M. , Noel Jude , Vignesh Shivakumar 
Published: October 2019

INTRODUCTION:
Chronic pancreatitis (CP) is a progressive, irreversible inflammation and fibrosis of the pancreas, leading to irreversible damage, chronic pain, and pancreatic insufficiency due to loss of endocrine and exocrine function. The most common etiologies are alcohol abuse, autoimmune pancreatitis, ductal obstruction, hypercalcemia, and hypertriglyceridemia.1

CASE DESCRIPTION/METHODS:
A 23-year-old male with history pancreatitis, tobacco smoking with multiple admissions due to epigastric pain, nausea, and vomit after lateral pancreatojejunostomy. Prior workup for autoimmune pancreatitis and hypertriglyceridemia was negative. Evaluation was significant for an MRCP (Figure 1) that showed pancreatic duct stones with near complete atrophy of the remaining pancreatic gland and an abdominopelvic CT scan (Figure 2) that showed no gallstones or dilation of the common bile duct. Endoscopic ultrasound showed a duodenal ulcer negative for H. pylori., one major criteria A and three minor criteria. Findings consistent with chronic pancreatitis as per Rosemont classification. Repeated upper endoscopy showed no evidence of prior duodenal ulcer. Abdominal pain, nausea, and pain persisted without significant improvement for months after surgery, with more than four admissions in six months.

DISCUSSION:
CP is a debilitating painful condition. Pain from CP is associated with mechanical obstruction, damaged intrapancreatic nerves and increased intraductal pressure, leading to dilation of the pancreatic duct.2,3 Treatment is focused on pain control with non-steroidal anti-inflammatory drugs, opioids, and celiac plexus block. Medical therapy often fails, and patients tend to require invasive measures such as endoscopic therapy and surgical procedures.4 Invasive interventions are used to relieve obstruction caused by pancreaticolithiaisis or strictures. Whipple resection and Puestow procedure are surgical procedures used for pain control. Modified Puestow is associated with decreased morbidity and decreases length of hospital stay. This procedure is designed to preserve healthy pancreatic tissue retaining exocrine and endocrine function of the pancreas.5 Complete pain resolution occurs in 80% of patients after lateral pancreaticojejunostomy. Nonetheless, failure rates are prevalent in numerous, creating frustration and depression in patients with this debilitating condition. Newer options are available, but most of them are offered at specialized centers, leading to limited access of these novel therapies.6
3008 Painless Jaundice, Sclerosing Cholangitis, and IgG-4 Related Disease
Authors: Weiss Matthew J. , Banaszak Lauren 
Published: October 2019

INTRODUCTION:
IgG4-RD can mimic PSC and Cholangiocarcinoma when presenting in the hepatobiliary system, and should be placed high on the differential diagnosis when there is multi-organ system involvement and negative workup for malignancy.

CASE DESCRIPTION/METHODS:
A 58 year-old male presented to the ED with painless jaundice and 6 months of episodic RUQ pain, cervical lymphadenopathy, increased anorexia, weight loss, and fatigue. Prior work-up included a CT abdomen/pelvis that showed intra-hepatic ductal dilation and possible stricture/mass at the common hepatic duct, as well as FNA biopsies of lymph nodes negative for malignancy. Initial lab work was significant for T bili of 8.5, AST of 289, AST of 231, and alkaline phosphatase of 1033, and lipase of 26. Physical exam was notable for scleral icterus, cervical lymphadenopathy, and jaundiced skin. Patient was admitted and underwent ERCP with findings of strictures with PSC-like beading; a stent was placed with improvement in his biliary obstruction. Brushings were obtained for cytology, which were negative for malignancy. Given concern for malignancy, further evaluation was performed including tumor markers which revealed an elevated CA 19-9. Staging chest CT revealed adenopathy concerning for metastases. Subsequent excisional biopsy of an enlarged cervical node was negative for malignancy but revealed a non-caseating granuloma. A second ERCP revealed an inflammatory stricture with brushings again negative for malignancy. Given lack of evidence of malignancy, an IgG4 level was checked which was elevated at 386. His presentation was thus thought to be most consistent with IgG4 sclerosing cholangitis, and he was started on systemic corticosteroids.

DISCUSSION:
IgG4-RD is characterized as a chronic relapsing fibro-inflammatory syndrome. Increased serum levels of IgG4 and infiltration of tissue by IgG4+ plasma cells are typical of IgG4-RD. Common histological findings include dense lymphoplasmacytic infiltrate with IgG4+ plasma cells, storiform fibrosis, and obliterative phlebitis. The above serological and histological findings together make a diagnosis of IgG4-RD likely. IgG4-RD can occur in multiple organ systems, with typical presentation in the pancreatico-hepatobiliary system as Autoimmune Pancreatitis or Autoimmune Sclerosing Cholangitis. Steroids are first-line treatment, with refractory cases requiring more aggressive immunosuppressive agents, such as Rituximab, to decrease the recurrence of inflammation seen in patients.
3011 Metastatic Pancreatic Cancer in 19-Year-Old
Authors: Yarra Pradeep , Thakur Kshitij , Tripathi Nishant , Aknabi Olalekan , Kudaravalli Praneeth 
Published: October 2019

INTRODUCTION:
Pancreatic cancer is a highly aggressive cancer. Worldwide, pancreatic cancer is the eighth leading cause of cancer deaths in both men (226,910 deaths annually) and women (205,332 deaths annually). Five-year survival rate even for node negative R0 pancreaticoduodenoectomy is only 30 percent and it is worse in case of node positive cancer at 10%.1 Here we present an extremely rare case of advanced metastatic cancer with metastasis to central nervous system at the age of 18 with no familial history.

CASE DESCRIPTION/METHODS:
19-year-old obese male presented as a transfer from outside hospital for increasing weakness and worsening confusion. His past medical history is significant for metastatic pancreatic cancer and smoking. On physical he was found to be lethargic, disoriented unable to answer questions with more than one word. Labs were CA 19-9 of 5423 and CEA of 244. MRI showed leptomeningeal enhancement and 3.8 cms mass at pancreatic head. Lumbar puncture was performed and CSF analysis showed the presence of malignant cells. He was now referred to hospice as he was no longer a treatment candidate.

DISCUSSION:
SEER (surveillance, epidemiology and end results program) database the incidence of pancreatic cancer in the age group our patient was in was 0.1% per 100,000 cases.2 In the NCRAS (National cancer registration and analysis service) database from 1998 to 2006 there were only 6 registered cases of pancreatic cancer.4 Early onset pancreatic cancer patients usually have an aggressive presentation and survivals are shorter with same tumor size.
3021 Recurrent Obstructive Jaundice from Iatrogenic Pancreatic Duct Stricture
Authors: Mehmood Faisal , Shah Yash , Korsten Mark 
Published: October 2019

INTRODUCTION:
There is always an intrinsic risk of complications with ERCP. The most common early complication include pancreatitis, followed by infection, bleeding and perforation.1 Late complications include pancreatic ductal and parenchymal changes, stent migration and malfunction due to occlusion. Here we present a case of an elderly man with recurrent obstructive jaundice and underwent multiple ERCP.

CASE DESCRIPTION/METHODS:
An 81 years old man was admitted for two weeks history of dark brown urine, light brown colored stools and diffuse itching of the skin. His past medical history included HTN and HLD. He had admission for similar symptoms twice within last one year. On initial admission, he was noted to have obstructive jaundice picture with multiple gall stones, dilated intrahepatic ducts, CBD and pancreatic duct. He underwent ERCP with removal of multiple small gall stones and later underwent cholecystectomy with normal liver functions on follow up. He required sphincteroplasty on later admission. He denied fever, chills, abdominal pain, weight loss, nausea, vomiting, and changes bowel habits. He denied alcohol or any drug abuse. On physical examination, he was afebrile, and was found to have scleral icterus, yellowish discoloration of skin and excoriations in extremities. Laboratory investigation revealed worsening hepatic function with ALT 192, AST 140, ALP 779, GGT of 1098, total bilirubin of 11.3 and direct bilirubin of 8.1. Other blood test results were normal including WBCs, serum electrolytes, TSH, toxicology screen, kidney functions, viral hepatitis panel and coagulation profile. US abdomen showed dilated common bile duct to 18 mm, pancreatic duct and intrahepatic ducts. MRCP showed persistent chronic CBD dilated to 14 mm, pancreatic duct to 4 mm and marked intrahepatic biliary dilatation and a focal stricture was seen in proximal pancreatic duct. He underwent ERCP and was found to have ampullary stenosis. Sphincterotomy was performed. His signs and symptoms resolved on follow up visit.

DISCUSSION:
It is challenging to diagnose biliary strictures. Most pancreatic duct stricture are iatrogenic from operative trauma. Moreover, it is difficult to estimate the procedural complications as there is always an inherent bias and patient underreporting. However, ERCP is associated with fourfold increased rates of severe complications than other endoscopic procedures. To avoid these complications, the procedure should be performed by experienced provider and trend towards therapeutic approach as opposed to diagnostic approach.
3024 Post Whipple's Pancreatitis: Post Procedure Inflammatory Changes Sub-Serving a Diagnostic Challenge
Authors: Nwaichi Chineme , Haque Zohaib , Elkhouly Mohamed A. , Vohra Ishaan , Attar Bashar M. 
Published: October 2019

INTRODUCTION:
Making an accurate diagnosis of pancreatitis in the post-operative setting after a Whipple's procedure can be difficult. Acute pancreatitis inflammatory changes occurring in the peripancreatic area may be indistinguishable from post-operative peripancreatic inflammation hence creating a diagnostic challenge.

CASE DESCRIPTION/METHODS:
A 54-year-old woman with a past medical history of Type 2 diabetes mellitus, hypothyroidism, and pancreatic head neuroendocrine tumor status post-Whipple's procedure with a residual mild postoperative pancreatic fluid collection which was drained three years ago. She presented with epigastric pain of 5 days duration. She was hemodynamically stable, serum lipase was elevated to 2,752. Abdominal CT done 2 weeks prior to admission for cancer surveillance revealed a stent in the main pancreatic duct. Repeat abdominal CT scan demonstrated the stent and showed acute interstitial pancreatitis. MRI/MRCP done showed mildly ectatic pancreatic duct with a linear structure concerning for a retained stent. She underwent ERCP and the stent could not be visualized with no intervention performed. She was managed with intravenous fluids and analgesics for pancreatitis and subsequently had her diet advanced as tolerated.

DISCUSSION:
The true incidence of post-Whipple's pancreatitis is unknown, and there are many difficulties in making an accurate diagnosis of pancreatitis. Postoperative findings after pancreaticoduodenectomy can include inflammatory changes and fat stranding, which can make the differentiation between pancreatitis and post-operative changes challenging. Serum levels of amylase and lipase are unreliable in the postoperative period. In severe cases, an abdominal CT would be needed to make the diagnosis of postoperative pancreatitis. Post-Whipple's pancreatitis can have significant prognostic implications, including a higher risk of pancreatic fistula and a higher risk of delayed gastric emptying.