bluuebunny/crossref_metadata_2025_split huggingface dataset:
1841 An Unusual Case of Persistent Globus Due to Granular Cell Tumor of the Distal Esophagus
Authors: Makar Ranjit , Maklad Muthena , Aziz Hamza , Lankarani Daisy S. , Fayad Joseph M. 
Published: October 2019

INTRODUCTION:
Granular cell tumors (GCT) are rare soft tissue tumors arising from the Schwann cells. Most common sites involved are head and neck, although the gastrointestinal tract can be rarely involved. GCT of the esophagus are rare; their incidence in endoscopy series has been estimated to be approximately 0.033 percent, representing approximately 1 percent of benign esophageal tumors. GCT are mostly benign but rarely can turn malignant in 2% cases1. Patient are usually asymptomatic, although when symptomatic, patients can experience GERD, dysphagia and rarely Globus. We present an unusual case of persistent Globus due to granular cell tumor of the distal esophagus.

CASE DESCRIPTION/METHODS:
46 yo male with past history of asthma referred to the Gastroenterology clinic for symptoms of intermittent dysphagia to solids along with a feeling of persistent Globus sensation for 3 months. He was also experiencing symptoms of intermittent dysphagia to solids but none to liquids. Barium Esophagogram failed to reveal any pathology. Patient subsequently underwent EGD which revealed a 5mm sub mucosal lesion in the esophagus at 32 cms from the incisors (Figure 1). EUS demonstrated the lesion limited to the submucosa. Biopsy from the lesion revealed Granular cell tumor confirmed with immunostain positive for S 100 (Figure 2). The esophageal lesion was subsequently removed en bloc using band assisted EMR (Figure 3). A follow up clinic visit revealed complete resolution of globus and dysphagia.

DISCUSSION:
GCT are rare soft tissue tumors most commonly arising from the tongue, skin and subcutaneous tissue. Intestinal involvement is rare. Esophagus is the most commonly involved site in the GI tract and these lesions can present as subtle submucosal lesions. Although asymptomatic, GCT have been reported to cause dysphagia and rarely globus. Immunostain is usually positive for S-100 protein. Early recognition followed by en bloc endoscopic mucosal resection has been associated with complete resolution of symptoms.
1846 Mammalian Meat Allergy Masquerading as IBS-D
Authors: Bensinger Andrew , Green Patrick 
Published: October 2019

INTRODUCTION:
Mammalian meat allergy, often referred to as alpha gal allergy, is a recently discovered and increasingly prevalent condition with a wide range of clinical manifestations resulting from an allergic reaction mediated by IgE antibodies directed against galactose-alpha-1,3-galactose. Patients can frequently experience nausea, diarrhea, indigestion, urticaria, angioedema or anaphylaxis typically arising three to six hours after ingestion of mammalian protein. Interestingly, patients have longstanding tolerance to mammalian meats years before symptom onset and were bitten by the lone star tick, Amblyomma americanum, prior to symptom onset. We present a case of mammalian meat allergy diagnosed after the discovery of a tick on a patient’s lower extremity during a colonoscopy.

CASE DESCRIPTION/METHODS:
A 64-year-old female with a history of IBS-D presented to our clinic several years of chronic urticaria, diarrhea, nausea and abdominal pain, typically occurring after food intake. An extensive workup of chronic diarrhea was largely unrevealing. However, during a colonoscopy a tick was discovered on the patient’s inner thigh and was removed. Given her symptom complex, additional blood work was pursued and revealed elevated levels of serum alpha gal IgE. Further history revealed multiple prior tick bites with severe localized skin reactions in the past. At a follow-up visit after avoidance of mammalian meat and byproducts, the patient reported a 90% improvement in her symptoms, with just one formed bowel movement per day. She continued to have some bloating and abdominal pressure, but overall her symptoms were drastically improved with a modified diet.

DISCUSSION:
This case illustrates the challenges in identifying alpha gal allergy, a unique and frequently misdiagnosed allergic condition that is increasing in prevalence. The clinical presentation of alpha gal is unique when compared to other food allergies as there are a lack of immediate oral symptoms and episodes only occur after lone star tick exposure. Additionally, onset of symptoms occurs three to six hours after mammalian meat consumption, making its association difficult to uncover. The case also highlights the importance of taking a thorough history, with higher suspicion in patients with recurrent episodes of urticaria, angioedema, gastroenteritis, or anaphylaxis without an obvious cause. Thus, improved awareness of alpha gal allergy is essential, particularly for providers located in endemic areas like the southeastern United States.
1847 Buspirone for the Management of Functional Dyspepsia With Rapid Gastric Emptying (RGE)
Authors: Radetic Mark , Gabbard Scott 
Published: October 2019

INTRODUCTION:
Functional Dyspepsia is characterized by epigastric pain/burning, early satiety, and post-prandial fullness in the absence of any gastrointestinal pathology. It affects 5-10% of patients world-wide and is responsible for up to 75% of all cases of chronic dyspepsia. Although the pathophysiology is not fully understood, several mechanisms have been proposed: abnormalities in gastric compliance, visceral hypersensitivity, and post-infectious complications. A subset of patients with Functional Dyspepsia have rapid gastric emptying (RGE) – defined as <30% gastric retention at 1-hour on Gastric Emptying Scintigraphy (GES). A case is reported of Functional Dyspepsia with RGE responsive to treatment with buspirone – a 5-HT1A agonist that has been shown to improve post-prandial symptoms in Functional Dyspepsia.

CASE DESCRIPTION/METHODS:
The patient is a 60-year-old male with advanced COPD s/p bilateral lung transplant who initially presented with heartburn and acid regurgitation. Esophageal pH testing demonstrated increased esophageal acid exposure consistent with GERD. He was treated with a proton pump inhibitor (PPI) with improvement in his symptoms. Over the next year, he started experiencing persistent epigastric discomfort, nausea/vomiting, early satiety, and loose stools culminating in 5 hospitalizations over a 1-year period. An EGD and colonoscopy were unremarkable with negative biopsies for H pylori. A GES revealed 7% gastric retention at the 1-hour mark – consistent with rapid gastric emptying (RGE). The patient was diagnosed with Functional Dyspepsia with RGE and started on buspirone. Within 1 week, he reported complete resolution of his symptoms.

DISCUSSION:
The natural history of Functional Dyspepsia results in symptom relapse and/or persistence in up to 50% of patients. Guidelines recommend a step-wise approach to therapy: a 4-8 week trial of a PPI followed by a tricyclic anti-depressant (TCA) for persistent symptoms. While treatment with PPIs and/or TCAs provides relief for some, a significant number of individuals continue to experience refractory symptoms. A fraction of patients with Functional Dyspepsia are found to have RGE, which may provide us with an additional therapeutic target. Buspirone has been shown to promote fundic relaxation/increase gastric accommodation which may help normalize the rate of gastric emptying by preventing early redistribution of a meal to the distal stomach. Thus, buspirone may be of benefit in patients with Functional Dyspepsia found to have RGE.
1849 Chronic Periumbilical Abdominal Pain: Abdominal Migraine in an Adult
Authors: Peng Frederick B. , Kaur Manreet 
Published: October 2019

INTRODUCTION:
Chronic abdominal pain is a challenging, but frequently encountered clinical complaint. For adults, the symptoms are often debilitating and have significant implications on their daily lives. Often, these patients have undergone extensive work-up with laboratory testing and imaging that have either been unrevealing or non-specific. The history therefore becomes a key element in delineating potential etiologies. Here, we present a case of recurrent periumbilical abdominal pain in an adult with historical elements consistent with abdominal migraine – a clinical entity more commonly described in pediatric patients.

CASE DESCRIPTION/METHODS:
A 52-year-old man with diabetes and hypertension requiring renal transplant presented with 48 hours of periumbilical abdominal pain, increased eructation, and bilious emesis. For years, his symptoms had been minimally managed with IV fluids, analgesia, and anti-emetics during emergency room visits or hospital admissions. His last pain episode was a year ago. Work-up has been extensive and largely unrevealing, including multiple endoscopies, several CT scans, and a gastric emptying study. These episodes are intense, triggered by a lack of sleep, and often last a day or more with intermittent periods of relief (weeks to months). The pain is always associated with nausea, vomiting, and photophobia. He has a family history of migraines, but no personal history of headaches. On exam, he is hemodynamically stable, but purposely keeps the room dark. He has normoactive bowel sounds and is mildly tender to palpation in the periumbilical region. There is no rebound tenderness or guarding. Laboratory and imaging findings are unremarkable. Of note, his symptoms were previously managed with amitriptyline. A single dose of sumatriptan relieves his pain and he is discharged with outpatient GI follow-up.

DISCUSSION:
An abdominal migraine is a diagnosis of exclusion and its diagnostic criteria is delineated in Rome IV (Table 1). The described prodrome often resembles that of a typical migraine and management is similar. Prophylactic therapies include amitriptyline, propranolol, and topiramate, while abortive therapies involve triptans. Thus far, the disease entity is more commonly seen in pediatrics, but there is an increasing number of cases reported in adults. Like other functional GI disorders, a thorough history after comprehensive evaluation of all other etiologies differentiates abdominal migraine as a distinct clinical entity.
1853 Impaired Gastric Accommodation: A Key Player in Functional Dyspepsia
Authors: Figueredo Carlos , Boroda Konstantin , Hertan Hilary 
Published: October 2019

INTRODUCTION:
Poor gastric accommodation (GA) causes inadequate relaxation of the stomach during a meal. This leads to early satiety, fullness sensation, nausea, and vomiting. Poor GA is frequently seen in functional GI disorders and often coincided with anxiety and stress. It should be considered in the absence of metabolic disorders, eating disorders, and self-induced vomiting. Poor GA is quantified by the average increase of gastric volume after a meal over 1 hour. Poor GA is thought to be caused by altered neuro-modulatory pathways that affect accommodation time after a meal.

CASE DESCRIPTION/METHODS:
A 53-year-old woman with history of Type II Diabetes with Hba1c: 9.4%, complicated by diabetic neuropathy was admitted for treatment of UTI and Herpes Zoster. She also complained of new onset nausea, vomiting, and early satiety for 1 week. She could tolerate only thin liquids but no solids, due to persistent emesis within 10-20 min of food ingestion. An EGD was done and ruled out gastric outlet obstruction, but revealed candida esophagitis, which was treated with Fluconazole. The patient was then started empirically on Metoclopramide for presumptive Gastroparesis in the setting of poorly controlled Diabetes. The dose was gradually titrated up without favorable response. Her therapy was then escalated to Erythromycin along with Zofran and Benadryl, with no success. The patient was unable to complete a Gastric Emptying (GE) Study twice due to emesis following radiotracer ingestion. However, images from incomplete GE studies showed rapid movement of radiotracer from the fundus to the antrum. The patient was then switched to Buspirone 5 mg 30 minutes before lunch and dinner with remarkable improvement of her symptoms in 2 days.

DISCUSSION:
Early redistribution of radiotracer seen on scintigraphy is suggestive of impaired accommodation and is usually associated with early satiety, dyspepsia, nausea and vomiting. Rapid clinical improvement after 5-HT1a receptor agonist therapy not only implies anxiety and stress as contributing factors in this disorder, but also the role of presynaptic inhibitory 5-HT1a receptor activation in the gastric accommodation reflex. This allows for better stomach relaxation both in fasting and postprandial states. This therapy should be considered in patients with gastroparesis-like symptoms, but rapid gastric emptying seen on scintigraphy.
1858 Corneal Injury After Routine Gastrointestinal (GI) Endoscopy With Moderate Sedation
Authors: Dixon Robert , Adler Douglas G. , Timm Stephanie , Fang John C. 
Published: October 2019

INTRODUCTION:
Corneal abrasion is the most common ocular adverse event from deep sedation and general anesthesia. Its occurrence during moderate sedation for gastrointestinal (GI) endoscopy has not been previously reported. We report 5 cases of corneal abrasion following standard GI endoscopy under moderate sedation.

CASE DESCRIPTION/METHODS:
Retrospective chart review of ocular adverse events during endoscopy collected prospectively from our endoscopy quality system.
5 cases were identified from May 2013 to January 2019. All patients (4 men, 1 woman; age 45-76) underwent routine endoscopy (2 upper endoscopies, 2 colonoscopies, 1 upper endoscopy and colonoscopy) and noted ocular discomfort during recovery from the procedure. All procedures were performed under moderate sedation with 4 patients receiving non-anesthesiologist administered propofol sedation in our hospital endoscopy lab and the 5th patient receiving monitored anesthesia care (MAC) propofol sedation in the medical ICU. Procedure times ranged from 15 minutes to 2 hours 18 minutes. Oxygenation methods included two by nasal cannula (4L/min and 6L/min), two by non-rebreather mask (12 L/min), and one by Bilevel positive airway pressure mask (BiPAP). Ophthalmological examination confirmed the presence of a corneal abrasion in all cases. No patients had prior ocular disease or injury.

DISCUSSION:
Moderate sedation for GI endoscopy is very safe, but there exists a risk for corneal injury which has not been previously reported. Endoscopists and unit staff should be made aware of this complication, which is likely underrecognized. Training to ensure patient’s eyelids are fully closed during procedure, supplemental oxygen delivery systems are properly fitted and that there is no direct contact between the dependent eye and underlying head support can prevent this complication.
1864 Gastric Outlet Obstruction as a Complication of Replaced Gastrostomy Tube
Authors: Walradt Trent , Martin Tracey , Kieber-Emmons AnnMarie , Wan David 
Published: October 2019

INTRODUCTION:
Percutaneous endoscopic gastrostomy (PEG) is a common procedure for the provision of long term enteral nutrition (1). Indications for PEG tube replacement include tube malfunction, dislodgement, or scheduled exchange (2). Complications of replacement include bleeding, infection, and tube misplacement (3). Gastric outlet obstruction (GOO) is a rare complication seen when the tube is inserted distal to the pylorus or the balloon is overfilled (4).

CASE DESCRIPTION/METHODS:
An 86-year-old woman with a history of previous stroke necessitating prolonged enteral feeding through PEG presented to the hospital due to a clogged PEG tube. The tube was replaced at bedside via the percutaneous route and gastric fluid was aspirated. The tube was noted to be 2 cm deeper than prior to the procedure. A water-soluble contrast study through the PEG tube was obtained to confirm proper position (Figure 1) which showed contrast within the small bowel. The radiologist concluded the gastrostomy tube was in satisfactory position and tube feedings were resumed. Overnight, the patient experienced several episodes dark emesis. An endoscopy the next morning revealed the gastrostomy tube balloon was inflated in the duodenal bulb causing a GOO (Figure 2). The tube was repositioned in the stomach (Figure 3) and the patient was discharged 4 days later.

DISCUSSION:
This case illustrates the importance of establishing a standardized approach to the confirmation and documentation of PEG tube replacement. The marker on the replacement tube should be close to that of the previous tube. Notably, resistance to traction at a greater depth than expected may represent post-pyloric placement of the balloon. Finally, when imaging is obtained, fluoroscopy should be performed at an oblique angle and contrast should be observed in the stomach to confirm correct placement.
1867 A Case of Mistaken Identities: Impact of Kayexalate on the Colon
Authors: Nagirimadugu Ankita , Hershman Melissa , Ascunce Gil 
Published: October 2019

INTRODUCTION:
End stage renal disease (ESRD) affects nearly 750,000 Americans each year. Kayexalate (sodium polystyrene sulfonate) is commonly used to manage hyperkalemia in ESRD. Kayexalate is a nonspecific cation exchange resin that acts in the large intestine to allow for the exchange of sodium for any cation (potassium, calcium or magnesium). Kayexalate has an inherent lattice structure. Addition of calcium ions can lead to crystal formation that appears basophilic, rhomboid/triangular with a fish-scale appearance on Hematoxylin and Eosin (H&E) stain. Studies show that the combination of kayexalate and sorbitol, an osmotic laxative, may lead to osmotic shifts and ischemic damage. However, the impact of kayexalate alone in gastrointestinal tract is less established. We present a case of kayexlate crystal deposition appearing as a pseudo-polyp in the appendiceal orifice.

CASE DESCRIPTION/METHODS:
A 51-year-old woman with a past medical history significant for systemic lupus erythematosus, radical nephrectomy for renal mass complicated by dialysis dependent ESRD, mitral and aortic valve replacement on Coumadin, presented to the hospital for hyperkalemia requiring emergent dialysis. The patient developed melena in the setting of supratherapeutic INR. Colonoscopy revealed a non-obstructing 10mm yellow mass protruding from, and tethered to, the appendiceal orifice. The pseudo-polyp appeared to be on a stalk. Resection was performed using a biopsy forceps at the base. Pathology revealed foreign crystalline material that was suggestive of kayexalate deposition. The source of gastrointestinal bleeding was later identified as a jejunal arteriovenous malformation.

DISCUSSION:
Reports of kayexalate effects on the gastrointestinal tract are somewhat limited, but include findings of acute inflammatory tissue injury in as early as 24 hours, potentially with colonic ulceration. Kayexalate can also cause mechanical obstruction secondary to the development of crystalline structures in the colon. Prolonged uses of this medication can likewise lead to reversible crystal deposition within the esophagus, stomach and duodenum. This case highlights the potential for crystal resin deposition to appear as a pseudopolyp. Gastroenterologists should carefully review medication history when approaching a patient with a mechanical obstruction or colon ulceration in the setting of ESRD.
1869 A Case of Black Esophagus
Authors: Haddad Ibrahim , El Kurdi Bara , Babar Sumbal , El Iskandarani Mahmoud , Al Momani Laith , Alomari Mohammad , Young Mark 
Published: October 2019

INTRODUCTION:
Acute esophageal necrosis (AEN), commonly known as “black esophagus”, is a rare clinical diagnosis that was described for the first time in 1990 by Goldenberg. Since its first description, less than 100 documented cases were found in the literature. We present a 47 years old female who had this rare lethal condition.

CASE DESCRIPTION/METHODS:
A 47-years-old female with a past medical history significant for alcohol use disorder, gastroesophageal reflux disease, and severe malnutrition, who presented with hematemesis that started after multiple episodes of induced vomiting aiming to detoxify her body from recent heavy drinking according to the patient. At presentation, the patient was in hypovolemic shock and was given normal saline boluses, intravenous omeprazole and admitted to the intensive care unit. Complete blood count showed a drop in her hemoglobin level form her baseline 9 mg/dl to 4.6 mg/dl and was transfused with two units of packed red blood cells. After clinical stabilization, urgent esophagiogastrodudenoscopy (EGD) was done and showed severe esophageal ulcerations, erosions, and necrosis, findings suggestive of acute esophageal necrosis (Figure 1) and active diffuse gastric bleeding. Patient’s hemoglobin dropped again to 4 mg/dl, upon which she received a massive transfusion, was intubated for airway protection and started on vasopressors for hypovolemic shock unresponsive to intravenous fluid. After 4 days patient’s blood pressure normalized, her hemoglobin level stabilized and was extubated successfully. The patient was discharged home on a proton pump inhibitor and sucralfate. EGD was repeated after 2 weeks from discharge (Figure 2) and showed significant improvement of the mucosal abnormalities compared to her initial EGD.

DISCUSSION:
AEN is a rare but potentially lethal condition that is believed to be multifactorial in origin with a combination of ischemic insult, corrosive injury from gastric contents and decreased the function of the mucosal barrier, all of them play a major role in its pathogenesis. The mortality rate ranges from 30% to 50% and it’s largely influenced by the severity of the coexisting medical problems. Complications might be acute such as bleeding, mediastinitis, and perforation or chronic such as strictures formation and stenosis. The management is focused mainly on treating the underlying conditions, improving blood supply and acid suppression.