bluuebunny/crossref_metadata_2025_split huggingface dataset:
1458 Colon Cancer Metastatic to the Pancreas Presenting as DKA
Authors: Bush Allison , Humes Ross , Young Patrick 
Published: October 2019

INTRODUCTION:
New onset diabetes mellitus (DM) in the setting of a pancreatic mass has been described, primarily with adenocarcinomas, due to the secretion of diabetogenic substances. DM related to pancreatic metastases is rarely seen. We present a case of colon cancer metastatic to the pancreas presenting as diabetic ketoacidosis (DKA).

CASE DESCRIPTION/METHODS:
A 69-year-old male with a 70 pack-year tobacco history and hypertension presented to the emergency department with fatigue, weight loss, and abdominal pain. Laboratory tests demonstrated a white blood cell count of 11.8 109/L, a hemoglobin of 8.0 g/dL, sodium of 125 mmol/L, carbon dioxide of 18 mmol/L, and a glucose of 656 mg/dL with positive serum ketones indicating diabetic ketoacidosis. He was admitted to the hospital and treated with insulin and IV crystalloids. A chest x-ray showed multiple lung nodules. A CT scan of the chest, abdomen, and pelvis revealed bilateral lung masses, an uncinate process pancreatic mass, multiple hypodense liver lesions, and thickening of the sigmoid colon. Bronchoscopy was performed and cytology revealed metastatic adenocarcinoma with suspected source of colonic, hepatobiliary, or upper gastrointestinal source. EUS/FNA was performed on the pancreatic mass and demonstrated poorly differentiated carcinoma of unclear primary source. Flexible sigmoidoscopy discovered a friable mass in the sigmoid colon. Biopsies were taken revealing adenocarcinoma on the background of high grade dysplasia consistent with a primary colon cancer. Given the widely metastatic nature of his disease he was offered FOLFOX + Bevacizumab as well as a palliative care referral.

DISCUSSION:
The majority of malignant pancreatic lesions are primary pancreatic tumors, with a small percentage due to metastases. The most common tumor to metastasize to the pancreas is renal cell carcinoma. Few cases of metastatic colon cancer to the pancreas have been reported. DKA as a first presentation of pancreatic adenocarcinoma is a very rare phenomenon with more typical presenting symptoms including abdominal pain, nausea and jaundice. Our case features two rare findings; metastatic colon cancer to the pancreas and DKA as the initial presentation of a pancreatic mass. This highlights the need to consider uncommon metastatic lesions in cases of symptomatic pancreatic masses.
1461 Pseudomembranous Colitis, Bowel Ischemia, and Phentermine: A Case Report
Authors: Gollol Raju Narasimha Swamy , Jayananda Sriraksha , Ali Eslam , Harvin Glenn 
Published: October 2019

INTRODUCTION:
Pseudomembranous colitis, though classically associated with Clostridium difficile infection, can be a consequence of other disease processes including severe ischemic colitis. Several drugs have been proposed to predispose to colonic ischemia including the appetite suppressant phentermine. We present a case of pseudomembranous colitis from severe bowel ischemia that likely was compounded by concomitant phentermine use.

CASE DESCRIPTION/METHODS:
A 55-year-old obese Caucasian female with hypertension presented with a week of abdominal pain and progressively worsening diarrhea that had subsequently turned bloody. She was a former smoker. Medication history was significant for using a family member's weight loss medication Phentermine 37.5 mg daily for several days prior to developing gastrointestinal symptoms. At presentation she was mildly hypotensive needing fluid resuscitation and brief vasopressor support. Laboratory profile was significant for acute kidney injury with creatinine 8.86 mg/dl, lactic acid 3.2 mmol/L and white blood cell count 12.3 k/uL. A non-contrast CT abdomen showed findings suggestive of acute colitis involving the splenic flexure and descending colon (Figure 1). Supportive care and broad-spectrum antibiotics were continued. Multiple stool studies were negative for clostridium difficile infection, bacterial cultures, and assays for ova and parasites. Antineutrophil antibodies and antineutrophil cytoplasmic antibodies were negative as well. Flexible sigmoidoscopy revealed severe ulcerations covered by thick exudate of the rectum and sigmoid colon (Figure 2). Histopathology of biopsy specimens showed colonic mucosa with fibrinopurulent surface adherent exudate with abundant neutrophils consistent with pseudomembranous colitis (Figure 3). Patient recovered with supportive care alone and was subsequently discharged with instructions not to use Phentermine again.

DISCUSSION:
Our patient, with risks for vascular disease, had several days of abdominal pain with diarrhea. At the time of her initial hospital presentation, she was hypotensive likely from gastrointestinal volume loss. The inciting event for her colonic ischemia is unclear. Possibilities include Phentermine induced colonic ischemia that was further compounded by volume loss vs prodrome of gastroenteritis leading to volume loss and hypovolemia with subsequent colonic ischemia compounded by patient's Phentermine use. Phentermine use in this patient would have been contraindicated secondary to her vascular risk factors.
1464 Malignant Perivascular Epithelioid Cell Neoplasm of Colon in Young Male
Authors: Karanfilian Briette , Jackson Ryan , Bhagat Vicky , Cristelli Ryan , Chekmareva Marina , Sarkar Avik 
Published: October 2019

INTRODUCTION:
Perivascular epithelioid cell neoplasms (PEComas) are a rare type of mesenchymal tumor that can be found in various visceral and soft tissues in the body. Approximately fifty cases have been reported in the gastrointestinal (GI) tract. Typically, management of these lesions is laparoscopic or open surgical resection followed by chemotherapy if there is metastatic disease. The majority of GI PEComas are benign, colonic masses in middle-aged females. This case describes a malignant, colonic PEComa in a 16-year-old male. To the best of our knowledge, this is the largest malignant, colonic PEComa in an adolescent, and this is the first case to demonstrate successful endoscopic mucosal resection (EMR) of a PEComa.

CASE DESCRIPTION/METHODS:
A 16-year-old male with history of IgA vasculitis during childhood presented with acute onset of bilious emesis in the setting of severe, intermittent, left lower quadrant abdominal pain and constipation for one month. Lab testing was unremarkable. Computed tomography revealed a non-obstructing, nodular mass in the transverse colon. The patient underwent colonoscopy, during which the 6-cm large, semi-sessile, broad-based polyp was removed by piecemeal EMR. EMR was technically challenging due to the size, broad base, and location of the mass. Histology of the tissue showed a predominance of fascicular spindled cells, scattered areas with epithelioid morphology, and prominent vasculature, consistent with a PEComa. The tissue stained positive for HMB-45, MART-1, and cathepsin. Based on the size (>5 cm), nuclear atypia, and high mitotic activity, the lesion was defined as malignant. Though the lesion was removed to the submucosa, there was concern for deeper extension, so he underwent laparoscopic transverse colectomy with primary anastomosis. Pathology confirmed there was not any residual tumor in the resected colon or metastasis to lymph nodes. Positron emission tomography did not show metastasis. Fifteen months have elapsed and the patient has not had recurrence on imaging.

DISCUSSION:
There are few cases of GI PEComas. This case demonstrates a rare presentation of a large, malignant GI PEComa in a young male and is the first case of successful endoscopic removal of a malignant PEComa. The surgical specimen revealed no evidence of residual PEComa, and the patient has not had evidence of recurrence on imaging, verifying successful removal of his PEComa. This supports the notion that EMR should be considered for definitive management in patients with these lesions.
1472 Hypokalemia-Induced Rhabdomyolysis From Budesonide Therapy in Crohn's Disease: A Case Report and Review of the Pathophysiology
Authors: Mandiga Pujyitha , Mansour Ramy , Thigpin Derek 
Published: October 2019

INTRODUCTION:
Here we present the case of a 71-year-old white male with active ileocolonic Crohn's disease, recently started on budesonide therapy, who presents with extreme weakness and muscle aches. He was diagnosed with hypokalemia induced rhabdomyolysis, three weeks after starting budesonide therapy.

CASE DESCRIPTION/METHODS:
We present the case of a 71-year-old male with hypertension and ileocolonic stricturing crohn's disease (CD) presents with severe muscle weakness and malaise. He presented for a five-month history of worsening watery diarrhea and unintentional weight loss. Colonoscopy to neoterminal ileum revealed Rutgeerts score of i3. He was started on oral 9 mg budesonide and began to experience weakness and muscle aches to a point where he was unable to walk or lift his arms above his head. He presented to the hospital and labs revealed hypomagnesemia 0.8 mg/dL, hypokalemia of potassium 1.7 mmol/L, creatinine 1.52 mg/dL, creatine phosphokinase (CPK) 15913 IU/L, hypocalcemia 7.1 mg/dL, normal albumin 3.7 g/dL. Urinalysis showed 3+ blood and 0-3 red blood cells. Labs two months prior were unremarkable (Table 1). He was diagnosed with rhabdomyolysis.

DISCUSSION:
Budesonide has long been accepted as induction therapy for mild-to-moderate CD. Hypokalemia induced rhabdomyolysis is due to laxative abuse, chronic diarrhea, renal tubular acidosis, diuretics use is well reported. Hypokalemia is a known side effect of budesonide.
1
Rhabdomyolysis is a syndrome which is characterized by muscle necrosis with CPK four times more than the upper limit of normal.
1
During a muscle contraction, potassium is released from the intracellular to extracellular space mediating the vasodilation and more blood flow to the muscle. When a patient has hypokalemia, there is a decrease in blood flow to the contracting muscles. This leads to constriction of arterioles causing ischemia of the muscles and myocytes destruction. The breakdown of the myofibril causes muscle necrosis and an increase in intracellular CPK and myoglobin, which is released into the blood circulation.
2
In this patient, several factors were taken into account for the cause of hypokalemia induced rhabdomyolysis. The patient rapidly responded to intervenous fluid and discontinuation of the budesonide.
1480 Colonic Spirochetosis Causing Ulcerative Proctitis
Authors: Durney Philip A. , Henry Christopher 
Published: October 2019

INTRODUCTION:
Intestinal spirochetosis is a rare infectious diarrheal illness. Here we present a case of colonic spirochetosis initially diagnosed and treated as ulcerative proctitis.

CASE DESCRIPTION/METHODS:
A 57-year-old male presented to the office with 2 months of diarrhea occurring over 10 times per day with urgency and bleeding. The patient had an unremarkable past medical and family history. On social history, he practiced high risk sexual behavior with unprotected anal intercourse. Initial work-up showed mild elevation of ESR/CRP and an elevated calprotectin. Colonoscopy revealed ulcerative proctitis extending to 15 cm with normal colonic mucosa proximally. Rectal biopsies showed moderately active chronic colitis, remaining biopsies of colon were normal. He was started on mesalamine with improvement and subsequent sigmoidoscopy showed remission. Eight weeks later the patient presented to the ED with blurry vision. He was seen by ophthalmology who identified left optic nerve edema. An RPR was sent and resulted with a titer of 1:1024. He was referred to Infectious Disease with high suspicion for ocular syphilis and completed 14 days of IV penicillin G. Lumbar puncture showed no neurologic involvement. His RPR titers downtrended and visual changes improved. One month later, the patient developed large volume loose stools. Again stool studies were negative. Pathology was contacted to conduct repeat histochemical stains on earlier specimens, which showed spirochetes in the colonic mucosa. He was given metronidazole for 14 days for intestinal spirochetosis with improvement. With suspicion that proctitis may have originally been infectious the mesalamine therapy was weaned.

DISCUSSION:
Clinical manifestations of colonic spirochetosis can vary from asymptomatic to watery diarrhea. Rectal ulcerations are an uncommon presentation of primary syphilitic infection when compared to other mucosal sites. A literature review revealed a range of endoscopic findings from normal mucosa to erythema, friability, and polypoid lesions. To our knowledge the development of multiple ulcers has not been reported. It is necessary to maintain a high clinical suspicion because the diagnosis can be missed on a histologic level without appropriate additional staining. Given the increasing prevalence of syphilis, this case highlights the importance of collecting a thorough sexual history as to not delay the diagnosis and prevent the progression of disease, especially since early disease can frequently be asymptomatic.
1481 Synchronous Esophageal and Colon Adenocarcinoma: A Case Report
Authors: Bierle Lindsey A. , Reddy Shravani , Kesar Varun , Chitnavis Vikas , Grider Douglas J. 
Published: October 2019

INTRODUCTION:
Synchronous carcinomas in the same patient were first elucidated in the early 1930s. Following this initial recognition, awareness of synchronous carcinomas coupled with advancements in medical technology have made diagnosis of two primary carcinomas from separate sites in the same time interval possible. We present a case of newly diagnosed synchronous primary esophageal and ascending colon adenocarcinomas in a patient presenting with lower gastrointestinal bleed.

CASE DESCRIPTION/METHODS:
A 74-year-old female with a history of abdominal aortic aneurysm repair on dual-antiplatelet therapy, chronic obstructive pulmonary disease (COPD) on continuous supplemental oxygen at four liters per minute, and tobacco abuse presented with complaints of bright red blood per rectum. Hemoglobin on presentation was 12.5 g/dL, down-trending to 9.0 g/dL the following day. Esophagogastroduodenoscopy (EGD) revealed a nodule in esophageal mucosa, a submucosal lesion in the esophageal body, 30 centimeters from the incisors, and a small hiatal hernia with initial pathology showing high grade dysplasia in Barrett mucosa. There was no active bleeding site and hemoglobin was stable. Patient was discharged with plan for repeat EGD for evaluation of dysplastic Barrett mucosa and complete work up for anemia. Repeat EGD with endoscopic mucosal resection showed Barrett esophagus and a distal esophageal mass at 30 cm. Colonoscopy showed an ascending colon mass. Histopathology with ancillary immunohistochemistry revealed synchronous primary esophageal adenocarcinoma and a second primary ascending colonic adenocarcinoma. The patient was then staged as esophageal adenocarcinoma T2N0 by endoscopic ultrasound with recommendations for esophageal resection and T2N0 colon adenocarcinoma with recommendations for hemicolectomy. Given comorbidities, she was deemed not a candidate for esophagectomy, however successfully underwent elective right hemicolectomy.

DISCUSSION:
Common synchronous carcinomas within the gastrointestinal tract include colon and appendiceal malignancies, followed by small bowel, gastric, and esophageal carcinomas. Colonic neoplasias (up to 20%) are the most common synchronous cancers in patients with primary gastric cancer; the incidence of esophageal and synchronous colon cancers is unknown, however, highlighting this case's uniqueness. Upon discovering multiple primary malignancies, accurate staging along with immunohistochemical analysis is key to distinguish each primary cancer and determine appropriate therapy.
1484 A Rare Case of Necrotizing Colitis in an Adult
Authors: Karim Syed S. , Jiyani Rucha , Jacob Bobby , Prasa Jarin , Rizvon Kaleem , Mustacchia Paul 
Published: October 2019

INTRODUCTION:
Necrotizing colitis has historically been primarily a disease of premature infants, affecting about 3/1000 live births. Adult necrotizing enterocolitis (ANEC) has seldom been reported, and to our knowledge, only a few case reports exist. We present an adult with necrotizing colitis and hope to provide some insight about presentation, diagnosis, and management.

CASE DESCRIPTION/METHODS:
A 54-year-old male with history of gastroesophageal reflux disease and hyperlipidemia presented with abdominal pain associated with vomiting, fever, and bloody diarrhea. He had both an unremarkable upper endoscopy and colonoscopy 3 years ago. His abdomen was soft, but tender on the left, with no rebound or guarding. CT scan revealed infectious and inflammatory colitis. Stool studies for bacteria, parasites and clostridium difficile were negative. Initially, the patient deteriorated despite aggressive hydration and antibiotics. Colonoscopy showed extensive ulcerated friable boggy colon, and severe colitis with pseudomembranes. Pathology confirmed necrotizing inflammation suggestive of necrotizing colitis. Ischemic work up with CT angiography showed patent abdominal arteries. Surgery was premeditated, however the patient gradually improved with medical management alone and was eventually discharged.

DISCUSSION:
Although the exact mechanism of ANEC is unknown, two possible explanations include infectious agents and bowel perfusion disturbances. Infection is the main cause in neonates due to an underdeveloped immune system. Both gram negative bacteria and viruses are culprits, most commonly, E. Coli and Klebsiella. In ANEC, the primary insult may be hypoxia-reperfusion injury due to vasoconstriction of non occlusive mesenteric vessels and bacterial overgrowth as a secondary insult. Patients present with abdominal pain, vomiting and hematochezia. Xray and CT usually show nonspecific findings. CT angiography rules out mesenteric occlusion. Histological analysis demonstrating necrotizing inflammation finalizes the diagnosis. Our patient's diagnosis was based on histology and the exclusion of mesenteric occlusion. Although, stool studies did not identify a causative pathogen, our patient eventually improved with antibiotics. It is postulated that an initial ischemic damage contributed to the patient's clinical deterioration but the second insult of bacterial translocation was treated with antibiotics. Although rare, ANEC is being reported and clinicians need to keep high index of suspicion for timely management.
1489 “Bi-Morphic” Post-Transplant Lymphoproliferative Disorder Masquerading as Inflammatory Bowel Disease
Authors: Mussarat Saad , Yoo Buyng S. , Oldfield Edward C. , Parekh Parth J. 
Published: October 2019

INTRODUCTION:
Post-transplant lymphoproliferative disorder (PTLD) is a serious complication occurring in up to 30% of post-transplant patients, usually within the first year; however, recurrent PTLD or development of multiple histologic subtypes is rare.1 Relevant to gastroenterologists, GI tract involvement can occur in up to 25% of cases and present as nonspecific clinical symptoms, abdominal pain, bleeding, or perforation.2

CASE DESCRIPTION/METHODS:
An 80-year-old African American male with a past medical history of living-donor kidney transplant presented to clinic to undergo surveillance colonoscopy. Nine months post-transplant, the patient was diagnosed with early PTLD on colonoscopy and treated with 4 cycles of rituximab without evidence of disease on repeat colonoscopy or PET scan. Follow up colonoscopy at 5 years did not show any recurrence of disease and the patient was recommended to undergo his next colonoscopy in another 5 years (10 years following PTLD treatment). Repeat colonoscopy at this time found multiple inflammatory polyps at the ileocecal valve and in the transverse and sigmoid colon. Additionally, the rectosigmoid colon showed evidence of moderate inflammation (Figure 1). Pathology reports indicated polyps of the ileocecal valve were consistent with polymorphic PTLD, whereas the biopsies of the rectosigmoid colon showed monomorphic PTLD (Figure 2). The patient was referred to Oncology and is currently undergoing repeat rituximab therapy for monomorphic PTLD and a dose reduction of immunosuppressants for polymorphic PTLD.

DISCUSSION:
Importantly, even though rates of PTLD are typically lowest for renal transplants (0.8-2.5%), early and recurrent PTLD is still possible in this population.3 Our patient, despite a previous response to rituximab, demonstrated evidence of rare, recurrent PTLD in addition to multiple pathologic subtypes spread diffusely throughout the colon. In particular, the emergence of monomorphic PTLD carries the worst prognosis with survival rates ranging from 25-60%.5,6 Given the frequency of GI tract involvement, it is essential gastroenterologists maintain high suspicion for PTLD in patients with prior transplantation and have a lower threshold for biopsy, as our case demonstrates advanced disease appearing endoscopically as inflammatory changes. Importantly, this recurrence was found 10 years after initial diagnosis, which signifies the importance of surveillance colonoscopy for early detection, monitoring for recurrence, and establishing disease prognosis in PTLD.
1492 Sporadic Colonic Hamartoma in an Adult Patient: A Rare Finding
Authors: Sehmbey Gurbir , Chuang Keng-Yu 
Published: October 2019

INTRODUCTION:
Colonic hamartomas are non-neoplastic polypoid lesions that are rare in adults and most commonly encountered in children between the age of 1 and 7 years. They are histologically characterized by cystic dilation of mucus-filled glands, prominent bands of fibrous stroma, and a rich vascular network. Hamartomatous polyps are often diagnosed during endoscopy and require histological identification.

CASE DESCRIPTION/METHODS:
A 43-year-old male was referred due to intermittent rectal bleeding and positive fecal occult blood test (FOBT). He did endorse a positive family history of colon cancer in his mother. Colonoscopy was performed, revealing: 3 small sessile polyps <3 mm in size and a single 2 cm pedunculated polyp in the sigmoid colon (Figure 1). Polypectomy was performed for each noted polyp. Histopathological examination of the sigmoid polyp revealed a benign hamartomatous polyp with cystic dilation and focal crypt abscess (Figure 2). Pathology of rest of polyps revealed benign colonic mucosa with mild non-specific inflammation. The patient did well and remained symptom-free on follow up visit.

DISCUSSION:
Hamartomatous polyps are characterized by disorganized growth of tissue native to the organ in which it occurs. The reported prevalence of hamartomatous polyps in the adult population is around 0.15%. The prevalence of hamartomas in patients with colon polyps at index colonoscopy is 0.073%. Colonic hamartomas can occur sporadically or may present with distinct syndromic and hereditary features. The syndromes commonly associated with hamartomatous polyps are Peutz–Jeghers syndrome (PJS), juvenile polyposis, and phosphatase and tensin homolog (PTEN) hamartoma syndrome (PTHS). Endoscopically, these polyps can appear as pedunculated or sessile lesions making them indistinguishable from adenomatous polyps, which makes it prudent for the endoscopist to remove these lesions for histologic examination. In pediatric patients, hamartomas usually are localized to the rectum, the left colon, and may cause rectal bleeding, abdominal pain, and transanal prolapse. In adults, colonic hamartomas are most frequently found in the left colon and the rectosigmoid region. Patients are most commonly referred for colonoscopy due to positive FOBT or rectal bleeding. It is important to distinguish sporadic polyps from syndromic polyps as the sporadic polyps generally have a relatively benign course, while those associated with a syndrome have a higher lifetime malignancy risk.