bluuebunny/crossref_metadata_2025_split huggingface dataset:
1498 A Rare Case of an Atypical Mass Involving the Sigmoid Colon
Authors: Sayad Michelle , Ramay Fariha , Goldberg Eric 
Published: October 2019

INTRODUCTION:
The etiology of colonic masses is broad including benign polyps, primary adenocarcinoma, metastases, and diverticular mass. Presentation may be similar; therefore, the differentiation generally involves biopsy for histological evaluation and appropriate diagnosis.

CASE DESCRIPTION/METHODS:
A 34-year-old female presented with hematochezia and constipation. Her past medical history was significant for tubo-ovarian ovarian abscesses (TOAs), endometriosis fibroids and schwannoma of the paraspinal area. She reported new onset red blood per rectum, worsening constipation, and pelvic discomfort. Family history was notable for esophageal and colorectal cancer. She subsequently underwent colonoscopy which demonstrated a 3-4 cm nodular, polypoid fungating mass in the distal sigmoid colon located at 20-25 cm from the anal verge (Figure 1). Biopsies were obtained and the site was tattooed. A subsequent MRI of the abdomen and pelvis showed a heterogeneous inflammatory soft tissue encasing the ovaries and tethering the rectosigmoid colon (Figure 2). Additionally, there was a enhancing soft tissue mass invading the inferior wall of the distal sigmoid colon with an intraluminal component. The MRI findings were felt to be consistent with invasive endometriosis. Histological examination of the sigmoid mass showed colonic mucosa with polypoid endometriosis without evidence of malignancy (Figure 3). Cells showed positive immunohistochemical staining consistent with endometriosis. Surgical resection was recommended.

DISCUSSION:
This case demonstrates the importance of having a high suspicion of endometriosis involving the bowel in reproductive age women presenting with abdominal pain, dysmenorrhea, dyspareunia, and dyschezia. Endometriosis is a condition involving the implantation of endometrial stroma and glands at extra-uterine sites. Endometriosis tends to involve bowel serosa. It rarely encompasses full thickness of the bowel wall. The latter represents invasive endometriosis. Many patients are incorrectly diagnosed given their presentation. This disease increases risk of gastrointestinal tumors, primarily adenocarcinoma. Therefore, prompt recognition and treatment with hormonal therapy or surgical excision is important for symptom relief, increase in fertility, and later complications such as bowel stenosis, hydronephrosis, and malignant transformation.
1512 A Rare Case of Sigmoid Leiomyoma Disguised as a Polyp
Authors: Patel Kalpesh , Patel Pavan , Rodriguez Raul , Galan Mark A. , Shulik Oleg 
Published: October 2019

INTRODUCTION:
Colonic leiomyomas are smooth muscle tumors which arise from either the muscularis mucosa or the proper muscle layer. Colonic and rectal leiomyomas are rare tumors and represent only about 3% of all gastrointestinal leiomyomas. Most patients are asymptomatic; however, some can have symptoms of abdominal pain, intestinal obstruction, hemorrhage, and perforation when the leiomyoma is of larger size. We present a case of sigmoid leiomyoma encountered on routine colonoscopy.

CASE DESCRIPTION/METHODS:
A 52-year-old man from Ecuador with a past medical history of hypertension, gastritis, osteoarthritis of the knees, presented to the clinic for evaluation of GERD symptoms. He was also due for repeat colonoscopy for surveillance of colon polyps. He underwent routine EGD and colonoscopy. EGD findings and biopsies of the stomach were unremarkable. The patient underwent a colonoscopy and was found to have an 8 mm sessile polyp seen in the sigmoid colon. The polyp was resected with cold snare and sent to pathology. The bowel preparation was excellent. Pathology revealed colonic mucosa containing smooth muscle proliferation. Immunostain with smooth muscle actin (SMA) supported the diagnosis.

DISCUSSION:
Leiomyomas have been first described by Virchow in 1854. They are usually considered benign and arise in the uterus, but may also be found in the skin, nipple, scrotum, and labia. Leiomyomas are less frequently encountered in the GI tract, and when found, are primarily seen in the esophagus or stomach. The management of leiomyomas is surgical resection, however, with the evolving field of gastroenterology, endoscopic removal is considered an alternative for resection. Given leiomyomas arise from the muscularis mucosa or the proper muscle layer, endoscopic resection represents a higher risk of perforation. Submucosal injection technique can be used to identify which layer the leiomyoma arises from. If the lesion cannot be lifted using a submucosal injection of saline, the lesion may have deep submucosal invasion or can originate from the proper muscle layer. This risk for perforation is higher when the leiomyoma arises from the proper muscle layer and it is a contraindication to endoscopic removal. We represent a rare case of sigmoid leiomyoma which was removed using endoscopic technique without any complication of perforation or bleeding.
1517 No Microscope Needed: A Macroscopic Presentation of Collagenous Colitis
Authors: Boyd Amanda L. , Vargas Pedro , Leiman David , Dufault Darin 
Published: October 2019

INTRODUCTION:
Microscopic colitis (MC) is a common cause of chronic secretory diarrhea. Diagnosis has been considered to be histopathologic with otherwise normal-appearing colonic mucosa. However, accumulating evidence suggests distinct endoscopic features may be associated with MC. We present a rare case of MC that illuminates the importance of recognizing these macroscopic findings as they not only aid in diagnosis but also have significant management implications.

CASE DESCRIPTION/METHODS:
A 61-year-old female with rheumatoid arthritis presented with one month of watery, non-bloody diarrhea. She reported lower quadrant, crampy abdominal pain and a 20 lb weight loss. Her medications included pantoprazole 20 mg, escitalopram 20 mg, and ibuprofen three times weekly. Physical exam demonstrated diffuse abdominal tenderness and laboratory assessment revealed acute renal insufficiency and ESR of 28 (normal range: 0-15). Infectious stool studies were negative. A CT abdomen/pelvis revealed diffuse colonic wall thickening and mild mucosal hyperenhancement consistent with pancolitis. Colonoscopy revealed diffuse erythematous mucosa and multiple shallow, linear mucosal rents were created with minimal insufflation of CO2 during scope insertion. Targeted biopsies were taken and pathology demonstrated significant subepithlial collagen deposition consistent with a diagnosis of severe collagenous colitis (CC).

DISCUSSION:
While endoscopic findings may occur in up to 16.5% of patients with MC, only 1.1% of cases detail isolated linear ulcerations. Association with transmural inflammation is even more rare and to our knowledge this is the first report of CC with both radiographic evidence of pancolitis and discrete mucosal ulcerations. It has been hypothesized that collagen deposition reduces colonic compliance predisposing to mucosal tears that may herald colonic perforation. Although some studies suggest similar diagnostic yields between right versus left-sided biopsies (98.7% v. 98.9%), there are no descriptions of targeted biopsies in this condition. While our patient did not have any noted procedural complications, a flexible sigmoidoscopy may have been sufficient for a diagnosis. This case highlights an atypical presentation of CC with pancolitis and discrete endoscopic lesions that should prompt endoscopists to alter management. Flexible sigmoidoscopy with CO2 insufflation or water emersion should be considered in patients with macroscopic findings of MC, but the case should be aborted if deep mucosal tears occur.
1518 Malone Antegrade Continence Enema for Treatment of Adult Slow Transit Constipation in Ehlers-Danlos Syndrome
Authors: Wade Francis , Al-Taee Ahmad M. , Ghoulam Elie , Prather Charlene 
Published: October 2019

INTRODUCTION:
Ehlers-Danlos syndrome hypermobility type (EDS-HT) is a multisystem disorder characterized by joint and spine hyperextensibility that may also involve the gastrointestinal (GI) tract resulting in various motility disorders. The Malone antegrade continence enema (MACE) procedure is most commonly used to treat severe constipation in children with neurogenic bowel disorders. We describe a case of severe EDS-HT related refractory constipation in an adult that was treated with the MACE procedure.

CASE DESCRIPTION/METHODS:
22-year-old female with history of EDS-HT and mast cell activation disorder presented to our clinic for evaluation of chronic constipation, food regurgitation, nausea, and vomiting. Workup included a gastric emptying study showing gastroparesis, a colonic transit study showing slow transit, anorectal manometry showing a weak anal sphincter but no signs of dyssynergic defecation, and a proctogram showing normal emptying with a weak pelvic floor and excessive descent. Clinical course was complicated by recurrent attacks of nausea, vomiting, and abdominal pain without evidence of obstruction resulting in repeated emergency room visits. Chronic constipation was attributed to dysmotility from EDS-HT. Various combinations of osmotic and stimulant laxatives were utilized with inadequate response. She elected to undergo MACE procedure. Her symptoms gradually resolved after the procedure and she started having one bowel movement daily with a simplified bowel regimen including once daily antegrade enemas.

DISCUSSION:
The pathophysiology of GI dysmotility in EDS-HT is not completely understood but possible mechanisms include altered biomechanical properties and gut neurodevelopmental changes from extracellular matrix abnormalities. The MACE procedure involves laparoscopic placement of an appendicocecostomy tube to allow daily enema administration at the level of the cecum (Figure 1). This procedure is most commonly utilized in children with neurogenic bowel disorders but should also be considered in adult EDS-HT patients with constipation refractory to medical therapy. This case highlights the potential for severe morbidity in EDS-HT-related GI dysmotility disorders and sheds light on the therapeutic potential of the MACE procedure in this patient population.
1521 Case Series of 5 Patients Detected With Gut Fermentation Syndrome
Authors: Malik Fahad , Wickremesinghe Prasanna , Kalinga Himanga , Saverimuttu Jessie 
Published: October 2019

INTRODUCTION:
Gut fermentation syndrome (GFS) is a rare medical phenomenon in which ingestion of carbohydrate meals results in alcohol production through different biochemical pathways. These patients are presumed to have intestinal yeast fermenting carbohydrate to alcohol. This is due to fungi overgrowth in the digestive tract. This can often result in alcohol toxicity without any exogenous alcohol intake. The aim of this study was confirmation and treatment of GFS using a standardized carbohydrate challenge test followed by upper and lower endoscopy to obtain intestinal secretions to detect fungal growth.

CASE DESCRIPTION/METHODS:
This presents five patients who presented with implications of alcoholism while denying use any exogenous alcoholic beverages. A long detailed history and physical examination was conducted in order to screen these patients whose symptoms were unlikely due to exogenous drinking. All other possible primary causes were ruled out. There are currently no established diagnostic criteria to confirm GFS or treat this condition. We therefore propose the following protocol for this. It was important to make certain that patients with suspected GFS who have elevated blood or breath alcohol levels were not surreptitiously drinking. In our provocative carbohydrate challenge test, we gave the patients 200 g of glucose by mouth after an overnight fast with blood drawn at timed intervals of 0, 1/2, 1, 2, 4, 8, 16, and 24 hours for glucose and blood alcohol levels. This test was aborted early if alcohol levels become elevated in the first few hours. This used algorithm, carbohydrate challenge results and a comparison of all five patients is shown in the Table 1 format. If any elevated serum alcohol was detected without any drinking then these patients were recommended to participate for further testing. Routine laboratory testing and stool microbiome were sent for specification. Upper and lower endoscopy were performed during which secretions were collected for bacterial and fungal cultures along with biopsies to further study.

DISCUSSION:
Any patient denying alcohol ingestion but who has elevated alcohol levels should be investigated. The earliest symptoms of GFS may be mood changes. Some of the patients were bought to us by a concerned family member. This condition was treated with dietary modifications, antifungal therapy, and probiotic use in our patients. We are only starting to recognize the complexity of this condition and are currently studying more patients using the proposed protocol.
1525 Atypical Presentation of Colon Cancer: Colon-Vaginal Fistula
Authors: Salas Noain Jesus M. , Gudipally Sindusha , Zheng Shengnan , Amaral Rafael 
Published: October 2019

INTRODUCTION:
A fistula is an abnormal communication between two epithelialized surfaces. Colovaginal fistulas usually present with stool or flatus per vagina, foul-smelling vaginitis resistant to treatment, previous hysterectomy, and history of diverticulitis. In this case report, we present colon cancer as a possible new risk factor for colo-vaginal fistula.

CASE DESCRIPTION/METHODS:
53 years old female with a past medical history of external hemorrhoids and GERD presented to the emergency department (ED) for evaluation of right lower quadrant abdominal pain for over a month associated with passing fecal material through her vagina for the past 2 days. The patient also reported having loose stools approximately 2 weeks prior to ED visit. She also reported decreased appetite, lightheadedness, 60 lb weight loss since last year, and significant rectal bleeding with straining which she attributed to hemorrhoids. She reported having an unremarkable colonoscopy 10 years prior to presentation. She denied any history of diverticulosis, ulcerative colitis, Chron's disease, radiation therapy, or family history of cancer. However, she did have a history of hysterectomy for the treatment of endometriosis 15 years ago. On arrival, she was found to have a hemoglobin of 5.4 g/dl. Physical exam was significant for pale mucous membranes, tachycardia, and fecal material in the vaginal canal. CT scan showed a ring-enhancing fluid collection interspersed between the vaginal cuff, and sigmoid colonic bowel loop, a colovaginal fistula between the vaginal cuff and the sigmoid colon, and wall thickening of the sigmoid colon measuring up to 1.5 cm. Colonoscopy showed a large friable obstructive mass seen at 20 cm from the anal verge. Biopsies of the sigmoid mass showed invasive, moderately differentiated adenocarcinoma.

DISCUSSION:
This patient has a history of total abdominal hysterectomy which is a known risk factor for the development of fistula; however, the hysterectomy was done 15 years before the appearance of the fistula, suggesting that the surgical procedure was not the primary cause of the development of the fistula. Inflammatory bowel disease and infectious process were ruled out by colonoscopic and histologic findings. From this case, we can learn that colon cancer can mimic other conditions such as Crohn's disease or complicated infectious process, therefore colon cancer should be part of the differential diagnosis of colo-vaginal fistulas and peri-colonic abscesses.
1529 An Interesting Presentation of Solitary Rectal Ulcer Syndrome Mimicking a Rectal Mass
Authors: Waintraub Daniel J. , Fazio Richard M. , Weinberger Jonathan , Srikanthan Roshan , Tu Jiangling , Rahmani Rabin , Iswara Kadirawelp 
Published: October 2019

INTRODUCTION:
Solitary Rectal Ulcer Syndrome (SRUS) is an uncommon benign disease. The diagnosis is based on clinical features, proctosigmoidoscopy findings, and histopathology. Men and women are equally affected. The term SRUS is a misnomer as ulcers are only found in 40% of patients and a solitary ulcer is only identified in 20% of patients. Clinical features include rectal bleeding, mucus discharge, excess straining, perineal or abdominal pain, sensation of incomplete evacuation, constipation or rectal prolapse. Characteristic histologic features include obliteration of the lamina propria by fibrosis and smooth muscle fibers extending from a thickened muscularis mucosa to the lumen. We present a case of SRUS presenting as a rectal mass.

CASE DESCRIPTION/METHODS:
A 70 year old female with a history of hepatitis C and colon polyps presented after a hospital admission for infectious colitis. Colonoscopy revealed a 3 cm multi-lobulated rectal polyp with superficial ulceration approximately 10 cm from the anal verge. Endoscopic mucosal resection was performed with complete piecemeal resection. Histopathology revealed solitary polypoid growth (Figure 2), fibromuscular hyperplasia and obliteration of the lamina propria (Figure 3) suggestive of solitary rectal ulcer syndrome. The patient was managed with a strict high fiber diet.

DISCUSSION:
The etiology of SRUS may include ischemia due to impacted stools and local trauma from self-disimpaction. 25% of SRUS cases may present as a polypoid lesion, 18% as patchy mucosal erythema and 30% as multiple lesions. Given the wide variety of presentations, rectal biopsies are critical for diagnosis. Anorectal physiology studies indicate 24-82% of patients with this condition may have dyssynergia with paradoxical anal contraction. Treatment options include diet and bulking agents, biofeedback therapy, and surgery. The differential diagnosis includes inflammatory bowel disease, ischemic colitis and malignancy. Our case highlights the variable presentations of SRUS and its ability to mimic advanced adenoma and rectal malignancy. Gastroenterologists must carry a high index of suspicion for SRUS when approaching rectal lesions in the proper clinical context.
1542 No Ordinary Colon Polyp: Schistosomiasis
Authors: Lanka Chandana , McMillan Natasha , Ibrahim Mohd Elmugtaba , Ali Walid , Mekasha Getachew , Aduli Farshad 
Published: October 2019

INTRODUCTION:
Schistosomiasis, is a common parasitic diseases affecting over 200 million people caused by blood flukes of the genus Schistosoma. It is prevalent in tropical areas, particularly in agricultural fishing communities and places with poor water sanitation. Transmission occurs when the cercariae, the infectious form of the parasite, is released from fresh water snails and penetrates human skin. Larvae then mature in the human blood vessels that supply the intestines and genitourinary system. Schistosomiasis commonly involves the intestinal system, it is rare however, for it to present as a large colon polyp.

CASE DESCRIPTION/METHODS:
A 31-year-old Ethiopian male presented with diffuse abdominal pain and bloody diarrhea for 5 years. A colonoscopy performed 5 years ago at the onset of symptoms was notable only for mild colitis. Due to the persistence of symptoms, he underwent a repeat exam that revealed a normal terminal ileum, cecum, and transverse colon. Mild colitis was seen in the ascending and sigmoid colon. There was moderately severe colitis in the rectum. These areas were biopsied. In addition, a single 2.1 × 2.1 × 1.1 cm pedunculated polyp was found in the sigmoid colon which was removed by snare polypectomy. The polyp was found to contain calcified Schistosoma eggs and worms. The rectal biopsies also showed Schistosoma and multiple calcified eggs. Examination of both the gross and microscopic specimens confirmed the diagnosis of Schistosomiasis mansoni.

DISCUSSION:
Schistosomiasis affects 10% of the population worldwide and is endemic in Africa, Asia and South America. Patients with Schistosomiasis may present with abdominal pain, bloody diarrhea, anemia, and weight loss as seen in this patient. Endoscopic findings include colitis, mucosal granularity and friability, punctate ulcers, and hemorrhage. Schistosomiasis may also present as an inflammatory polyp. Microscopically, this Th2 cell mediated inflammatory responseis due to the reaction to ova. Worms are known evade the immune response. During the active phase, intense inflammation, granulomas and increased eosinophils can be seen. In the chronic phase, there is less inflammation, however fibrosis, and calcified ova are seen. Calcified eggs, seen in this patient's biopsy, parallels his 5 years of symptoms. Praziquantel is the treatment of choice for schistosomiasis. It is given as a single dose and is most effective four-six weeks after exposure because it does not work on larval forms of Schistosoma. It is curative in 85% of cases.
1552 A Tale of Two Ganglioneuromas
Authors: Lopez Carmen , Staudinger Robin , Kovacic Dianne , Humphrey Felicia 
Published: October 2019

INTRODUCTION:
Ganglioneuromas are rare benign tumors of nerve fibers, ganglion cells, and supportive cells that rarely occur in the GI tract. GI ganglioneuromas come in three forms including solitary polypoid ganglioneuroma, ganglioneuromatous polyposis, and diffuse ganglioneuromatosis. These classifications are vital to recognize as some are associated with genetic syndromes which require close cancer surveillance. Here we present two cases of ganglioneuromas: one as a solitary ganglioneuroma and the other as part of a hereditary syndrome.

CASE DESCRIPTION/METHODS:
Patient 1 was a 61 yo man with hypertension. Screening colonoscopy revealed a 1.3 cm pedunculated polyp in the ascending colon. Path revealed spindle cell proliferation expressing S-100, consistent with ganglioneuroma. EGD was normal. After confirmation of complete removal, he will proceed with standard screening intervals. Patient 2 was a 52 yo man with OSA and skin lipomas. Screening colonoscopy revealed polyps too numerous to count dispersed throughout. Biopsies showed a mix of ganglioneuromas, tubular adenomas, and hyperplastic polyps consistent with ganglioneuromatous polyposis. Genetic testing identified a PTEN mutation confirming Cowden Syndrome. He was then scheduled for an EGD, repeat colonoscopy in 6 months, and cancer screening per ACG Hereditary Cancer Guidelines.

DISCUSSION:
While both patients had ganglioneuromas, the management was significantly different. Patient 1 had a solitary ganglioneuroma, which is often found incidentally. Due to their benign nature, solitary ganglioneuromas do not necessitate more frequent screening. Ganglioneuromatous polyposis, as seen in patient 2, is associated with Cowden syndrome and diagnosed by a PTEN mutation. Patients have multiple types of polyps, including ganglioneuromas. They must get regular cancer screening of the colon, breast, thyroid, skin and kidney. Current recommendations are to repeat colonoscopies usually every 2 years depending on findings. Diffuse ganglioneuromatosis often appears as thickening of the bowel with involvement of the myenteric plexus. This is associated with MENIIB and more rarely Neurofibromatosis type 1. This may be handled conservatively but if obstruction results then resection of the involved bowel may need to be considered. Recognition of these presentations takes careful consideration including detailed history and physical exam to ensure correct diagnosis, which may tailor future cancer surveillance programs for patients diagnosed with polyposis syndromes.