bluuebunny/crossref_metadata_2025_split huggingface dataset:
2549 Unique Thoracic Cause of Atypical Adult Small Bowel Intussusception
Authors: Patel Neej J. , Kahn Allon , Lidner Thomas , Samadder Jewel 
Published: October 2019

INTRODUCTION:
Rare in adults, intussusception can occur anywhere in the gastrointestinal (GI) tract causing an array of symptoms from abdominal pain, distension, and emesis to obstruction and bleeding. Most adult cases are caused by benign or malignant neoplasms while less are due to infection, surgical sequelae or congenital conditions. This unique case outlines the high suspicion warranted for rare causes and manifestations of small bowel intussusception (SBI).

CASE DESCRIPTION/METHODS:
A 70-year-old woman with a recent left parietal lobe hematoma with mass effect was admitted with 2 days of melena and symptomatic anemia. She quit smoking 1 month ago, takes aspirin, no NSAIDs and had no other significant histories. She had normal vitals and a benign abdominal exam. Rectal exam revealed nonbleeding external hemorrhoids, no melena or hematochezia. Initial Hgb was 5.9 g/d. After resuscitation, EGD and colonoscopy were performed. EGD revealed a normal upper GI tract with no source of bleeding. Colonoscopy revealed clotted blood throughout the colon but no source of bleeding. A video capsule endoscopy (VCE) was deployed the next day to evaluate suspected SB bleeding. While the VCE was recording, she bled briskly overnight with painless hematochezia. Urgent imaging revealed mid-jejunal SBI with active bleeding. She was stable, but given the concern for an underlying malignancy (large right upper lobe lung mass), she underwent an exploratory laparotomy with evidence of palpable, firm, immobile luminal masses in the jejunum corresponding well with her VCE findings, which is quite rare. This portion of SB was resected with end-end anastomosis. Pathology yielded 3 metastases from primary lung adenocarcinoma. She received 1 cycle of chemotherapy before pursuing hospice after suffering another intracerebral hemorrhage with severe mass effect.

DISCUSSION:
Intraluminal lead points in SBI are benign, metastatic or inflammatory. Despite most benign lesions being adhesions, Meckel diverticula, adenomas, lipomas or hemangiomas; malignancies can account for 15%-30% of cases. Malignancies are more common in colonic intussusception (65%-80%). Primary SB cancers are often leiomyosarcoma, lymphoma, adenocarcinoma, GIST, carcinoid and NETs. Metastatic melanoma commonly spreads to SB, while lung cancer rarely involves SB. Thus, our patient and her timely diagnostics/therapeutics highlight the clinical acuity garnered for this rare thoracic metastatic cause of an atypical adult SBI.
2553 A Rare Discovery of Duodenal Noncaseating Granulomas
Authors: Contino Krysta , Weiss Alexandra , Mohan Neena , Enriquez Miriam , Griech-McCleery Cynthia , Giordano Samuel 
Published: October 2019

INTRODUCTION:
Duodenal involvement of sarcoidosis is infrequently reported. It can manifest with a spectrum of symptoms and mimic other gastrointestinal diagnoses.

CASE DESCRIPTION/METHODS:
This is the case of a 59-year-old man with a history of pulmonary sarcoidosis on hydrochloroquine and deep venous thrombosis on apixaban who presented with weight loss with associated abdominal pain, decreased appetite, early satiety, and intermittent dysphagia to both solids and liquids. He reported a colonoscopy 2 years prior that was normal. Labs were notable for a hemoglobin of 11.5 with an MCV of 77. CMP, TSH and HIV were normal. Physical exam revealed a thin male, unremarkable vital signs and normal cardiac, pulmonary and abdominal evaluations. He underwent upper endoscopy and was found to have white esophageal plaques suggestive of candidiasis, gastritis with gastric nodularity, and a normal duodenum. Gastric biopsies were consistent with gastritis with positive staining for H.pylori for which he was subsequently treated. He underwent abdominal CT revealing diffuse small bowel wall thickening and enlarged retroperitoneal and mesenteric lymph nodes. Decision was made to proceed with repeat upper endoscopy as well as endoscopic ultrasound. Upper endoscopy noted gastritis and new duodenitis. Gastric biopsies showed chronic gastritis, negative staining for H.pylori, and positive CD20 and CD3 staining consistent with a reactive process. Duodenal biopsies showed noncaseating granulomas and villous blunting (Figure 1). EUS was unrevealing except for peripancreatic and porta hepatis lymphadenopathy for which he underwent fine needle aspiration. Flow cytometry was negative. The patient was started on high dose steroids given the duodenal involvement of his sarcoidosis followed by a taper over a few months. During the taper, he returned with worsening anemia and diarrhea. Repeat upper endoscopy revealed more extensive involvement of the duodenum with severe inflammation and plan for outpatient colonoscopy and follow up with his sarcoidosis specialist to discuss treatment regimen.

DISCUSSION:
Although duodenal sarcoidosis is rare, it is important to include this in the differential diagnosis in the appropriate clinical setting. It's symptoms and pathology can have overlap with some common diseases such as celiac, Crohn's disease, and even lymphoma. Tissue acquisition is imperative to confirm the diagnosis and can be performed at the time of endoscopy with treatment aimed at management of the underlying disease process.
2557 Duodenal Duplication Cyst—A Rare Congenital Anomaly
Authors: Then Eric O. , Flores Carlos , Ofosu Andrew , Are Vijay S. , Culliford Andrea , Gaduputi Vinaya 
Published: October 2019

INTRODUCTION:
Enteric duplication cysts are uncommon congenital abnormalities of the gastrointestinal tract that arise from a disruption in the normal recanalization of the developing gut. Most frequently they are located in the jejunum or ileum, rarely will an enteric duplication cyst present in the duodenum. Here we present a rare case of an enteric duplication cyst in the duodenum.

CASE DESCRIPTION/METHODS:
Patient is a 48 year old male with a medical history of alcohol abuse who presented to our emergency department (ED) complaining of severe epigastric pain and non-bloody vomiting for 1 day. The patient reported drinking 3 beers daily and had one previous episode of similar symptoms one year prior. Notable workup in the ED included an elevated Lipase of 6443 U/L. A computed tomography (CT) scan of the abdomen without contrast was also done and showed inflammatory changes surrounding the pancreas and an ovoid hyperdense object adjacent to the junction between the duodenum and jejunum. The patient was then admitted under the impression of acute pancreatitis. Given the findings of the CT scan a repeat scan was done with oral and intravenous contrast. This showed the same ovoid soft tissue abnormality with findings suggestive of mildly complex enteric duplication cyst (Figures 1 and 2). During his hospital stay the patient was managed with morphine for pain control, intravenous fluids and was discharged two days later with follow up appointments scheduled.

DISCUSSION:
Several mechanisms have been proposed to explain the pathogenesis of enteric duplication cysts but no clear cause has been elucidated. The cystic structure is composed of a smooth muscle outer wall and internal epithelium that may be stratified, ciliated, or columnar. The majority of cases are diagnosed during the perinatal period and early childhood with rare cases being diagnosed during adulthood. It can be discovered either as an incidental finding during routine imaging such as CT scan, endoscopy, or laparotomy. When symptoms are present, they widely vary depending on the size and the location. Symptomatic disease can present in the form of gastrointestinal bleeding, gastric outlet obstruction, pancreatitis, dysphagia, intussusception, volvulus or obstruction of the biliary tree. Duodenal localization of duplication cysts is rare but may have significant clinical and therapeutic importance due to the nearby anatomic structures that can be disrupted by the abnormality.
2560 Small Bowel Carcinoid Causing Chronic Anemia
Authors: Kaushik Chandni , Clark August , Merwat Shehzad N. 
Published: October 2019

INTRODUCTION:
Carcinoids are a relatively rare tumor that are often discovered incidentally. If symptoms are present, they may include abdominal pain, carcinoid syndrome, and occasionally bleeding.

CASE DESCRIPTION/METHODS:
A 59-year-old woman was admitted for bloody bowel movements. Past medical history includes hypertension and morbid obesity. She had chronic microcytic iron deficiency anemia and was evaluated in 2015 with EGD, colonoscopy, and capsule endoscopy. EGD was normal with no bleeding source, colonoscopy showed blood throughout colon without diverticulosis or AVMs, and capsule endoscopy revealed a jejunal ulcer. At presentation, vital signs were stable. Laboratory profile revealed iron deficiency anemia with hemoglobin 7.3 g/dL. Colonoscopy revealed a medium-sized mass in terminal ileum with oozing present and appearance concerning for carcinoid tumor. The mass was tattooed and a clip was placed. CT showed 2.1 cm mass in ileum as well as 1.9 cm enhancing lymph node concerning for metastasis. She underwent laparoscopic small bowel resection with removal of ileal mass and was noted to have multiple lesions along small bowel concerning for metastasis and grossly enlarged mesenteric lymph nodes, which were also removed. Pathology showed well-differentiated grade 1 neuroendocrine tumor with a lymph node positive for metastasis. Patient is scheduled to follow-up with oncology to determine treatment plan.

DISCUSSION:
Carcinoids are relatively rare with an incidence of 4.7 per 100,000 with rising incidence due to increased detection on endoscopy and imaging as well as increased provider awareness. They can arise in the gastrointestinal tract, lung, and genitourinary tract and are relatively slow growing and less aggressive than other cancers. Within the gastrointestinal tract, most carcinoids are found in the small intestine, rectum, and stomach, while small bowel carcinoids are commonly located in the ileum. Small intestine carcinoid tumors have been characterized as more aggressive in nature and commonly metastasize to lymph nodes or the liver. They require multidisciplinary evaluation with gastroenterologists, oncologists, and surgeons. In our case, the patient had chronic anemia many years prior and had undergone work-up prior to presenting with hematochezia. Previous evaluation showed a jejunal ulcer thought to be due to NSAID use. However, she continued to have iron deficiency anemia. This case illustrates the importance of repeat endoscopic evaluation in cases of persistent iron deficiency anemia.
2562 Duodenal Perforation From an Inferior Vena Cava Filter as a Rare Cause of Persistent Abdominal Pain
Authors: Khan Walid , Zhang Wei , Weiner Brian , Clark Virginia 
Published: October 2019

INTRODUCTION:
Deep vein thrombosis (DVT) continues to be a significant source of morbidity for surgical patients. Inferior vena cava (IVC) filter placement is indicated for DVT in patients who have contraindications to anticoagulation or failure of anticoagulation. Over the last decade, there is exponential increase of IVC filter placement with increased complications reported. These include IVC penetration, IVC occlusion, insertion complication and filter migration. We report a rare case of symptomatic duodenal perforation by an IVC filter migration.

CASE DESCRIPTION/METHODS:
A 33-year-old female with a history of paraplegia secondary to motor vehicle accident, recurrent DVTs, and placement of IVC filter 10 years ago presented to the hospital for persistent epigastric pain for the past 5 years. Patient denied any nausea, vomiting, diarrhea, or hematochezia. Physical exam showed epigastric tenderness. Labs including complete blood count were unremarkable. CT scan showed a longstanding IVC occlusion with collaterals and displaced IVC filter into the duodenum and into the L3 vertebral body (Figure 1). An EGD confirmed prong migration to the second portion of the duodenum (Figure 2). This was distal to the ampulla and penetrating the duodenal wall with the tip embedding the opposite wall. Due to multiple workups being otherwise negative and symptomatic duodenal perforation of the IVC filter, she has been scheduled for an open IVC filter extraction with duodenal and caval repair.

DISCUSSION:
Duodenal and aortic perforations by IVC filters have been increasingly reported in the past 10 years although still rare. Penetration of the filter struts through the wall of the IVC can be asymptomatic. However symptomatic patients may present with epigastric pain, gastrointestinal bleeding and small bowel obstruction. Currently, there are no guidelines for the management of such patients. Most cases have been repaired using an open repair with excellent outcomes; however, endovascular retrieval and repair is being recognized as an alternative option especially in high risk patients. This case illustrates that even though IVC migration and perforation is a rare complication, it needs to be recognized as a potential cause for gastrointestinal symptoms in these patients. Retrievable IVC filters should always be removed if possible when deemed unnecessary to prevent complications such as migration from developing.
2570 Capecitabine-Induced Ileitis: A Case Report
Authors: Tageldin Omar , Kalakota Neeharika , Bartholomew Catherine 
Published: October 2019

INTRODUCTION:
Capecitabine is a fluoropyrimidine chemotherapy agent used in the treatment of colorectal cancer. Gastrointestinal side effects are common, including diarrhea, nausea, vomiting, abdominal pain, severe hepatic impairment, and decreased appetite. Here we report a case of Capecitabine-induced ileitis with severe diarrhea leading to hypovolemic shock and acute kidney injury. The patient was admitted to the intensive care unit (ICU) twice during hospitalization and required cessation of capecitabine.

CASE DESCRIPTION/METHODS:
Our patient is an 82-year-old male with a history of prostate cancer now with stage IIA rectal adenocarcinoma who was started on Capecitabine neoadjuvant chemotherapy without radiation due to previous pelvic radiotherapy for the prostate cancer. He tolerated the first treatment cycle without any side effects. At the beginning of the 2nd cycle, he reported eight watery non-bloody bowel movements a day. CT abdomen showed wall thickening of multiple loops of the distal small bowel. He was admitted to the ICU, started on vasopressor therapy and broad-spectrum antibiotics, but diarrhea persisted. Physical exam showed mild diffuse abdominal tenderness. Laboratory studies were notable for elevated creatinine but stool culture, ova and parasites, and Clostridium difficile PCR were negative. Antibiotics were stopped and loperamide was started without significant improvement. Gastroenterology was consulted and colonoscopy showed linear ulcers at terminal ileum and ulceration at ileocecal valve - pathology showed active ileitis with ulceration. Diarrhea improved with supportive management and cessation of Capecitabine.

DISCUSSION:
Although Capecitabine's side effects are mostly well tolerated, they can occasionally lead to prolonged hospitalization and even ICU admission. Capecitabine is not a cytotoxic drug in itself, it is absorbed from the intestine and metabolized in the liver then in the tumor cells by three-step enzymatic cascade to be converted to 5-FU. Capecitabine-induced ileitis has been reported in the literature and was diagnosed by a combination of symptoms, CT scan, colonoscopy, and/or histopathology. The mechanism is reported to be due to the susceptibility of the intestinal vascular endothelium to 5-FU by the generation of free radicals which may lead to a hypercoagulable state. In summary, treating physicians should be aware of this critical side effect and intervene early when diarrhea is reported.
2572 Metastatic Renal Cell Carcinoma to the Small Bowel: A Rare Cause of Gastrointestinal Hemorrhage
Authors: Buckshaw Ricky , Malik Anam , Vaze Reema , Kloska Michal , Andrews Robert , Shah Hiral 
Published: October 2019

INTRODUCTION:
We present a case of overt gastrointestinal blood loss which after thorough investigation, was found to be a manifestation of metastatic renal cell carcinoma (RCC).

CASE DESCRIPTION/METHODS:
A 55 year-old female with a history of clear cell RCC removed with nephrectomy and breast cancer on chemotherapy presented with melena and abdominal pain. The patient was assessed in the ED and was hemodynamically stable. On exam she had tenderness in her left lower quadrant. She was found to have a hemoglobin of 8.2 g/dL. CT revealed active diverticulitis, but no obvious masses were noted. Gastroenterology evaluated the patient and recommended admission and EGD for further evaluation. The EGD was obtained which did not reveal any source of bleeding, which prompted colonoscopy. The colonoscopy demonstrated sigmoid diverticulosis, patchy segmental inflammation of the sigmoid colon, but no active bleeding. Approximately one week later, the patient was readmitted for worsening fatigue and continued melena. A capsule endoscopy was done which revealed a bleeding mass in the proximal and distal small bowel. A push enteroscopy was advanced to the jejunum but no bleeding was found. MRE was completed, which revealed a 1.9 × 1.6 cm nodule in the left pelvic small bowel, diverticulitis as well as a 3.2 × 2.2 cm left lower pole renal mass. The patient later went for an exploratory laparotomy with resection of two segments of small bowel. Pathology showed a diagnosis of metastatic renal cell carcinoma.

DISCUSSION:
Renal cell carcinoma is a common urological malignancy that can have many systemic complications. RCC presents with metastasis in as many as 30% of cases, however some signs may not lead physicians to timely diagnosis. RCC metastasizes to the small bowel in less than 0.5% of cases. Of these cases, gastrointestinal bleeding occurs in 1% of cases with <1% of cases coming from the small bowel. Small bowel involvement is rare and there are only a few case reports reporting this presentation. GI bleeding from metastatic RCC is an underdiagnosed disease and can cause increased morbidity and mortality. Being able to diagnose metastatic cancer and small bowel bleeding can be difficult. When it causes potentially life threatening symptoms, it becomes a priority to diagnose it. Prompt treatment requires knowledge of complications of RCC. Being able to identify these complications will not only allow us to improve outcomes in patients, but to better understand and anticipate future complications for our future patients.
2577 Dysdiadochokinesia, Ataxia, and Anemia: A Sign of Intraluminal Malignant Mesothelioma in the Small Bowel?
Authors: Rozner Raquel N. , Shah Shawn L. , Crawford Carl V. 
Published: October 2019

INTRODUCTION:
Malignant mesothelioma (MM) is a rare cancer of the serosal membranes, the pleura and peritoneum, and causes significant morbidity and mortality. While implants of the bowel wall are common, only two case reports on intraluminal involvement exist. We present a case of an elderly male with dysdiadochokinesia found to have abdominal lymphadenopathy, and a jejunal mass from peritoneal mesothelioma (PM).

CASE DESCRIPTION/METHODS:
An 87 year-old male with a family history (FH) of colon cancer in one first-degree relative presented with one month of unintentional weight loss, gait instability, and trouble performing alternating movements. Two months prior to admission, evaluation included a negative MRI of the brain but positive CSF analysis for neuron-restricted autoantibody treated empirically with five days of intravenous immunoglobulin (IVIG) and three days of pulse dose steroids. Physical examination was notable for ataxia and dysdiadochokinesia and a benign abdominal exam. He had normal electrolytes and liver chemistries, but was anemic. PET/CT revealed intensely FDG-avid abdominal and mesenteric lymph nodes, one inseparable from the small bowel (Figures 1 and 2). Lymph nodes were not accessible by IR-guided biopsy, so he underwent push enteroscopy and colonoscopy, in light of his FH, to evaluate for anemia. A large, oozing ulcerated mass was found in the jejunum and biopsied (Figure 3). Immunostaining was positive for cytokeratin, CK7, WT1, and calretinin consistent with PM. His neurologic decline was then linked to PNS secondary to PM. He was discharged with plans for carboplatin therapy.

DISCUSSION:
MM is strongly associated with asbestos exposure, and is four to five times more prevalent in men than women. PM limited to the small bowel is exceedingly rare. Only one previous case report describes a mass spanning the entire small bowel, identified as mucin-positive epithelial mesothelioma. PNS affects 1 in 10,000 patients with cancer; more than 85% of cases are linked to gynecologic and breast cancers causing cerebellar dysfunction via purkinje cell destruction by anti-Yo antibody (Ab). Two cases of PM associated PNS with anti-Yo Ab in the CSF have been reported; one was treated with IVIG and high dose steroids. The treatment of PM is key to stabilizing neurologic symptoms, such as dysdiadochokinesia. The prognosis of PM and associated PNS remains poor. Anemia with cerebellar symptoms should trigger a search for malignancy and rarer causes such as PM.
2584 Running Into a Stone Wall: A Rare Case of Gastric Outlet Obstruction
Authors: Shah Ruchit N. , West Sara , Shafqet Muhammad A. , Foernges Luiz , Diehl David L. , Khara Harshit S. 
Published: October 2019

INTRODUCTION:
Bouveret syndrome is an extremely rare and serious form of gallstone ileus with an incidence of 1-3% and a surgical mortality rate approaching 15-33 percent. Treatment often involves a combination of endoscopic and surgical interventions. We present a case of gastric outlet obstruction and duodenal ulceration caused by 3 impacted gallstones, treated ultimately with surgery.

CASE DESCRIPTION/METHODS:
A 57-year-old male with no known medical conditions was admitted to the intensive care unit with a one-week history of epigastric pain, nausea, and dark emesis. He was tachycardic and hypotensive on arrival. On exam, the patient was diaphoretic with dark-bloody return from the nasogastric tube. Hemoglobin was 5.6 g/dL (ref: 14.0-16.8 g/dL) with a leukocytosis of 17.69 K/uL (ref: 4.0-10.8 K/uL). Liver enzymes were unremarkable. Given concerns for an upper gastrointestinal bleed, patient underwent an esophagogastroduodenoscopy showing a 3-cm non-bleeding ulcer in the duodenal bulb, a cholecystoduodenal fistula, and a large impacted gallstone in the first portion of the duodenum distal to the fistula (Figure 1). Subsequent contrast-enhanced computed tomography demonstrated significant pneumobilia and a perforated duodenal ulcer (Figure 2). Removal of the obstructing gallstone was unsuccessful despite using a Raptor grasping device, Roth net retriever, and snare. Patient subsequently underwent exploratory laparotomy with cholecystectomy, pyloric exclusion, Roux-en-Y gastrojejunostomy, and duodenal enterorrhaphy with Graham patch (Figure 3). He tolerated the procedure well and was discharged to a rehabilitation facility.

DISCUSSION:
Bouveret Syndrome is a rare form of gallstone ileus characterized by gastric outlet obstruction secondary to gallstone impaction within the duodenum or pylorus through a cholecystoduodenal or choledochoduodenal fistula. Prompt imaging is warranted and in patients with gallstone ileus, may reveal pneumobilia, bowel obstruction, and ectopic gallstone, also known as Rigler's triad. Enterolithotomy, gastrostomy with cholecystectomy, and fistula repair are considered the mainstay of management, but prompt gastroenterological evaluation is warranted to evaluate the possibility of mechanical extraction or stone fragmentation.