bluuebunny/crossref_metadata_2025_split huggingface dataset:
2666 Disseminated Renal Cell Carcinoma Presented as Obscure Gastrointestinal Bleeding
Authors: Curras-Martin Diana , Mehta Amit , Wan David 
Published: October 2019

INTRODUCTION:
Metastatic disease to the gastrointestinal tract is frequently observed in patient with known disseminated malignancies. Among those, melanoma, breast and lung cancer are commonly reported. Renal cell carcinoma (RCC) metastasis to small bowel is rare and the presentation varies from obstructive symptoms, intussusception, as well as, gastrointestinal bleeding.

CASE DESCRIPTION/METHODS:
A 85 years old male with medical history of pulmonary embolism on apixaban and progressive stage IV RCC despite multiple lines of therapy on lenvatinib, presented with progressive fatigue and melenic stools. Denied abdominal pain, change in bowel habits, prior episodes of bleeding, or NSAIDs use. Vital signs were unremarkable. Physical exam was pertinent for non-tender abdomen, no distention, active bowel sounds, no rebound or guarding, and a rectal exam that revealed melenic stools. Labs: Hemoglobin of 6.8 g/dL (Baseline 10.3 g/dl), electrolytes, kidney and liver function tests were unremarkable. Computerized tomography (CT) of the abdomen and pelvis revealed multiple hepatic, retroperitoneal and mesenteric metastases. He received two units of packed red blood cells with appropriate response. Apixaban was held and he was admitted for workup of gastrointestinal bleeding. Esophagogastroduodenoscopy was unrevealing, while colonoscopy showed a few non-bleeding colonic and rectal angioectasias. A subsequent capsule endoscopy demonstrated an actively bleeding jejunal lesion (Figure 1). He continued to have large melenic bowel movements, and his hemoglobin decreased to 5.5 g/dL. A computed tomography angiography showed a blush of contrast in the jejunum, near the site of a tumor implant (Figures 2 and 3). An interventional radiology embolization was performed, with successful hemostasis.

DISCUSSION:
One autopsy series reported that only 2 out of 44 metastatic tumors to the small intestine were duodenal implants of RCC. In recent years, however, the number of published reports of RCC small bowel metastasis has been increasing. Retrograde venous spread to the paravertebral vessels has been propose as the route of dissemination of RCC to the intestine and solitary, bulky hypervascular lesions might be diagnostic if seen on CT scan. Luminal evaluation may localize the bleeding and offer potential treatment, however, angiography with embolization is the preferred therapeutic approach for small intestine lesions. Small bowel metastases must be considered as an etiology of bleeding when patients with RCC present with melena.
2671 Sparing the Knife: A Case of Emphysematous Gastritis Managed Conservatively
Authors: Randhawa Tejinder , Attar Bashar M. , Omar Yazan Abu , Vohra Ishaan , Flores Estefania , Agrawal Rohit 
Published: October 2019

INTRODUCTION:
Emphysematous gastritis (EG) is a rare and obscure disease that carries a high mortality rate, whilst posing a diagnostic challenge. EG is caused by gas forming bacteria invading the gastric wall through disruptions in the mucosal barrier. Diagnosis is made with abdominal computed tomography (CT) scan demonstrating gas in the gastric wall. Traditionally EG has been managed surgically with partial gastrectomy, however recent case based studies support the role of conservative medical management in treating this aggressive disease. Here we present a case of non-surgically managed emphysematous gastritis.

CASE DESCRIPTION/METHODS:
A 28-year-old male with a history of uncontrolled type 1 diabetes mellitus (Hemoglobin A1c: 14.70) presented with a three-day history of diarrhea, melena, and orthostatic dizziness. Earlier that week the patient had been diagnosed with diabetic and initiated on metoclopramide. Despite stopping metoclopramide, the patient's diarrhea continued. Upper and lower endoscopy was performed and was largely unremarkable. The patient was discharged on erythromycin. The patient returned to the ED the following morning after developing severe abdominal pain. The physical examination revealed a soft abdomen with diffuse tenderness to palpation. Abdominal CT scan demonstrated emphysematous gastritis. Treatment was initiated with aztreonam, clindamycin, vancomycin, levofloxacin, and caspofungin. Within twenty-four hours, the patient improved clinically and repeat abdominal CT scan demonstrated significant improvement in gastric wall emphysema. After five days of broad-spectrum antibiotics the patient had complete resolution of abdominal pain.

DISCUSSION:
EG is a rare condition caused by gastric wall invading bacteria. Recently there has been a drastic shift in the preferred management strategy for this deadly condition that carries a mortality rate as high as 60%. A retrospective review demonstrated that prior to the year 2000 62.5% of patients with EG underwent surgical management, after 2000 this percentage dropped to 22.2%. In deciding on appropriate regimens, it is important to have broad coverage for gram-negatives, anaerobes, and fungi. Despite the lethality of EG, our case contributes to the growing body of literature that suggests that with early diagnosis and initiation of broad spectrum antibiotics, patients can be spared operative management and have successful recovery.
2673 Acute Hemorrhagic Gastritis During Treatment With PD-1 Inhibitor Nivolumab for Stage IV Endometrial Cancer
Authors: Chong Michelle , Singh Simi 
Published: October 2019

INTRODUCTION:
PD-1 inhibitors block immune checkpoints and activate the immune system. They show benefit in treating many advanced cancers, but are also associated with various immune-related adverse effects, including inflammatory diseases of the gastrointestinal (GI) tract. We present a rare side effect of hemorrhagic gastritis.

CASE DESCRIPTION/METHODS:
A 53-year-old woman with Lynch syndrome and metastatic endometrial cancer presented to our office after two weeks of epigastric abdominal pain associated with nausea and vomiting. Her primary care provider had prescribed pantoprazole and ondansetron and obtained an abdominal ultrasound, which was normal. She had been treated with nivolumab for stage IV endometrial cancer for the preceding three years, and had no evidence of disease after two years of treatment. Sucralfate was prescribed, and an upper endoscopy was scheduled. This showed white plaques in the esophagus and a severely hyperemic stomach with friable mucosa. Stomach biopsies revealed diffusely eroded gastric mucosa with marked acute and chronic inflammation, crypt abscesses, and increased intraepithelial lymphocytes with crypt degeneration and dropout. Esophageal biopsies showed mildly reactive squamous mucosa with scattered intraepithelial lymphocytes and rare eosinophils. Stains for fungal organisms, CMV, HSV, EBV, and H. pylori were negative. Nivolumab-induced acute hemorrhagic gastritis was suspected. After two weeks of prednisone 1 mg/kg daily, her symptoms did not improve. The dose was increased to 2 mg/kg and her symptoms significantly improved within one week. She was then slowly tapered off prednisone without recurrence of her symptoms at three month follow-up. She continues off nivolumab with no plans to resume further treatment by her oncologist.

DISCUSSION:
Immune checkpoint inhibitors are novel anti-cancer agents with increasingly widespread applications. They are associated with immune-mediated adverse effects, including inflammation of the GI tract. The diagnosis is made through pathologic and endoscopic features in the appropriate clinical context. Standard treatment is prednisone starting at 1 mg/kg, which can be increased to 2 mg/kg, and the immune checkpoint inhibitor should be discontinued. Infliximab may be considered if the disease does not respond to initial therapy. As immune checkpoint inhibitors become more common, it will be important to consider hemorrhagic gastritis in patients on such a medication who present with acute epigastric pain, nausea, and vomiting.
2682 The Evolution and Cure of Multifocal Gastric Cancer
Authors: Debesai Meron , Mikityanskiy Yevgeniy , Bernstein Michael 
Published: October 2019

INTRODUCTION:
Gastric cancer incidence and mortality has continued to steadily decline but remains the second leading cause of cancer death worldwide. Predominantly, gastric cancers are known to arise from a single lesion whereas gastric cancer arising from multiple lesions is uncommon. We present a case of a 67 year-old female who was initially found with gastritis in the antrum that evolved into a multifocal gastric cancer within 1 year.

CASE DESCRIPTION/METHODS:
The patient was a 67 year-old female who was first seen in Hepatology clinic for chronic hepatitis C with early fibrosis. After successful treatment, she underwent upper endoscopy for non-specific gastric symptoms. EGD showed gastritis in the antrum and biopsy revealed intestinal metaplasia and H-Pylori was negative so repeat endoscopy was recommended in a year. Upon returning for repeat endoscopy, evaluation revealed a small antral erosion and a raised area of erythematous mucosa in the fundus. Unexpectedly, biopsies revealed extensive intestinal metaplasia and high-grade dysplasia in both lesions. The patient was immediately referred to an academic center for upper endoscopic ultrasound and mucosal resection. Both studies were unremarkable, so the patient returned to our facility and underwent upper chromo-endoscopy. By this time, the antral erosion had markedly increased in size and became an ulcer with circumferential induration and staining centrally with methylene blue. There was also methylene blue uptake in two other erosions within the fundus. Repeat biopsy of the ulcers now showed nascent well-differentiated adenocarcinoma associated with high-grade dysplasia. Whole body computerized tomography showed no evidence of metastasis so patient underwent total gastrectomy. Surgical pathology revealed multiple foci of intestinal type gastric adenocarcinoma in the background of high-grade dysplasia and intestinal metaplasia. All lymph nodes and margins were negative.

DISCUSSION:
There have been less than 50 cases of multifocal gastric cancer reported in the literature with even fewer cured by total gastrectomy. Upper gastrointestinal endoscopy remains the gold standard for diagnosing gastric lesions. Generally, surveillance isn’t recommended for findings of intestinal metaplasia. However, our case serves to highlight the importance of diligent endoscopic surveillance and tissue sampling, even if findings convey low suspicion. Our patient was successfully cured of multifocal gastric cancer, a disease that usually carries a very poor prognosis.
2683 Gastric Metastasis From Renal Cell Carcinoma: A Case Report
Authors: Nasir Umair M. , Ahmed Ahmed , Panchal Dayna , Rodgers Brandon , Patel Kalpesh , Lenza Christopher 
Published: October 2019

INTRODUCTION:
Renal cell carcinoma (RCC) is the most common renal malignancy in adults and possesses extensive metastatic potential. At the time of diagnosis, over 30% of cases have metastatic lesions and a 10% risk of developing metastatic disease after 5 years. The most commonly involved sites for metastasis include regional lymph nodes and distant organs such as the lungs, liver, and brain. In very rare cases, it can spread to gastrointestinal tract.

CASE DESCRIPTION/METHODS:
The patient is a 74 year old male found to have a 5 cm right kidney mass while undergoing workup for uncontrolled HTN. Histology and workup after radical resection confirmed clear cell carcinoma limited to the right kidney. Follow up CT a year after diagnosis revealed bilateral adrenal gland nodules. Biopsy of which was consistent with metastatic renal cell carcinoma at which point chemotherapy was started. Restaging two years thereafter and multiple follow up surveillance CT scans revealed no evidence of disease progression. Nine years after the original diagnosis, patient was admitted for hypotension and anemia. EGD done in evaluation of anemia, revealed multiple gastric submucosal polyps, biopsy of which revealed metastatic renal cell carcinoma. Immunostaining with PAX-8 and renal tumor markers were positive further proving RCC as the primary carcinoma. At this point the patient was restarted on chemotherapy and discharged with close follow up.

DISCUSSION:
Within the gastrointestinal tract, metastasis of RCC to the stomach is the rarest, at a rate of <0.2%. The process by which tumor cells migrate from the primary site to distant organs and the predilection to metastasize to specific organ systems is not well understood. In the rare instance that RCC metastasizes to the stomach, it most frequently presents as a polypoid submucosal protruding mass leading to gastrointestinal bleeding and symptomatic to anemia . The optimal treatment for RCC remains controversial and the utility of resection on mortality remains unclear. In our patient, the period from radical resection to detection of metastatic gastric lesions was over nine years. At the time of resection, the lesion was confined to the left kidney only as per staging imaging obtained. This raises many questions: how can metastatic lesions present after the resection of a tumor with no invasion of the kidney capsule? How can these new lesions appear almost a decade later? And finally, how effective is resection of primary RCC tumor in regards to preventing metastasis?
2684 Gastric Sarcoidosis
Authors: Naseer Usman , Mansoor Muhammad Sohail , Wazir Ali , Arslan Mustafa Erdem , Chung Jae , Ells Peter F. , Fitzpatrick Michael 
Published: October 2019

INTRODUCTION:
Sarcoidosis is a systemic inflammatory disease of unclear etiology. It can involve almost any organ in the body, with pulmonary involvement being the most common. Gastrointestinal (GI) involvement is rare (0.1- 0.9% of all cases) with symptomatic gastric sarcoid, even more rare (with a handful of cases reported in the literature). We present a case of a patient who developed symptomatic gastric sarcoidosis.

CASE DESCRIPTION/METHODS:
A 48-year old African American male was seen in the GI clinic for a 5-year history of diffuse intermittent abdominal pain. The patient had a known diagnosis of severe sarcoidosis diagnosed 10 years ago. He had multiple organs effected including lungs (Restrictive disease on PFTs), liver (bridging fibrosis with hyalinized nodular sclerosis on the biopsy) and skin involvement (resulting in chronic pruritus treated with Plaquenil). The patient also had a history of H.pylori with multiple small clean-based ulcers in the gastric corpus and erythematous duodenopathy diagnosed on esophagogastroduodenoscopy (EGD) 11 years ago. Following that he completed the triple antibiotic regimen. The patient for the last four months reported severe periumbilical pain with several ED visits. He underwent 3 colonoscopies over the course of the last 5 years, which were unremarkable. EGD was repeated, which showed multiple nonbleeding duodenal ulcers with gastric biopsy showing non-caseating granulomas. His H.Pylori stain was negative on this occasion. At this time a diagnosis of gastric sarcoidosis was made. The patient was placed on a proton pump inhibitor with an escalation in the dose of his systemic steroids resulting in resolution of his symptoms.

DISCUSSION:
Most cases of gastric sarcoidosis are initially asymptomatic. The most commonly reported symptom is epigastric pain. Other symptoms include nausea, vomiting, hematemesis, melena, and weight loss. Due to the non-specific nature of these reported symptoms, making the diagnosis purely on clinical history is difficult, and a high index of suspicion is needed to make the diagnosis. Endoscopically it can present with ulceration or a diffuse linitis plastica like the involvement of stomach. Pathology is key to diagnosis and shows non- caseating granulomas. Asymptomatic patients do not require treatment though for symptomatic patients recommended treatment is a combination of proton pump inhibitors with systemic steroids. Marvin A. Chinitz et al. reported symptom improvement in 66% of gastric sarcoid patients with systemic steroids.
2685 Gastric Volvulus: A Forgotten Cause of Hematemesis
Authors: Remouns Julian , Alexandre Cassidy , Mansoor Muhammad Sohail , Parsa Nour , Baharith Harith 
Published: October 2019

INTRODUCTION:
Gastric Volvulus, a pathologic torsion of the stomach, is a diagnosis that is often difficult given the rarity of the condition and nonspecific symptoms on initial presentation. Borchardt’s triad (sudden constant abdominal pain, retching with little vomitus and inability to completely pass a nasogastric tube) has been reported in many documented cases. Imaging studies often lack specificity. Here we present a rare case of hematemesis due to gastric volvulus.

CASE DESCRIPTION/METHODS:
An 85-year-old female with PE on apixaban, paroxysmal Afib presented with recent episodes of hematemesis. She initially had few episodes of non-bilious non-bloody emesis with nausea attributed to viral gastroenteritis with self-improvement. On the day prior to admission, she underwent a nuclear stress test after which nausea recurred followed by abdominal pain and coffee-ground emesis. She denied angina, SOB, fevers, chills, constipation, melena or hematochezia. In addition to apixaban, she took aspirin for CAD. She had no prior history of GI bleeding or abdominal surgeries. She was mildly tachycardic and hypertensive, but abdominal exam was unremarkable. CMP revealed hypokalemia of 2.6 mEq/L. CBC and lactic acid were normal. Abdominal ultrasound of RUQ revealed cholelithiasis without evidence of acute cholecystitis. Abdominal X-ray showed no abnormalities. Differential included PUD, gastritis and AVM so an EGD was performed. EGD revealed red blood in the entirety of the esophagus, diffuse severe mucosal changes characterized by black eschar in the middle and lower thirds of the esophagus and gastric fundus, a large paraesophageal hernia, gastric volvulus and mild gastritis in the body and antrum. Patient was subsequently treated with conservative medical management as she declined surgical intervention.

DISCUSSION:
Our patient presented with nonspecific signs and symptoms of gastric volvulus. Due to the rarity of the condition and the patient’s increased risk factors for other diagnoses on the differential, gastric volvulus was not expected. It was through endoscopy that we discovered not only the volvulus itself, but also a large paraesophageal herniation, which are known to have high associations with organoaxial volvulus-twisting about the longitudinal axis. Gastric volvulus is a surgical emergency due to a high morbidity and mortality. This case is an example of the insidious effects of gastric volvulus and demonstrates that clinical suspicion is hindered without familiarity of this condition.
2689 Gastric Volvulus: A Difficult Situation of Diagnosis and Management
Authors: Palamaru Andreea Luiza , Toader Elena 
Published: October 2019

INTRODUCTION:
Gastric volvulus is a rare entity defined as an abnormal rotation of the stomach around its short or long axis leading to variable degrees of gastric inlet and outlet obstruction. Organoaxial and mesentericoaxial volvulus are distinguished according to the direction of rotation. A rotation of more than 180 degrees can cause strangulation, necrosis and finally perforation.

CASE DESCRIPTION/METHODS:
We present the case of a 43-year-old female that complained of severe abdominal pain, nausea and vomiting for 2 days after eating a large meal. She did not have any flatus or bowel movements in the last 48 hours. On admission in our clinic, biological findings included an inflammatory syndrome, an anaemic syndrome and hypokalaemia. The radiology images highlighted a high air-fluid level in the chest and the ultrasound examination showed a significant stomach fluid distension. The upper digestive endoscopy revealed multiple ulcerated lesions and stasis fluid at the gastric angle, a point from which exploration could no longer be continued. Computed tomography (CT) of the abdomen and pelvis showed a dilatation of the stomach and the displacement of the antrum above the gastroesophageal junction; the stomach appeared upside-down with the antrum and pylorus superior to the fundus and proximal body. Based on clinical manifestations, biological results, radiograph images, ultrasounds, upper endoscopy and CT scan, the patient was diagnosed with high occlusion via congenital organo-axial volvulus. Initial management was nasogastric decompression to decrease the intragastric pressure. The patient was transferred to the Surgery Department, where he underwent a laparotomy which confirmed an organoaxial volvulus at the level of the antrum and body of the stomach. Gastropexy was implemented and the stomach fixed to the posterior abdominal wall to prevent recurrence. Postoperative recovery was uneventful and the patient returned to his rehabilitation facility on the fourth post-operative day.

DISCUSSION:
We present this case because it is an uncommon life-threatening disease. Given its rarity and unusual presentation, the clinical index of suspicion is always low. Diagnosis of gastric volvulus is challenging due to the non-specificity of the symptoms and rarity of the condition. Early diagnosis and treatment will reduce the risk of developing chronic gastric volvulus to acute gastric volvulus.
2691 Quadruple Therapy: A Cure for Gastric High Grade B-Cell Lymphoma?
Authors: Jessamy Kegan , Ozden Nuri , Antoine Marsha , Tambe Vikrant 
Published: October 2019

INTRODUCTION:
H. pylori contributes to approximately 75 % of stomach cancers internationally. Gastric MALT lymphoma is a rare disease with an incidence of 0.38 per 100,000 people in the United States of America (USA). The majority of gastric MALT lymphoma cases are cured with H pylori eradication therapy while chemotherapy is the mainstay of treatment for gastric diffuse large B-cell lymphoma (DLBCL). Gastric high grade DLBCL is rare and there is limited data in which treatment with H pylori eradication can attain complete remission. We present a case of a woman with DLBCL and was treated for H pylori and attained complete remission.

CASE DESCRIPTION/METHODS:
A 59 year old woman presented to our clinic for evaluation of epigastric pain for 2 months. A trial of Prior proton pump inhibitor (PPI) treatment did not improve her pain. Abdominal CT imaging was significant only for diverticulosis. Esophagogastroduodenoscopy (EGD) showed a 25 mm non-bleeding cratered gastric ulcer with pigmented material at the incisura of the stomach. Incisiural biopsies revealed high grade B cell lymphoma and antral/body biopsies showed H pylori. PET CT imaging showed diffuse fluorodeoxyglucose uptake along the lesser curvature of the stomach corresponding to the known area of lymphoma. There was no evidence of metastatic disease. The patient declined chemotherapy due to fear of associated side effects. Instead, she was given H pylori quadruple therapy with a 14 day course of Pantoprazole, Bismuth subsalicylate, Metronidazole, and Tetracycline. Repeat EGD with endoscopic ultrasound at 1 and 4 months later were unremarkable and biopsies at the site of the healed ulcer were negative for neoplasia. To date, she remains asymptomatic.

DISCUSSION:
To date, there is no established standard management strategy for primary gastric lymphoma. Major guidelines recommend chemotherapy as the initial treatment for DLBCL. The efficacy of HP eradication for gastric pure DLBCL has mostly remained unknown, with limited data available. Despite histological remission, lymphoma recurrence is possible. Given the limited data available, long term, careful follow-up should be done for all patients if they are treated with antibiotics for DLBCL.