bluuebunny/crossref_metadata_2025_split huggingface dataset:
1524 Using Transillumination to Aid Dilation of a Severe Colorectal Anastomotic Stricture
Authors: Nasir Umair M. , Delle Donna Paul , Rodgers Brandon , Salimi Qasim M. , Ahlawat Sushil 
Published: October 2019

INTRODUCTION:
Colorectal anastomotic strictures are common complications of low anterior resection. Strictures in the lower rectum can be treated with direct digital dilation, but if in the upper rectum, endoscopic balloon dilation or electrocautery can be done. However, both procedures depend on the advancement of the wire through the circumferential scar/narrowed lumen. We present a unique case of endoscopic dilation of a severe anastomotic stricture using an innovative method.

CASE DESCRIPTION/METHODS:
A 44-year-old male with a history of rectal adenocarcinoma s/p low anterior resection with colorectal anastomosis and loop ileostomy formation presented to the GI clinic for constipation. Barium enema study revealed a stricture at the anastomotic site. A flexible sigmoidoscopy confirmed a severe anastomotic stricture, which could not be traversed nor lumen distal to the stricture visualized. And despite multiple attempts the guidewire could not pass through the stricture. Ten weeks after surgery, a pediatric colonoscope was passed through the ileostomy and advanced to the area of the stricture. Position was confirmed with fluoroscopy. At the same time an adult upper endoscope was inserted into the rectum and advanced to the stricture. The pediatric colonoscope was used to transilluminate the stricture and a needle was then used to puncture through the stricture under direct visualization. A guidewire was advanced through the newly created lumen retrograde and the tract was dilated up to 8 mm. A double pigtail plastic stent was inserted across the newly created tract. On repeat colonoscopy three weeks later, the double pigtail stent was removed and the stricture was dilated up to 15 mm. On subsequent colonoscopy, the stricture was dilated to 18 mm and the patients loop ileostomy reversed. The stricture was dilated again to 20 mm via Flexible sigmoidoscopy a month after the reversal after which constipation and bowel habits significantly improved.

DISCUSSION:
In patients who develop severe colorectal anastomotic strictures after a low anterior resection, endoscopic dilation can be challenging. In such patients ileoscopy and colonoscopy can be done simultaneously and using transillumination, position can be confirmed and a needle can be used to create a lumen through which a guide wire can be passed, allowing for serial dilation. Endoscopic dilation, should be tried and exhausted before considering surgical correction of a stricture, which can be difficult and increase morbidity.
1532 Colorectal Metastasis of Ovarian Cancer: A Case Report
Authors: Chowdhary Tarika , Tazi Karim , Bishara Tarek , McFall Tim 
Published: October 2019

INTRODUCTION:
A 38-year-old Caucasian female with a history of stage IV clear cell carcinoma of the ovaries with metastasis to the liver presented with anemia. The patient presented to clinic for evaluation of symptomatic tachycardia and shortness of breath. She was found to have a hemoglobin of 6.2 at that time. On further questioning, the patient stated that she had been having bloody diarrhea for several days which had gradually been improving. She endorsed some lower abdominal pain along with increased swelling in her abdomen. The patient was admitted for a GI bleed at that time. The patient was on treatment with Abraxane and Carboplatin and was due for a second cycle, which was delayed due to significant cytopenias.

CASE DESCRIPTION/METHODS:
A colonoscopy was performed and the patient was found to have two ulcerated masses at 40 and 20 cm from the anal verge which were biopsied. CT chest abdomen pelvis was done upon admission and showed liver lesions, pelvic lymphadenopathy, small right ischiorectal fossa nodule and subcutaneous lesions concerning for metastatic disease. There were also lesions seen adjacent to the bladder concerning for drop metastasis. The patient also had a gastrograffin enema and was found to have scalloping of the margin of the distal sigmoid colon concerning for a mass. The pathology report and immunochemical stain evaluation revealed the adenocarcinoma to be positive for cytokeratin 7, negative for cytokeratin 20, negative for CDX2, and negative for WT-1 which argued against a colorectal primary. Surgical biopsy and pathology were also consistent with metastatic clear cell ovarian cancer. The patient did have an elevated CA-125 of 440.3.

DISCUSSION:
Four percent of ovarian carcinoma metastases are to the colorectal region. Isolated rectal metastasis is even more rare. Immunochemical stains are helpful in determining the primary lesion and source of malignancy. Cytokeratin 7 positive and cytokeratin 20 negative immunostaining is almost 100% specific for primary ovarian origin.
1
The patient was transfused blood and her hemoglobin improved with no further bleeding and she was discharged home. She was started on Carboplatin-Taxol every 3 weeks for six cycles and was going to be tested for the BRCA gene.
1534 Concomitant Clostridium difficile and Immunotherapy-Induced Colitis: A Case Report
Authors: Sidhu Tahnee , Almeqdadi Mohammad , Krishnan Sandeep 
Published: October 2019

INTRODUCTION:
For patients on immunotherapy a possible serious side effect includes immunotherapy-induced colitis, which often results in termination of treatment. However, it is important to rule out other etiologies such as infectious causes in the setting of immunosuppression. We report a case of concomitant Clostridium difficile colitis and ipilimumab-induced colitis, treated with simultaneous oral vancomycin and systemic steroids.

CASE DESCRIPTION/METHODS:
A 54-year-old man with 3-year history of clear cell metastatic renal carcinoma with distant metastases (stage IV) status post right nephrectomy on palliative ipilimumab and nivolumab presented with 15 nonbloody watery bowel movements a day for 10 days after finishing his third course of immunotherapy. Medical history was significant for a recent 3-month use of steroids for cervical spinal metastasis. He had abdominal cramping relieved with bowel movements, a 15-20 pound weight loss, and fatigue. White blood cell count was 10.8 × 103/υl and creatinine was 1.2 mg/dl. Clostridium difficile PCR was positive in the stool and he was initiated on oral vancomycin. Infectious work-up was completed and negative for giardia, cryptosporidium, stool ova, and parasites. Stool lactoferrin was positive. Abdominal/Pelvic CT did not show evidence of toxic megacolon. He did not improve significantly with oral vancomycin, and was started on simultaneous systemic steroid taper for presumed immunotherapy-induced colitis secondary to ipilimumab, with significant improvement thereafter.

DISCUSSION:
Immune related adverse colitis is an important consideration for patients on immunotherapy, specifically those medications well known to cause it such as ipilumumab. It is crucial to consider infectious causes but it also is important to continue to consider immunotherapy-induced colitis, which may coexist with the infection. There are no clear guidelines on treatment for concomitant Clostridium difficile colitis and immunotherapy colitis. Review of the literature revealed one case of simultaneously treating both Clostridium difficile colitis and ipilumumab induced colitis. Additional review of the literature revealed that patients with inflammatory bowel disease who are on corticosteroids for a flare and develop Clostridium difficile, concurrent corticosteroids is supported by expert opinion. This case supports the notion of using systemic steroids for treatment of suspected immunotherapy-induced colitis, while simultaneously treating an infectious colitis.
1536 An Uncommon Case of Small Bowel and Pan-Colonic Varices
Authors: DiCarlo Vick S. , Ravi Sujan , Shoreibah Mohamed , Kamath Patrick 
Published: October 2019

INTRODUCTION:
We present a case of idiopathic varices in the small bowel and colon discovered after extensive work up for iron-deficiency anemia and portal hypertension.

CASE DESCRIPTION/METHODS:
41-year-old with no known medical history underwent esophagogastroduodenoscopy (EGD) and colonoscopy for evaluation of iron-deficiency anemia. EGD was normal. Colonoscopy revealed diffuse colonic varices extending from the cecum to the rectum (Figure 1). Computed tomography enterography showed numerous varices of the mid jejunum. Magnetic resonance imaging of the abdomen showed patent portal circulation and no other abnormalities. Echocardiogram did not show any evidence of right heart failure. Transjugular liver biopsy showed a portosytemic pressure gradient of 4 mm of Hg indicating the absence of portal hypertension. Liver biopsy only showed mild steatosis and no fibrosis. A direct measurement of portal pressure was 3 mmof Hg again indicating the absence of portal hypertension.

DISCUSSION:
Given the extensive workup with no evidence of portal hypertension, patient is thought have idiopathic varices in the small bowel and colon. Ectopic varices, especially in the colon are rare and are usually associated with portal hypertension. Idiopathic colonic varices in association with small bowel varices are even more infrequently described in existing literature. Clinical presentation has been reported with massive hemorrhage, recurrent bleeds and even as incidental findings in endoscopies and imaging performed for other reasons. Management options include conservative frequent follow up or surgery if there is evidence of recurrent bleeds or massive hemorrhage.
1537 Colonic Gallstone Obstruction in the Setting of Cholecystocolonic Fistula
Authors: Doniparthi Meghana , Shah Natasha , Brasky Jeffrey 
Published: October 2019

INTRODUCTION:
Gallstone ileus is a relatively rare complication of cholelithiasis, estimated to account for approximately 1%-4% of all cases of mechanical intestinal obstruction. Cholecystoenteric fistulas form as a result of an inflamed gallbladder adhering to adjacent small bowel or colonic tissue, opening a channel by which gallstones can enter the intestinal tract. Fistula formation is most commonly to the duodenum (32.5-96.5%) but can also infrequently occur in the colon leading to gallstone impaction past the ileocecal valve.

CASE DESCRIPTION/METHODS:
Our patient is a 63 year old female who presented to the emergency room with one week of nonradiating stabbing left lower quadrant abdominal pain and constipation. She reported associated anorexia, and nausea without emesis. She was afebrile and hemodynamically stable. On exam, she was tender to palpation in the lower quadrants. No stool was present in the rectal vault. She had a negative Murphy's sign. Labs revealed WBC count 18.6 thousand/mcL, normal AST, normal ALT, and alkaline phosphatase 158 unit/L. Computed tomography (CT) scan abdomen/pelvis revealed gallbladder wall thickening with pneumobilia, cholelithiasis, normal common bile duct, and a large curvilinear hyperdensity in the distal colon (A). This was suspected to be a displaced gallstone in the sigmoid colon related to a fistula between the gallbladder and hepatic flexure (B). Removal of the stone was attempted by flexible sigmoidoscopy with snare and basket but was unsuccessful. She was then taken for exploratory laparotomy, transverse colotomy with extraction of 5 × 3.4 cm gallstone, loop transverse colostomy, and ventral hernia repair (C). She received IV antibiotics for 5 days and was discharged home.

DISCUSSION:
This case highlights a rare etiology of colonic gallstone obstruction in a patient without risk factors including underlying malignancy, colonic stricture, or diverticulum. Optimal surgical management of gallstone ileus with associated fistula is still being defined as few cases have been reported in the literature. One large retrospective survey found enterotomy with stone extraction to be associated with improved survival outcomes and decreased postoperative complications compared to surgery with fistula closure and bowel resection. Our patient had stable gallbladder changes and persistent cholecystoenteric fistula on CT scan over the next three months and expressed several gallstones through her colostomy without requiring further surgery.
1539 Drug-Induced Colitis as a Side Effect of Calcitonin Gene-Related Peptide (CGRP) Antagonist for Migraines
Authors: Hansen Daniel J. , Linzay Catherine , Kale Hemangi 
Published: October 2019

INTRODUCTION:
Drug-induced colitis is a documented though relatively uncommon side effect of several drug classes, and is under-recognized and under-reported. In May 2018, an injectable calcitonin gene-related peptide (CGRP) antagonist, erenumab, was approved by the FDA for migraine prophylaxis. In the following case, this new medication is implicated as a possible cause for severe colitis resembling an inflammatory bowel disease-like picture both clinically and endoscopically.

CASE DESCRIPTION/METHODS:
A 33-year-old Caucasian female presented with complaints of rectal bleeding, diarrhea, and abdominal pain 2 weeks after starting a CGRP antagonist, erenumab, for chronic refractory migraine headaches. Pertinent laboratory studies showed leukocytosis with bandemia. CT Abdomen/Pelvis showed diffuse colonic wall thickening. Stool studies did not indicate any infectious etiology and an IBD panel was negative. She underwent a colonoscopy that showed severe, deep punched out ulcerations throughout the entire colon. Biopsy showed active colitis. She had a prior colonoscopy in 2009 for work up of IBS, which was endoscopically and microscopically normal. The patient's symptoms and clinical findings resolved after discontinuing the drug. A follow up colonoscopy performed one month after discharge showed evidence of ulcer healing with no new areas of inflammation.

DISCUSSION:
Blocking CGRP receptors of the central nervous system may reduce headaches, however blocking those of the enteric system can promote breakdown of the colonic mucosal barrier and induce a systemic inflammatory reaction. In animal models, extensive mucosal damage was noted in the subjects receiving CGRP receptor antagonists. This case implies that certain patients may be at risk for developing mucosal barrier disruption from the blockade of the calcitonin gene-related peptide receptor with erenumab or similar drugs. Further research may be needed to elucidate risk factors that may contribute to susceptibility to these deleterious effects. Once those patients that are more at risk are identified, there may be a role for endoscopic surveillance in certain patients taking these medications. While drug-induced colitis is likely to be an uncommon manifestation of blocking CGRP, clinicians should be aware of this potential side effect of targeted therapy and counsel patients receiving this therapy.
1554 An Unusual Cause of Hematochezia: Anorectal Inflammatory Myoglandular Polyp
Authors: Peng Frederick B. , Tan Mimi C. 
Published: October 2019

INTRODUCTION:
Colorectal polyps are an unusual cause of hematochezia and usually result from overlying ulcerations on adenomas or cancers. Non-adenomatous polyps, such as inflammatory polyps, may be a rare cause of gastrointestinal bleeding. Here, we present a case of a patient with painless hematochezia found to be originating from a bleeding anorectal inflammatory myoglandular polyp related to rectal prolapse.

CASE DESCRIPTION/METHODS:
A 51-year-old man with alcohol abuse and hepatitis C presented with fatigue and light-headedness along with 7-8 years of small volume painless hematochezia with bowel movements. He endorsed straining with bowel movements and something protruding from his anus that he would push back in. On physical exam, he was hemodynamically stable with a normal abdominal exam and a rectal exam revealing a palpable rectal mass without overt signs of bleeding. His lab work was notable for a hemoglobin of 5.5 g/dL. Magnetic resonance imaging (MRI) of the pelvis revealed rectal wall thickening and an enhancing mass abutting the anal sphincter (Figure 1). Colonoscopy revealed left-sided diverticulosis without bleeding and an ulcerated, vascular mass in the anal canal, best seen on retroflexion (Figures 2 and 3). Biopsies of the mass were consistent with an inflammatory myoglandular polyp thought to result from intermittent rectal prolapse. The mass was resected via transanal excision with complete resolution of hematochezia.

DISCUSSION:
Inflammatory myoglandular polyps are rare, non-neoplastic pedunculated polyps that are predominantly incidental findings during enemas or endoscopy but can present with hematochezia. While concentrated mostly in the distal colon, they can be seen in the descending and transverse colon as well. The etiology remains unknown, but there may be an association with mucosal prolapse and sigmoid diverticulosis. Specifically, it is hypothesized that chronic trauma from intestinal peristalsis may distort colonic crypt architecture, which results in muscularization of the lamina propria. This leads to subsequent redundancy and passive venous congestion that contributes to prolapse of these lesions. Generally, symptomatic inflammatory myoglandular polyps require endoscopic or surgical resection, which is curative. In this case, given the patient's symptoms along with the size and location, surgical management was indicated.
1559 Chronic Peri-Oral Dermatitis as the First Manifestations of Crohn's Disease
Authors: Isseh Mahmoud , Ghanimeh Mouhanna Abu , Naffouj Sandra , Horton Nicholas , Isseh Nazih , Kaur Nirmal 
Published: October 2019

INTRODUCTION:
Oral manifestations (OM) have been reported in crohn's disease (CD). The prevalence of these manifestations ranges between 0.5%-50% in adults and 10%-80% in pediatrics. OM of CD may coincide with the intestinal manifestations, or less commonly precede them. Aphthous ulcers, angular cheilitis, swelling of the lips and gingiva, cobblestoning of the mucosa, deep linear ulcers and periodontal disease have been reported in the literature.

CASE DESCRIPTION/METHODS:
An 18-year-old female with no significant history presented to her PCP with recurrent lip swelling and dryness. She was diagnosed initially with angioedema without urticaria. History of an environmental exposure was inconsistent and testing for hereditary angioedema, including C1 esterase and C4 levels were unremarkable. She was referred to a dermatologist who diagnosed her with peri-oral dermatitis. Treatment with antihistamines, topical steroids, antifungals, antibiotics and petroleum jelly were unsuccessful. She was treated with PO prednisone for a presumed pemphigus vulgaris with symptomatic improvement, but with relapse two weeks after weaning steroids. Due to chronicity of symptoms, a lip biopsy was done and showed a psoriasiform dermatitis with a granulomatous inflammation. Direct immunofluorescent testing was unremarkable. Results were concerning for CD versus cheilitis granulomatosa. She denied GI symptoms, weight loss or family history of IBD. Further testing revealed a normal ferritin, vitamin B12, folate, ANCA, and QuantiFERON-TB. She was referred to GI for further evaluation. An EGD showed a normal esophagus, stomach and examined duodenum. Biopsies from stomach and duodenum were unremarkable. A colonoscopy showed a normal perianal area, colon and terminal ileum. Biopsies from the left colon showed a focal active colitis, foci of neutrophilic cryptitis and focal epithelioid granuloma without dysplasia. Stains for acid fast bacilli and fungi were negative. Biopsies from the right colon and terminal ileum were unremarkable. MRE showed no evidence of active small bowel CD. Given the early onset and widespread distribution, the decision was to start adalimumab. Her OM improved significantly. A repeat colonoscopy with biopsies was unremarkable.

DISCUSSION:
The recognition of OM can play an important clue in diagnosis and management of CD, especially that an isolated oral disease is uncommon as a first presentation. Infections, nutritional deficiencies and medication side effects are important to consider as differential diagnosis.
1563 Lower Intestinal Bleeding Caused by a Left Ventricular Assist Device (LVAD) Driveline
Authors: Kaminsky Thomas J. , Gessel Luke 
Published: October 2019

INTRODUCTION:
Gastrointestinal bleeding (GIB) is a common symptom in patients with advanced cardiovascular disease. Among those at highest risk are patients with non-pulsatile left ventricular assist devices (LVADs).1 This has been attributed to multiple factors including therapeutic anticoagulation, degradation of von Willebrand factor,1 formation of angiodysplasias and advanced age.2,3 Such conditions predispose bleeding from arteriovenous malformations (AVMs) as well as other commonly occurring lesions. However, an overlooked cause of bleeding in these patients is direct injury from tunnelization of the LVAD driveline. Here we review a case of overt GIB, months after direct colonic injury from an LVAD driveline.

CASE DESCRIPTION/METHODS:
A 72 year old man with history of end stage heart failure underwent placement of an LVAD in January of 2019. His post-operative course was tumultuous and complicated by polymicrobial driveline infection. He recovered gradually and was discharged to medical rehabilitation in February with therapeutic warfarin and low dose aspirin. In April the patient presented to the Emergency Department after a syncopal episode and subsequent dizziness. He was found to have heme positive stool and hemoglobin of 7.8 g/dL (from 9.0 g/dL one month earlier). Other labs revealed iron deficiency with serum Iron level of 48 ug/dL and international normalized ratio (INR) elevation to 1.9 with warfarin therapy. Gastroenterology was consulted for evaluation of gastrointestinal blood loss with anemia. The patient underwent EGD and colonoscopy. EGD showed only retained gastric contents and no active bleeding. Colonoscopy revealed a linear, rigid foreign body penetrating the colonic wall and traversing the lumen (Figure 1). Review of prior CT scans confirmed the LVAD driveline had penetrated and passed through the transverse colon (Figures 2 and 3). The patient was subsequently taken to surgery for transverse colon resection with washout and exteriorization of the contaminated LVAD driveline.

DISCUSSION:
Gastrointestinal bleeding is common in cardiac patients following LVAD placement.1 Contributing factors include the use of anticoagulation and acquired von Willebrand disease, which most commonly causes bleeding from from AVMs.1,2 However, this case describes late bleeding after direct mucosal injury with LVAD driveline placement. Although a rare occurrence, this complication should be considered in LVAD patients, especially those with history of prior driveline infection.