bluuebunny/crossref_metadata_2025_split huggingface dataset:
1830 Granular Cell Tumor as a Rare Cause of Dysphagia
Authors: Moore Andrew , Lee Salina , Jakate Shriram 
Published: October 2019

INTRODUCTION:
Granular cell tumors are a rare cause of dysphagia and dyspepsia. While rare and difficult to detect, diagnosis and resection of GCTs can often provide symptomatic relief in patients. We present a case of a patient with chronic dyspepsia and dysphagia, with a seemingly incidental finding of an esophageal granular cell tumor.

CASE DESCRIPTION/METHODS:
Patient was a 32-year-old female with a past medical history significant for SLE-Sjogren’s overlap syndrome who presented to the GI clinic for a follow-up appointment with new complaint of dysphagia for two weeks. Patient was evaluated one year prior with complaints of nausea, vomiting, and dyspepsia which was managed with levbid and amitripyline; however, she continued to have symptoms of epigastric abdominal pain. Physical exam was unremarkable. Given continued epigastric abdominal pain and now dysphagia, PPI was increased to twice daily. Repeat EGD showed a nodule in the esophagus, and pathology was consistent with granular cell tumor (GCT) (Figure 1). Patient underwent endoscopic ultrasound (EUS) which showed a sub epithelial 7x3mm hypoechoic nodule in upper third of esophagus within the luminal interface/superficial mucosa and deep mucosa (Figure 2). Patient underwent endoscopic mucosal resection (EMR) of the nodule one month later. On histological evaluation, the resection appeared complete, but there was one margin with tumor extending to the margin, so there was a plan for the patient to repeat EUS/EGD in six months. At six month follow-up, her dysphagia had resolved and her functional abdominal pain had improved enough to allow decreasing her medication requirements.

DISCUSSION:
Thought to originate from Schwann cells, GCTs are extremely rare tumors that can occur at any anatomical location. Nestin expression in GCTs indicates that they may arise from a common stem cell in the GI tract, which can differentiate along both interstitial cells of Cajal and peripheral nerve pathways, leading to the common abdominal symptoms of abdominal pain, distention, and dysphagia. Decision for removal is determined based on size, with those less than 1 cm in diameter usually being treated conservatively, and those greater than 1cm typically removed, regardless of symptoms, due to increased incidence of malignancy. Our case highlights that GCTs are a rare cause of non-specific abdominal symptoms and of dysphagia but should be considered in all middle aged patients presenting with these symptoms.
1835 Closure of a Large Gastroesophageal Anastomosis Leak With Endoscopic Suturing After the Failure of Stent Therapy
Authors: Khan Ahmad , Chowdhry Monica , Sohail Abdullah , Singh Shailendra 
Published: October 2019

INTRODUCTION:
Gastroesophageal anastomotic leaks remains a potentially life-threatening post-esophagectomy complication. Surgical repair or conservative therapy have been used traditionally with suboptimal outcomes. Endoscopic methods are now an effective alternative to surgery for the management of anastomotic leak. We report a case of closure of a large Gastroesophageal anastomotic leak using a combination of endoscopic suturing with OverStitch (Apollo Endosurgery, Austin, Texas, USA) and esophageal stent after patient failed to respond to esophageal stent alone.

CASE DESCRIPTION/METHODS:
A 49-year-old male with a history of adenocarcinoma of distal esophagus underwent distal esophagectomy and placement of a percutaneous gastrostomy tube. The postoperative course was complicated by sepsis and empyema. Broad-spectrum antibiotics were started, and a percutaneous drain was placed in the mediastinum for drainage of empyema. EGD was then performed by the surgical team, which led to the identification of dehiscence of the gastroesophageal anastomosis and leak. A fully covered, 23 mm by 105 mm esophageal metal stent was placed. The patient was not able to tolerate liquids orally and continued to complain of nausea and vomiting. He continued to have a large amount of drainage from the mediastinal percutaneous drain. Repeat esophagram 8 weeks post op revealed persistent leak at the anastomosis (Figure 1). Gastroenterology was then consulted for endoscopic closure of the leak. Endoscopy was performed, and the fully covered metal stent was removed. Endoscopic examination after stent removal revealed a gastroesophageal anastomosis defect about 20 mm in diameter with necrotic appearing mucosa at the site of the leak (Figure 2). The anastomotic defect was then successfully closed with approximating the healthy gastric and esophageal mucosa. A figure-of-8 pattern of endoscopic sutures was placed using the Apollo OverStitch device. Another layer of reinforcement sutures was also placed. One fully covered 23 mm by 105 mm esophageal stent was placed over the anastomosis. The patient was started on a clear liquid diet. Esophagram performed on day 5 (Figure 1) showed no anastomotic leak. Diet was then further advanced, and the patient was discharged home.

DISCUSSION:
Large gastroesophageal anastomotic leak remains a potentially life-threatening complication post-esophagectomy. Patients failing stent therapy usually with large leaks can be successfully treated with a combination of endoscopic suturing and stent placement.
1838 Esophageal Leukoplakia
Authors: Hernandez Patricia V. , Snyder Diana L. , Kahn Allon , Wang Kenneth K. , Katzka David A. , Horsley-Silva Jennifer L. 
Published: October 2019

INTRODUCTION:
Epidermal metaplasia is a histological correlate to a white patch on the surface of a mucous membrane that cannot be rubbed off, known as leukoplakia. It is a common finding in oral mucosa, however rare in esophageal mucosa. Etiology of this condition in the esophagus is unclear, thought to be associated with esophageal tobacco and alcohol exposure or possibly an unusual response to chronic acid reflux. In contrast to oral leukoplakia there is a female predominance. Although generally asymptomatic, symptom presentation can include dysphagia. Endoscopic features include slightly elevated whitish surface, which can be translucent or cobblestone-like in appearance. The natural history is unknown though there is concern for an increased risk of squamous cell cancer. Due to paucity of published studies about this condition, we aim to report a case treated with endoscopic submucosal dissection (ESD).

CASE DESCRIPTION/METHODS:
A 64-year-old Caucasian man with a history of tobacco use and stable weight, presented to Gastroenterology clinic due to an 11-month history of solid food esophageal dysphagia. Physical examination was unremarkable. Upper endoscopy demonstrated white plaques at the gastroesophageal junction (Figure 1A and B). Biopsies obtained from this abnormality showed esophageal epidermoid metaplasia consistent with leukoplakia and mild patchy active chronic inflammation. GMS stain for fungal organisms was negative. An ESD procedure was planned, due to lesion size to ensure complete removal. Chromoscopy with methylene blue was used to mark the borders of the lesion and ESD was accomplished without adverse events (Figure 1C). Histologic examination confirmed hyperplastic squamous esophageal mucosa with marked hyperkeratosis without dysplasia and negative margins. During 2 year follow up, patient reported complete resolution of his dysphagia.

DISCUSSION:
The management strategy for esophageal leukoplakia is not well defined though reports suggest that endoscopic resection and surveillance are warranted. Here we represent a case where symptoms resolved and the lesion was completely removed by ESD.
1839 From the Lap to the Lung: The Esophagus Is the Answer
Authors: Chung Erica , Advani Rashmi , Baron Sarah 
Published: October 2019

INTRODUCTION:
Esophageal pathologies are significant yet under-reported complications of laparoscopic adjustable gastric banding (LAGB). We report a case of LAGB-associated esophageal dilatation and dysmotility that resulted in multifocal aspiration pneumonia (PNA) and a lung abscess 8 years after LAGB.

CASE DESCRIPTION/METHODS:
A 48-year-old morbidly obese man who underwent LAGB in 2011 presented with productive cough, dyspnea, and pleuritic chest pain for 3 weeks. He also reported intermittent postprandial gastric reflux and regurgitation of food since his LAGB, which he had been managing with lifestyle modifications. In the Emergency Room, he was febrile to 102F with leukocytosis to 16.8k/uL. CT chest revealed a fluid-filled esophagus (Figure 1) and a thick-walled cavity in the right lower lobe with an air-fluid level, consistent with a lung abscess (Figure 2). Additional consolidations were seen in the bilateral upper lobes. An esophagram was done due to a suspicion for aspiration PNA, and this confirmed a dilated distal esophagus (Figure 3) with impaired peristalsis and nonpropulsive contractions indicative of dysmotility. The patient’s esophageal pathologies and multifocal PNA were determined to be complications from his LAGB. He completed 3 weeks of antibiotics and was discharged with bariatric follow up for revision or removal of his LAGB.

DISCUSSION:
LAGB has several advantages over other bariatric procedures including band adjustability, reversibility, and small surgical risk. Despite this, the prevalence of LAGB has declined significantly due to several long-term complications including esophageal pathologies. In fact, one study reported esophageal dysmotility in 68% and esophageal dilatation in 25% of patients 5-7 years after LAGB. Esophageal dilatation is thought to occur from an overly tight band and in patients who overeat and use their distal esophagus as a food reservoir. This results in unsynchronized esophageal contractions and, thus, dysmotility. These patients may report reflux, vomiting, and regurgitation, which put them at high risk for aspiration PNA and, more rarely, complications such as lung abscesses. Patients who present with aspiration PNA or lung abscesses require antibiotics, but esophageal pathology alone should lead to consideration of band deflation or removal in order to prevent future recurrences. This case of LAGB-associated esophageal dysfunction highlights the importance of long-term monitoring of LAGB patients, especially in the setting of continued reflux or regurgitation.
1848 Chronic Diarrhea Complicated by Hyponatremia as a First Clue to Establish the Diagnosis of Pellagra
Authors: Wu Lesley , Disla Jenny Placido , Laskova Violetta 
Published: October 2019

INTRODUCTION:
We report a case of middle age man with a history of chronic alcohol abuse, who presented with chronic diarrhea for a month resulted in moderate to severe hyponatremia and was diagnosed with a rare in Western World disease of Pellagra.

CASE DESCRIPTION/METHODS:
This is a relatively young man 49yo with long history of alcohol abuse, who presented with mainly GI symptoms of nausea, non bloody vomiting, watery diarrhea for a month, abdominal pain, and leg rash. Blood work was significant for hyponatremia (121), thrombocytopenia (133), and alcohol level of 87.5. The physical exam was significant for erythematous, dry rash with areas of desquamation on both legs, associated with pruritus and LLQ tenderness. He was evaluated by MICU team, treated for moderate to severe hyponatremia in ER with IV fluids and admitted to medical floor for chronic diarrhea and LE rash workup. Patient has been evaluated by dermatology and Pellagra with other nutritional deficiencies vs Tinea was suspected. He underwent a punch biopsy and started on niacin as well as urea 40% cream. Pathology was consistent with nutritional deficiencies (i.e. zinc, niacin). After careful compilation of all parts of history, physical exam, and pathology, patient was diagnosed with Pellagra and continued on niacin supplementation with resolution of diarrhea and improvement of skin appearance.

DISCUSSION:
Pellagra is a nutritional disorder that results from inadequate intake of niacin or its precursor, the essential amino acid tryptophan. Pellagra is a disease very nearly eradicated in US and Europe except sporadic cases in at-risk groups (chronic alcoholism, malnutrition, malabsorption. It is classically described by the 3 D’s “diarrhea, dermatitis, and dementia”. While the life threatening presentation of Pellagra is very uncommon nowadays, the most severe cases are usually presented as encephalopathy. In our case patient presented with chronic diarrhea, which caused almost life threatening hyponatremia. Diarrhea as the first presenting symptom along with characteristic rash and history of chronic alcohol leaded to diagnosis of Pellagra, the disease easily treated with prompt administration on niacin. Pellagra is mostly a clinical diagnosis and careful collection of all parts of history and physical exam required to early recognize the disease and initiate a niacin intake. Physicians should have a high index of suspicion in certain groups of patients to early diagnose and cure this potentially fatal but treatable disease.
1865 Gastric Perforation During PEG Tube Placement in ALS Patient With Severe Malnutrition
Authors: Gupta Kapil , Marcus Akiva 
Published: October 2019

INTRODUCTION:
The natural progression of amyotrophic lateral sclerosis (ALS) usually leads to malnutrition because of decreased oral intake from dysphagia, reduced salivation, and anorexia. A decrease in weight of 5-10 kg or BMI < 20 requires intervention to improve nutrition. Intervention includes placing a feeding gastrostomy surgically, endoscopically (percutaneous gastrostomy or PEG), or radiologically. Complications range from dislodgement to parietal necrosis and death. This case involves a patient with severe malnutrition who had a significant gastric perforation during PEG tube placement, which we attribute to a patient’s nutritional status and mucosal/muscular atrophy.

CASE DESCRIPTION/METHODS:
80 yr-old man with PMH of end-stage ALS presented to the hospital for failure to thrive and significant weight loss. He underwent an EGD for PEG tube placement. During the EGD, the gastric body was notable for diffuse atrophic mucosa and hiatal hernia. Using standard technique, a 20 Fr EndoVive Safety gastrotomy tube was safely pulled through the mouth using guidewire into the stomach. The trocar needle was removed, and the PEG was pulled out from the stomach through the skin. When confirming position of the PEG tube by relook endoscopy, we found a 4 cm perforation in the stomach at the diaphragmatic hiatus with associated hemorrhagic mucosa. At which point, a large amount of subcutaneous emphysema was seen in the chest and neck. The gastroscope was immediately withdrawn, and surgery was called. The patient was transferred to the ICU. After a discussion with surgery, patient, and his family, they agreed to palliative care as patient adamantly refused further procedures. The patient was transferred to hospice care and expired three days later.

DISCUSSION:
This case is a rare presentation of a severe complication during PEG tube placement that we attributed to the poor nutritional status of the patient. We believe that the gastric mucosa and muscular atrophy from severe malnutrition led to the large perforation when the guidewire or the internal bumper of the PEG transversed the diaphragmatic hernia. This is the first case describing a complication of PEG tube placement in a severely malnutritioned ALS patient. In conclusion, this case highlights the possibility of altering procedural techniques for PEG tube placement and the necessity for increased caution during PEG tube placement in ALS patients with severe malnutrition.
1873 Colonic Perforation and Pneumothorax: Rare Complications of Upper GI Endoscopy
Authors: Shah Maulik , Truscello David , Itidiare Michael , Walters Richard 
Published: October 2019

INTRODUCTION:
Esophagogastroduodenoscopy (EGD) is a commonly performed diagnostic and therapeutic procedure with a low risk of adverse events, which can include cardiopulmonary events, hemorrhage, infection and perforation. Perforation can occur at the esophagus, stomach or duodenum, leading to pneumoperitoneum. However, what follows is a unique case of a patient who suffered a colonic perforation and pneumothorax after undergoing EGD.

CASE DESCRIPTION/METHODS:
A 71-year-old male presented with a 4-month history of epigastric pain, nausea and weight loss. His medical history was notable for coronary artery disease, hypertension, and chronic obstructive pulmonary disease. On exam, he exhibited epigastric tenderness without rebound, rigidity or guarding. CT scan showed wall thickening of the second portion of the duodenum. Magnetic resonance cholangiopancreatography showed biliary ductal dilatation without definitive obstructive lesion. EGD revealed pangastritis with nodular-appearing, edematous, and hyperemic gastric folds along with thickened duodenal folds, concerning for malignancy. At the completion of the procedure, the patient developed tachycardia and crepitus in his anterior chest wall extending into his neck. A flat plate indicated free intraperitoneal air. Repeat CT imaging discovered a large right-sided pneumothorax and a chest tube was placed. Exploratory laparotomy revealed extensive tumor burden within the mesentery of the large and small bowel with a perforation at the anterior portion of the transverse colon, which was resected with ostomy creation. Pathology was remarkable for invasive colon adenocarcinoma.

DISCUSSION:
While cases of large bowel perforation after colonoscopy are known, we found only one documented case following EGD involving a patient with pneumoperitoneum caused by a perforated sigmoid diverticulum. For our patient, pathology found that the malignancy had eroded through the lumen of the transverse colon. It is suspected that manipulation of the upper GI tract caused perforation of the transverse colon due to fibrosis in the mesentery and adhesions due to omental “caking” from extensive tumor burden. Since our patient’s injury occurred in the transverse colon, air from the perforation was able to travel to the mediastinum via fenestrations in the diaphragm which allowed air to enter the pleural space. Colonic perforation with pneumothorax is a rare complication after EGD and should be kept in mind by practitioners when the EGD shows friable tissue concerning for malignancy.
1874 Atypical Polyp Within a Diverticula: A Hidden Cancer Copycat
Authors: Shen Helen M. , Lee Brian T. , Idos Gregory 
Published: October 2019

INTRODUCTION:
Inflammatory granulation polyps inside of a diverticulum are rarely reported in the literature. We report a case of a large inflammatory granulation polyp, which appeared to be a malignant polyp discovered inside of a diverticulum.

CASE DESCRIPTION/METHODS:
A 65-year-old Hispanic female with a history of diverticulosis was referred from her primary care provider for a colonoscopy. The patient reported significant weight loss over the past year and had laboratory evidence of iron deficiency anemia (hemoglobin 11.7 g/dL, mean corpuscular volume 73.4 fL, ferritin 20 ng/mL, iron saturation 12%, TIBC 400 ug/dL). Prior records indicated that the patient underwent a colonoscopy that revealed multiple polyps within her colon. Given her worrisome presentation, a colonoscopy was performed. The colonoscopy was notable for three polyps as well as diverticulosis of the sigmoid colon. Two of the polyps were removed easily and returned as tubular adenoma. However, the third polyp was a large 10-millimeter raised lesion found inside of a diverticulum. The mucosa of the lesion was friable with a central ulcerated indentation, concerning for malignancy. Histology was notable for numerous blood vessels, neutrophils, lymphocytes, plasma cells, and reactive fibroblasts, consistent with an inflammatory granulation polyp. The patient was referred to colorectal surgery for further evaluation in the setting that endoscopic mucosal resection may not be plausible.

DISCUSSION:
Granulation polyps are more commonly observed in the setting of inflammation, such as inflammatory bowel disease, as well as in response to other insults such as infectious or ischemic etiologies. These polyps are difficult to distinguish from a neoplasm. Morphologically, they appear friable with overlying ulceration and exudate, mimicking submucosal invasive cancer. Similarly, our polyp had a classic appearance of malignancy as a sessile polyp with a centrally ulcerated indentation, concerning for submucosal invasion. Given the location of this polyp inside of a diverticulum, polypectomy may be technically challenging. Removal can be associated with an increased risk of bleeding or bowel perforation. There is no data regarding the malignant potential of these polyps in the setting of diverticulosis, although in the setting of inflammatory bowel disease, these polyps have intermediate risk. Although diagnosis is based on histology, endoscopists should be aware of this clinical entity and weigh the risks and benefits of resection versus surveillance.
1877 An Unfortunate Turn of Events: A Rare Case of Splenic Hematoma Following Colonoscopy for Post-Polypectomy Bleeding
Authors: Duriseti Parikshit , Alhudairy Maad , Tandon Manish 
Published: October 2019

INTRODUCTION:
Post-polypectomy bleeding has been reported to occur in 0.3 to 6.1% of colonoscopic polypectomies. Splenic injury after colonoscopy is a rare complication with a described incidence of less than 0.017%.

CASE DESCRIPTION/METHODS:
A 66-year-old male with a past medical history of hypertension was admitted with post-colonoscopic polypectomy bleed. He underwent a colonoscopy in July 2018 for a history of adenomatous polyps. The colonoscopy revealed multiple non-bleeding polyps (about 15) throughout the large bowel and 8 polyps were removed with endoscopic mucosal resection (EMR). A follow up colonoscopy was performed for resection of the remaining polyps in October 2018. He presented to the hospital one-week post second colonoscopy with acute onset of hematochezia. On presentation, he was afebrile, with HR 64 and BP 108/62. Labs were notable for hemoglobin of 7.1 g/dl (from a baseline of 11 to 12 g/dl) concerning for post-polypectomy bleeding. Colonoscopy repeated after admission showed no active bleeding; a clean based ulcer was noted in the transverse colon at the site of EMR which was the likely source of bleeding. Hospital course was complicated by severe left upper quadrant pain and shock with BP dropping to 70s/40s requiring ICU admission one day after the colonoscopy. He was found to be coagulopathic with an INR of 4.9 requiring vitamin K and FFP. Hemoglobin dropped to 5.3 g/dl and he received a total of 10 units of pRBC transfusions. CTA abdomen/pelvis showed a splenic hematoma measuring 12.3 x 10 x 17 cm. Splenectomy was deferred per surgery recommendations and coil embolization of the proximal splenic artery was successfully performed. He improved clinically after splenic artery embolization and was discharged home with follow-up.

DISCUSSION:
Splenic injury is a potentially catastrophic complication of colonoscopy with a reported mortality of about 5%. Several mechanisms of splenic injury associated with colonoscopy have been described which include difficult procedure, traction on the splenocolic ligament, external abdominal pressure during colonoscopy, perforation of the splenic flexure and direct trauma to the spleen, and traction of adhesions between the spleen and colon. Patient-related risk factors such as abdominal surgeries leading to adhesions, splenomegaly and pancreatitis increase the likelihood of splenic injury during the procedure. With increasing number of cases, further studies are required to re-assess the incidence and risk factors for splenic injury after colonoscopy.