bluuebunny/crossref_metadata_2025_split huggingface dataset:
3040 An Uncommon Presentation of Post-Cholecystectomy Bile Leak in the Setting of Existing CBD Stent Successfully Managed With Metallic Stent Placement
Authors: Javaid Toseef , Al-Chalabi Ahmed , Tabassum Sadia , Sodeman Thomas , Nawras Ali 
Published: October 2019

INTRODUCTION:
About 1% of patients undergoing cholecystectomy develop bile leaks. Bile leaks from cystic duct stump or from a duct of Luschka are the most common sites. Endoscopic biliary sphincterotomy and stent placement remains cornerstone in management of most post-operative bile leaks. We present an unusual case of post cholecystectomy bile leak from cystic duct stump in the presence of existing common bile duct stent.

CASE DESCRIPTION/METHODS:
A 48-year-old lady presented with 4 days history of worsening abdominal pain after cholecystectomy. She was admitted one week ago for acute exacerbation of chronic pancreatitis and underwent repeat ERCP. A plastic biliary and pancreatic stent was placed. She complained of RUQ pain and underwent HIDA scan which showed delayed gall bladder emptying suspicious for chronic cholecystitis. Given history of recurrent acute pancreatitis and chronic cholecystitis, cholecystectomy was recommended. Patient underwent laparoscopic cholecystectomy one week before this presentation. Abdominal exam on admission showed severe diffuse abdominal tenderness. X ray abdomen in ER showed non obstructive bowel pattern and possible ileus but no perforation. Labs showed WBC 13,000, TB 1.0, AST 11, ALT 20, ALP 186 and lactate 1.0. Given significant abdominal tenderness a CT abdomen and pelvis was done which showed moderate to large subcapsular and intraperitoneal fluid and 2 cm caudal migration of CBD stent with slight prominence of the adjacent common bile duct. HIDA scan showed collection of radionuclide activity along the inferior margin of the liver, increasing overtime, consistent with bile leak. A CT guided percutaneous drain was placed. Patient underwent ERCP 2 days after presentation. Cystic duct stump bile leak was seen which was treated with placement of 8 mm × 60 mm self-expandable fully covered metallic biliary stent (FCSEMS). Distal common bile duct stricture was again seen, measured 2.5 cm in length. Patient underwent repeat ERCP one month later with showed healed site of cystic duct stump leak.

DISCUSSION:
Presence of CBD stent does not preclude diagnosis of post cholecystectomy bile leak. In our case, CBD stricture, multiple previous endoscopic interventions and stent migration were reasons for failure to eliminate the transpapillary pressure gradient, thereby permitting preferential extravasation at the site of the leak. Further research is needed to establish role of FCSEMS in management of complicated biliary leaks especially in setting of CBD stricture.
3053 A Non-biopsied Mystery: Vasculitis or HSV Colitis?
Authors: Zghyer Fawzi , Wan David , Buffie Charlie 
Published: October 2019

INTRODUCTION:
Ischemic Colitis is uncommon in patients with systemic lupus erythematosus (SLE). Herpes Simplex Virus colitis is also very uncommon and tends to occur in immunocompromised patients. Here we report a case of a patient with a lupus flare with ulcers in the colon and HSV esophagitis.

CASE DESCRIPTION/METHODS:
A 21-year-old female with a PMH of SLE complicated by lupus nephritis, thrombotic thrombocytopenic purpura, and factor XI deficiency admitted for nausea and low urine output. The patient was found to have an active SLE flare, complicated by Guillain-Barre syndrome. Ten days after admission, she was found to have BRBPR, loose stools and mild epigastric abdominal pain. She denied hematemesis. Clinical exam showed bright red blood and evidence of melena on digital rectal exam. Initial workup showed 1 g/dl hemoglobin drop. The patient's EGD revealed a non-bleeding distal esophageal ulcer which was biopsy proven to be herpetic HSV-1 esophagitis (Figure 1), and a single bleeding gastric angioectasia which was treated with argon plasma coagulation. Colonoscopy revealed multiple scattered small circumferential ulceration in the right colon suggestive of ischemic colitis which were not biopsied (Figures 2 and 3). The patient's GI bleed resolved, she was started on Acyclovir. She had complete resolution in her abdominal pain in a week.

DISCUSSION:
Vasculitis is one of the most commonly recognized complications of SLE. Ischemic colitis due to Intestinal vasculitis can often go unrecognized. The pathophysiology behind gastrointestinal ischemic colitis is the deposition of immune complexes in active disease which leads to tissue damage. Herpes simplex virus enteritis is a very rarely reported entity and tends to complicate the course of inflammatory bowel disease patients and immunocompromised patients. The case we are presenting is likely to be ischemic colitis secondary to SLE vasculitis. The segmental findings of ulcers on the right side of the colon suggest ischemia involving branches of the SMA and point towards SLE vasculitis as the vasculopathy leading to direct tissue damage and eventually ischemia. HSV colitis causes terminal diarrhea, and unlikely to be evident macroscopically. Nonetheless, the patient had active esophageal HSV and is on an aggressive immunosuppressive regimen, so high risk for disseminated HSV. Ultimately, colonic biopsies of the colonic ulceration would have confirmed a diagnosis, but given the overall clinical picture, SLE colitis is more likely.
3059 A Serious Case of Fecal Impaction
Authors: Bui Rosa 
Published: October 2019

INTRODUCTION:
Fecal impaction is well described in the elderly and those with neurologic or psychiatric diseases, immobility, structural colon or anorectal abnormalities. Despite numerous laxatives on the market, chronic constipation remains a major problem. This case highlights fecal impaction, whether associated with underlying comorbidities or not, can lead to serious complications.

CASE DESCRIPTION/METHODS:
A 20 year old male presented with bilateral leg weakness and ataxic gait. CT scan showed massive stool burden in the rectum, distended to 11.3 cm by 10.4 cm. There was a resulting mass effect on the bladder and lumbar nerve roots. He underwent fecal disimpaction in the operating room under general anesthesia. Manual evacuation was performed followed by insertion of 32F chest tube and irrigation with normal saline, mineral oil and milk of magnesia. Post-op day 2, the patient was able to ambulate normally and was discharged.

DISCUSSION:
Causes of fecal impaction include colon cancer, strictures, adhesions, rectoceles as well as Hirschsprung's and Chagas disease. Manual disimpaction and enemas should first be attempted. If no success, rectal tube placement past the point of obstruction and irrigation, as in our case, is reasonable. Sigmoidoscopy is another option. Washout using oral laxatives can be attempted but is contraindicated with concurrent bowel obstruction. In extreme cases, decompressive laparotomy may be necessary. While any of these treatments can be attempted, prevention is key. Adequate fiber and hydration and biofeedback for anorectal dysfunction are crucial. Discontinuation of medications including opiates and anticholinergics are also important. If left untreated, complications include stercoral ulcer leading to hemorrhage, hydronephrosis, SIRS, bacteremia, perforation and even death. In a systematic review by Falcon et al., the most common complication was perforation, followed by obstruction, ulcer, and finally obstructive uropathy. Our case report is unique in identifying a young patient with such severe fecal impaction that led to neurologic compromise. Unfortunately, he never presented for outpatient followup and therefore no colonoscopy or anorectal manometry was done. Our patient could potentially have developed permanent neurologic sequelae, perforation and even death if treatment was delayed any further. This case highlights fecal impaction, whether associated with underlying comorbidities or not, can lead to serious complications therefore mandating prompt diagnosis and treatment.
3061 Solitary Brain Metastasis as the Initial Manifestation of Descending Colon Cancer
Authors: Yazawa Kentaro , Azuma Yuki , Kurokawa Tomohiro , Tsurita Giichiro , Shinozaki Masaru 
Published: October 2019

INTRODUCTION:
Brain metastasis of colon cancer is often accompanied by metastasis to other organs, and the prognosis is poor. However, long-term survival is reported in some solitary brain metastasis cases. We present a case of descending colon cancer with brain metastasis and relatively long survival after surgery.

CASE DESCRIPTION/METHODS:
Having suffered from amnesia, dysgeusia and headache for 2 weeks, a 58-year-old woman visited a nearby hospital. With a projected tumor in the right occipital brain, she was referred and then admitted to our hospital. A CT scan showed a descending colon tumor, while the PET/CT scan showed fluid accumulation in a right brain tumor and a descending colon lesion. An open resection was indicated to remove a 35 × 40 mm brain tumor, followed by colonoscopy 7 days later, with the scope unable to pass through the entire circumferential tumor. Histopathologic diagnosis confirmed moderately and highly differentiated adenocarcinoma of the colon and moderately differentiated adenocarcinoma of the brain. This indicated colon cancer spread to the brain. The patient was treated with total brain irradiation of 30 Gy/10 times. With no evident distant metastases, she underwent left hemicolectomy 27 days after the brain surgery, removing a nearly 2-cm omental nodule neighboring the tumor. The serosa showed that the main lesion (a non-exposed type-2 tumor of 40 × 50 mm) retracted surrounding tissue. It mainly comprised moderately differentiated adenocarcinoma and poorly differentiated adenocarcinoma at the infiltration tip. Vascular invasion into the subserosa (SS) was observed with five lymph node metastases (N2) and adenocarcinoma in omental nodules (P1). Experiencing a good postoperative course and after treatment with chemotherapy, the patient survived 20 months after the brain surgery without evident brain metastasis relapse, despite liver metastasis 7 months after surgery.

DISCUSSION:
Although rare (0.4-1.8%), brain metastases have a high metastasis rate (82%), resulting in a low one-year survival rate after diagnosis (16%) and poor prognosis. However, long-term survival is frequently reported in cases with solitary brain metastasis. Resection is indicated for brain metastasis of colon cancer when life prognosis is longer than several months; excision causes no serious neurological symptoms; and brain metastasis spreads to no other organs or is well controlled. Surgical treatment, therefore, was considered suitable for our patient.
3062 Strongyloides stercoralis: A Rare Etiology of Infectious Colitis
Authors: Then Eric O. , Hernandez Kimberly , Ofosu Andrew , Gayam Vijay , Bengualid Victoria , Gaduputi Vinaya 
Published: October 2019

INTRODUCTION:
Strongyloides colitis is a rare parasitic infection caused by the nematode (roundworm) Strongyloides Sterocalis. This infection is endemic to tropical and subtropical regions with poor sanitation, but it is also prevalent in rural regions of the United States. Here, we present a rare case of strongyloides colitis in a patient with human immunodeficiency virus.

CASE DESCRIPTION/METHODS:
The patient is a 40-year-old male with no significant past medical history who presented to the emergency department (ED) with progressive diffuse abdominal pain. The pain previously occurred with meals, but then became constant. Notable laboratory workup included a hemoglobin of 8.7 gm/dL and increased eosinophil count of 0.86 103/uL (ref range 0.04-0.54). The patient also tested positive for human immunodeficiency virus. A computed tomography scan of the abdomen showed a thickened colon from the level of the splenic flexure to the rectum indicating colitis as a possible diagnosis. Colonoscopy was then performed and showed diffuse severely ulcerated mucosa that oozed. In addition, there were prominent edematous folds with superimposed inflamed mucosa without the presence of discernible mass lesions. Intravenous antibiotics were started and there was symptomatic improvement leading to the patient's discharge. Three days post-discharge, the colonic biopsies returned showing parasitic larvae in the lamina propria of the colonic mucosa suggestive of Strongyloides species. The patient was contacted and stated he would return for follow-up to his doctor for treatment.

DISCUSSION:
Strongyloides colitis is an easily treated infection, however if untreated can have a high mortality rate. This is especially true for immunocompromised patients and those given immunosuppressive agents, such as those with inflammatory bowel disease (IBD). Considering this infection can present clinically and morphologically similar to IBD, it is important to differentiate the two before steroids and other immunosuppressive agents are administered. The feared complication of this infection is dissemination via autoinfection. Autoinfection is characterized by penetration of the intestinal mucosa by the larvae where they can then travel to the lungs causing pneumonia and acute respiratory distress syndrome. The larvae can also travel to various other organs causing multi-organ failure and death. This, however, can be avoided with proper diagnosis and successful treatment with Ivermectin or Albendazole.
3063 Colon Cancer in 41-Year-Old With Presenting Symptom of New Onset Ascites Masked by History of Alcoholism
Authors: McDonald Emmanuel , Skrove Jamie L. , Sobrado Javier , Mohan Karthik 
Published: October 2019

INTRODUCTION:
Colorectal cancer remains one of the leading causes of cancer-related deaths in the United States to this day. What was primarily seen in the 50+ population, is now being diagnosed more frequently in younger adults, with the proportion of cases diagnosed in individuals younger than age 50 increasing from 6% in 1990 to 11% in 2013. 72% of these cases occur in patients in their 40s. It is important not to dismiss the possibility of this diagnosis in a differentially solely based on patient age, especially when symptoms may be explained away by other more obvious diagnoses.

CASE DESCRIPTION/METHODS:
A 41 yr old male with history of hypertension, reflux, 30 pack year smoking history and 30 years of daily vodka intake presented with 10 day history of worsening abdominal pain, distention and constipation. Abdominal CT showed mild/moderate ascites, unremarkable spleen and liver, and no identifiable masses. Paracentesis was performed and 2.3 liters of ascitic fluid was removed. SAAG was calculated at <1.1 and BF protein >2.5, which was not indicative of alcoholic hepatitis or portal hypertension. Acute hepatitis panel was negative. MELD score was 8 and liver enzymes were WNL. Liver ultrasound was performed and ruled out portal vein thrombosis. Primary team was convinced the ascites was from the history of alcoholism and convinced patient of the same. Liver biopsy was ordered, however after discussing the case with the primary team and the patient, EGD and colonoscopy was finally agreed upon with much reluctance. EGD showed gastritis. Colonoscopy showed a flat, hardened area in the cecum that resembled colitis visually. Biopsies were taken and resulted as adenocarcinoma.

DISCUSSION:
The classic triad for cecal cancer of right sided pain, a palpable mass, and microcytic anemia were not seen in this patient; and most cases of early colon cancer present with no symptoms at all. The fact that this patient had ascites and generalized abdominal pain that brought him to the hospital was a blessing so to speak. If the opportunity had been squandered to get the correct diagnosis due to ease of another more reasonable explanation, the results would have been injurious. This case is an important lesson that physicians cannot dismiss a full differential just because there may be a more plausible explanation. If the workup had stopped at the liver in this patient, the diagnosis of colon cancer in a 41 year old young man would have been missed, and that would have been detrimental.
3065 Foreign Body Colonic Perforation: Considerations Beyond the Colon
Authors: Bommena Shoma , Mann Sarabdeep , Seetharam Anil 
Published: October 2019

INTRODUCTION:
Toothpick ingestion may cause gastrointestinal tract perforation; associated injury of extracolonic vasculature or soft-tissue is rarely reported. We present a case of toothpick related sigmoid colon perforation and associated internal iliac artery injury requiring sigmoid colon resection.

CASE DESCRIPTION/METHODS:
A 44-year-old male with Marfan syndrome and COPD presented to our hospital with progressive right hip pain for a week. On physical exam he was febrile, tachycardic, and had tenderness of his right lateral thigh. He was found to have a leukocytosis of 18k, as well as an elevated ESR and CRP. Blood cultures grew Bacteriodes. An abdominal CT showed a right psoas abscess and a thin, dense linear structure extending from the distal sigmoid colon, through the right internal iliac artery, and terminating just anteromedial to the right sacroiliac joint. IV antibiotics were initiated. Interventional radiology performed a CT guided abscess drainage. GI was consulted as there was suggestion of a sigmoid fistula/foreign body on imaging. The patient had no recollection of ingestion of a foreign body. Flexible sigmoidoscopy showed a foreign body traversing the wall of the distal sigmoid colon (Figure 1). It was not removed endoscopically due to perforation through the colonic wall, as it was unclear what was on the extra luminal side of the object. Colorectal surgery was consulted and he urgently underwent a hand-assisted laparoscopic partial sigmoid resection on the same day. Intraoperative findings showed a perforation of the distal sigmoid colon due to a toothpick with associated injury to internal iliac artery. The affected portion of the sigmoid colon with the toothpick was removed laparoscopically, after which there was noted to be pulsatile bleeding from the internal iliac artery that resolved with manual pressure for 20 minutes. The iliac artery was subsequently repaired and a primary colonic anastomosis was performed. Gross operative specimen is shown in Figure 2. Post-operative course was uncomplicated and the patient was discharged home in stable condition.

DISCUSSION:
Ingestion of sharp pointed objects such as toothpicks pose a significant risk of organ injury. We demonstrate a case of an ingested toothpick resulting in a perforation through the sigmoid colon and the internal iliac artery, presenting initially as a psoas abscess. This was successfully treated surgically and the patient did well post-operatively.
3084 A Case of CMV Colitis: Both a Cause and Consequence of Acute Renal Allograft Rejection
Authors: Radow Mark 
Published: October 2019

INTRODUCTION:
Cytomegalovirus is an extremely common pathogen that usually causes a mild, self-limiting disease in the immunocompetent host. The risk of active CMV disease increases in states of immunosuppression (AIDS, transplant recipients, cancer, IBD, use of immunosuppressive agents). CMV infection in transplant recipients has a predilection for the gastrointestinal tract.

CASE DESCRIPTION/METHODS:
A 46 yo African American male with history renal transplant in 2002 presented to the hospital for worsening creatinine. He was previously doing well on immunosuppression with sirolimus, cyclosporine, and prednisone. His baseline creatinine was 2.2-2.6 mg/dL. On admission his Cr was 5.8. He underwent a renal biopsy that was suspicious for antibody-mediated rejection. He received high dose IV steroids, plasmapheresis, and IVIG. His Cr improved to 4 and he was discharged on tacrolimus, mycophenolate, and a tapering prednisone dose. He returned to the hospital 3 weeks later with dyspnea and peripheral edema. He also had 2 episodes of hematochezia the day prior. His Cr increased to 7.2 and his hemoglobin dropped from 8.9 g/dL to 6.9. He was started on dialysis. His hemoglobin initially improved with a transfusion but 3 days later dropped to 6.9. GI was consulted. Colonoscopy revealed a 7 × 7 mm ulcer at the ileocecal valve. Biopsies confirmed CMV colitis. He was evaluated by infectious disease for treatment.

DISCUSSION:
CMV infection of the GI tract is relatively common in organ transplant recipients and can involve the upper or lower GI tract. It can result in mucosal injury, ulcerations, hemorrhage, GI dysmotility, or perforations. CMV colitis can present with fever, abdominal pain, diarrhea, hematochezia, toxic megacolon, or perforation. Lower GI bleeding is the most common initial presentation. Endoscopic findings of CMV colitis are categorized into 3 groups: well-demarcated ulcers, diffuse infiltrative ulcers, and pseudomembranous patterns. Sometimes hemorrhagic colitis is seen with multiple punctuate lesions. CMV reactivation can be elicited by high intensity immunosuppression and disease can lead to allograft dysfunction and rejection. Patients at risk for CMV infection should be started on antiviral prophylaxis. With symptoms of disease, a prompt diagnosis is necessary in order to start antiviral therapy with IV ganciclovir or oral valganciclovir. A delay in treatment can result in high morbidity and mortality and therefore clinicians need to have a high index of suspicion.
3087 Combined Endoscopic and Surgical Management of Small Bowel Polyposis in a Patient With Peutz-Jeghers Syndrome
Authors: Li Feng , Liska David , Cauley Christy , Dionigi Beatrice , Mankaney Gautam , Kalady Matthew F. , Church James M. , Burke Carol A. , Bhatt Amit 
Published: October 2019

INTRODUCTION:
A 55-year-old male with history of Peutz-Jeghers syndrome was referred for a colonoscopy for management of a large ileal polyp. Surgical history was notable for two laparatomies for small bowel obstructions in the setting of intussusception as well as multiple enterotomies for removal of polyps.

CASE DESCRIPTION/METHODS:
Colonoscopy confirmed a polypoid mass in the distal ileum that was partially obstructing. Endoscopic submucosal dissection of the polyp stalk was performed but revealed two feeding arteries as well as a thick muscular band, concerning for muscularis propria, that precluded further safe dissection. Hemoclips were placed on the feeding arteries in an attempt to cause necrosis of the lesion. After discharge the patient developed hematochezia. Repeat colonoscopy did not show any ongoing bleeding but the mass appeared to be necrotic. Repeat colonoscopy was planned in the operating room to evaluate the mass. If the necrosis was not complete, dissection of the stalk would be re-attempted with plans to convert to surgical resection if needed. On endoscopy, the mass appeared to have revitalized. Another attempt at submucosal dissection of the polyp stalk was performed. However as the area had already been dissected through, the submucosal plane was not easily identified in the stalk and did not feel that it was safe to continue the submucosal dissection. Subsequently, the patient was converted to surgical resection of the ileal polyp, which also revealed multiple polyps more proximally throughout the small bowel. The bowel resection included the initial large polyp and another large polyp at a prior ileal anastomosis that could not be removed without a resection. Multiple other polyps were removed via enterotomies. To clear the remaining small bowel of residual polyps, we performed a clean sweep. A pediatric colonoscope was introduced orally and the scope was able to be advanced distally to the ileal anastomosis by plicating the bowel over the scope. Multiple further polypectomies were then performed using standard endoscopic mucosal resection technique. On 3 month follow up MR enterography, there were no convincing polyps identified in the entire small bowel.

DISCUSSION:
This case demonstrates the importance of a multi-disciplinary approach to the management of this patient's polyposis. The combination of endoscopic and surgical approach allowed for effective management of both the large ileal polyp as well as his overall polyp burden.
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