bluuebunny/crossref_metadata_2025_split huggingface dataset:
3224 A Rare Case of Duodenal Adenocarcinoma in Situ Arising in the Background of Villous Adenoma
Authors: Rana Navpreet , Minhas Umair , Mahl Thomas 
Published: October 2019

INTRODUCTION:
Villous adenomas (VA) of the small bowel are the most common benign periampullary neoplasms with the highest potential for malignant transformation to adenocarcinoma. Adenocarcinoma of the small bowel accounts for only 1% of all gastrointestinal malignancies and duodenal adenocarcinoma (DA) constitutes approximately half of these cases. Although a rare and aggressive cancer, DA has the more favorable outcomes than other periampullary malignancies. Hence, it is important to understand the pathogenesis of DA as well as pre-malignant lesions such as VA. We present a male with long standing history of iron deficiency anemia found to have a duodenal mass identified as adenocarcinoma in situ arising in the background of VA.

CASE DESCRIPTION/METHODS:
A 73-year-old male, with a medical history of hypertension, Hepatitis C status post treatment and iron-deficiency anemia was referred for anemia with a hemoglobin of 6.2. He reported recent fatigue with no dyspnea, chest pain, melena, hematochezia or hematemesis. Colonoscopy 1-year ago was significant for a tubular adenoma with recommendation to repeat procedure in 5 years. Patient was transfused 1 unit of red blood cells on admission and started on oral iron supplement. He remained hemodynamically stable. Push enteroscopy showed a circumferential mass in the 3rd portion of the duodenum without obstruction. Biopsy noted adenocarcinoma in situ arising in the background of villous adenoma. Patient was evaluated by the surgical team with a plan for resection and subsequent follow-up with an Oncologist.

DISCUSSION:
VA accounts for only 1% of all duodenal tumors. Given their rarity, pathogenesis and rate of transformation to adenocarcinoma is unclear. Symptoms associated with VA depends on their location in the duodenum and can range from vague abdominal complains to biliary or small bowel obstruction, pancreatitis or iron deficiency anemia. Iron deficiency anemia in our patient was likely secondary to impaired absorption of iron in the duodenum due to the mass. Duodenal adenomas are associated with an increased risk of colonic adenomas, similar to our patient given his history of tubular adenoma in the colon. Hence, concomitant colonoscopy is warranted for early diagnosis of potentially pre-malignant colonic lesions in patients with duodenal adenomas. With regards to treatment, complete resection of VA is recommended given their high risk of malignant transformation.
3226 Complications of Meckel's Diverticulum from Helicobacter pylori
Authors: Behzadpour Jabiz , Mehdi Shaun , Villa Eduardo 
Published: October 2019

INTRODUCTION:
Meckel's diverticulum is a disease most prevalent in children. It is rare for it to present in adulthood, especially with complications. Below is a unique case of Helicobacter Pylori (H. Pylori) causing an abdominal abscess which led to the discovery of an adult male's Meckel's diverticulum.

CASE DESCRIPTION/METHODS:
A 26-year-old male with no past medical history presented to the emergency room complaining of intermittent midline abdominal pain in the lower quadrant for the past two weeks, with associated decrease in appetite, fever, nausea, and vomiting that started two days prior to arrival. The pain was worsened with eating and ambulation, and improved when lying down. One week ago he was in the emergency room for similar symptoms and was discharged home with given intravenous fluids, omeprazole, ranitidine, calcium carbonate and then subsequently discharged home. His pain did not improve, so three days later he went to his primary care physician's office where outpatient CT was ordered and patient was prescribed azithromycin, ciprofloxacin, and tramadol. Primary care physician contacted patient after obtaining CT scan results, and instructed him to immediately go to the emergency room. In the emergency room physical exam was significant for periumbilical and suprapubic tenderness with palpation and mild guarding. The CT scan showed a complex multiloculated 5 cm abscess in the mesentery of the midline lower abdomen. Patient was admitted and started on ceftriaxone and metronidazole. Surgery evaluated the patient and recommended laparoscopic exploration. During the procedure the perforated small bowel was resected and mesenteric abscess was suctioned. While in the hospital patient complained of a history of dyspepsia for the past three years which worsened 1-2 hours postprandially. This prompted him to be tested for H. Pylori IgG antibody and stool antigen. Serum IgG antibody was positive and stool antigen was negative. Ciprofloxacin and flagyl were continued, and he was also treated for H. Pylori with metronidazole prior to being discharged home. Etiology of patient's abdominal pain was determined to be a complicated H. Pylori infection and transmural perforation followed by auto seclusion via the mesentery.

DISCUSSION:
This case presents with unusual etiology for a diagnosis that is uncommonly discovered in adults. It highlights the importance of getting a thorough history with supportive diagnostic labs and imaging while maintaining a wide differential diagnosis during the initial workup.
3229 Helicobacter pylori-Negative Gastric Mucosa-Associated Lymphoid Tissue Lymphomas: A Challenge in Treatment Options
Authors: Nahar Ritu , Elden Andrew C. , Moleski Stephanie 
Published: October 2019

INTRODUCTION:
Primary gastric lymphoma is a rare entity of which the specific variant, mucosa-associated lymphoid tissue (MALT) lymphomas may be the best recognized given its association with Helicobacter pylori (H. pylori) infection. It has been thought that repetitive immune stimulation from underlying infection is influential in the pathogenesis of this tumor. However up to 10% of gastric MALT lymphomas are diagnosed without a concomitant H. pylori infection. The pathogenesis and management of H. pylori-negative gastric MALT lymphomas remains uncertain.

CASE DESCRIPTION/METHODS:
65 year old woman with Celiac disease and GERD presented with worsening severe reflux and epigastric pain. She underwent EGD which revealed multiple superficial ulcers in the cardia with notable nodularity, ulceration, and friability. Cold forceps biopsies of the abnormal mucosa demonstrated diffuse atypical small B-Cell lymphoid infiltrate with features compatible with low grade MALT lymphoma. Of note, immunostain for H. Pylori was negative. Subsequent H. pylori stool antigen assay as well H. pylori IgG, IgM, and IgA were all negative. Given her negative antibodies indicating she truly had no exposure to H. Pylori, the patient has been referred to oncology for multidisciplinary management.

DISCUSSION:
This case of early stage gastric MALT lymphoma without evidence of active H. pylori infection elucidates that there is limited literature for the management for these patients. Studies have suggested that H. pylori eradication therapy can be efficacious for a proportion of H. pylori-negative gastric MALT lymphomas, possibly due to a false negative detection by biopsy. Local radiation therapy with curative intent and single agent rituximab therapy rather than H. pylori eradication have also been explored as alternate options. The data stems from retrospective studies and single agent prospective trials. Thus, there may be a role for future research directly comparing treatment strategies for optimal management of this clinical entity.
3230 Metastatic Signet Ring Cell Carcinoma to the Pelvis in a Young Female
Authors: Likhtshteyn Michelle , Iqbal Sadat , Arroyo-Mercado Fray Martin M. , DeRoche Ketisha , Rao Prameela 
Published: October 2019

INTRODUCTION:
Gastric Cancer is the fifth most frequently diagnosed cancer in the world. While the incidence of gastric cancer has been decreasing, the incidence of signet-ring cell carcinoma (SRCC) continues to increase; with data from 2014 SEER analysis showing incidence of 0.4 per 100,000 cases [1-3]. The incidence of SRCC has increased ten-fold between 1970 and 2000 [3]. SRCC tends to occur in younger patients with a mean age ranging from 55 to 61 years [4]. Here we present a case of SRCC in a 23-year-old female with metastasis to the pelvis.

CASE DESCRIPTION/METHODS:
23-year-old female w/medical history of iron deficiency anemia presents with 6 months of abdominal pain, nausea, vomiting and 20-pound weight loss. CT scan showed a 4 cm mass of the right pelvic side wall contiguous with the uterus and ascites. Recent endoscopy showed a 4 cm ulcerated mass in the body of the stomach, pathology was positive for poorly differentiated adenocarcinoma with signet ring cell features invading the lamina propria positive for CK20, CK7, AE1/3, EMA. Patient underwent laparoscopy, pelvic washing and peritoneal biopsy, which was positive for malignant cells. The immunostains were positive for CK7, Ber-EP4, MOC31; consistent with gastric adenocarcinoma. Further imaging did not show any distant metastasis and she was referred to oncology after discharge for further treatment.

DISCUSSION:
SRCC carries a poor prognosis and therapeutic strategy remains unclear; overall prognosis depends on the stage of the cancer [3]. Some studies have shown that prognosis of early stage SRCC cancer might be equivalent to other gastric adenocarcinomas. On the other hand, prognosis of advanced SRCC is very poor with a 5-year survival rate as low as 9% [3]. SRCC differs significantly from non-SRCC oncogenic pathway, as it involves loss of cell-cell adhesion and collection of mucin in large vacuoles. It has been shown that e-cadherin deficiency might initiate carcinogenesis in SRCC at an earlier stage than other cancers [3]. Furthermore, as compared to non-SRCC cancers, gastric SRC patients has reduced sensitivity to chemotherapy [5]. Young patients with SRCC tend to present with more advanced disease; however, they have improved survival as compared to older patients [6]. This is consistent with our young female patient, who presented with metastatic disease. Further studies need to be done concerning treatment strategies and prognostic factors in young patients who present with advanced SRCC.
3231 Gastric Outlet Obstruction in a Patient After Hip Surgery
Authors: Kraus Fabian B.T. , Mehta Amit , Wan David 
Published: October 2019

INTRODUCTION:
Until the 1970s, peptic ulcer disease was the most prevalent cause for gastric outlet obstructions (GOO) and accounted for 90 percent of all cases. However, with the introduction of proton pump inhibitors (PPI) and the treatment of H. pylori infections, the etiology of GOO changed rapidly. Today, only around two percent of all peptic ulcers lead to GOO. Here we report the case of a woman with nausea, abdominal pain and coffee ground emesis, found to have a GOO, whose symptoms completely subsided under PPI treatment of a 12 mm large peptic ulcer (Forrest III) in the duodenal bulb.

CASE DESCRIPTION/METHODS:
A 62-year-old female patient with a history of hypothyroidism, recent left hip fracture repair and subsequent pulmonary embolism, presented with nausea, hematemesis, melena, epigastric pain, decreased appetite and weight loss. She was treated with daily aspirin 325 mg and apixaban, and denied any drug abuse. PPI prophylaxis was not administered. Her physical examination was unremarkable. Initial blood tests included blood count, electrolytes and coagulation monitoring, and were unremarkable except for mild anemia (hemoglobin 9.9 g/dL). Contrast CTs of the abdomen and pelvis with PO/IV contrast showed marked gastric distension with luminal narrowing at the level of the duodenal bulb. Small and large bowel appeared normal in caliber and neither obstructions nor wall thickenings could be found. Accordingly, an esophagogastroduodenoscopy was performed showing a non-bleeding, cratered ulcer with a clean ulcer base (Forrest III) in the duodenal bulb. The lesion was 12 mm in largest dimension and surrounded by edema and erythema, resulting in a complete luminal obstruction. Upon gastric decompression with a nasogastric tube and PPI treatment, the patient recovered quickly and was discharged after four days.

DISCUSSION:
Due to an increase in PPI administration and H. pylori eradication in the last decades, peptic ulcers are nowadays treated early on, and gastric outlet obstruction has become a rare complication of peptic ulcer disease. In this case, we report on a 62-year-old patient who developed an obstructive peptic ulcer following extensive hip surgery and anticoagulation with aspirin and apixaban. We hereby want to highlight the importance of a timely PPI prophylaxis for peptic ulcer disease in severely ill patients with chronic NSAID intake. Conservative measures can moreover suffice to resolve the issue.
3232 Metastatic Adenocarcinoma of the Stomach With Elevated AFP but Normal CEA in a White American Patient
Authors: Ishtiaq Rizwan , Wilhelm Darlene M. , Ahmad Sumair 
Published: October 2019

INTRODUCTION:
Globally, gastric cancers are the fourth most common cancer and second most common cause of cancer-related mortality. Alpha-fetoprotein (AFP) is a glycoprotein that is typically found during the process of fetal development. It has a very short half-life and is cleared from the body rapidly after birth. Increasing concentration of this glycoprotein in adult life is associated with malignancy of the liver, yolk sac tumor of testis, mediastinum and other conditions like hepatitis and cirrhosis of the liver. Alpha-fetoprotein (AFP) producing gastric adenocarcinoma is very rare. Its incidence is reported to be only 2.7 to 8% amongst all gastric cancers. Most of the cases of gastric adenocarcinoma producing AFP reported in the literature are from Asia. It is a very aggressive tumor with an estimated survival time of less than one year because of its rapid spread to lymph nodes and liver.

CASE DESCRIPTION/METHODS:
In this case report, we present a unique case of AFP producing gastric adenocarcinoma in a white American patient. AFP producing gastric adenocarcinoma have elevated levels of both AFP and carcinoembryonic antigen (CEA). Our case had closer to normal levels of CEA despite very high levels of AFP. The levels of AFP in our patient did not correlate with the size, stage or prognosis of the tumor. Despite the presence of liver metastasis, our case had a very good prognosis so far and had received up to six cycles of chemotherapy without any complications.

DISCUSSION:
In this case report, we have discussed the histological subtypes of AFP producing gastric adenocarcinomas. We have emphasized the use of immunohistochemical markers in the differentiation of primary hepatocellular carcinoma from AFP producing gastric adenocarcinoma. We have also discussed up to date treatment options, prerequisites for treatment, monitoring of treatment response and prognosis of AFP producing gastric adenocarcinomas in detail in this case report.
3236 This Can't Be GOO-D: Gastric Outlet Obstruction Cause by Bulky Lymphadenopathy
Authors: Likhtshteyn Michelle , Lewis Akeem , Gupta Nikita , Arroyo-Mercado Fray Martin M. , Iqbal Sadat , Al-Ani Firas , Cheung Derrick 
Published: October 2019

INTRODUCTION:
Mechanical impediment to gastric emptying is the underlying pathology for GOO; the most common cause of GOO is due to pancreatic adenocarcinoma extension to the stomach. Here we present a patient with GOO due to underlying bulky lymphadenopathy (LAD) without obvious malignancy.

CASE DESCRIPTION/METHODS:
A 60-year-old male with hx of ulcerative colitis for 25+ years, HTN, CKD, presenting with progressively worsening lower abdominal pain for two weeks with constipation, nausea, vomiting and weight loss (8 lbs in 2 weeks). For his ulcerative colitis, patient has been taking sulfasalazine for 20+ years and 6-MP for 2.5 years; he has no family history of cancer. Physical exam was benign. Labs were normal except for a creatinine of 3.43. CT abdomen and pelvis with contrast showed extensive mesenteric, retroperitoneal and pelvic LAD and markedly distended stomach with likely gastric outlet obstruction at the level of the third portion of the duodenum due to the aforementioned LAD (Figures 1–3). LAD also caused obstructive uropathy eventually leading to hemodialysis. EGD showed extrinsic compression of the second portion of the duodenum from LAD. A nasal duodenal tube was first placed and then at a later time a PEJ tube. Biopsy of the lymph nodes with IR guidance showed poorly differentiated carcinoma of unknown primary. Plan was to start chemotherapy but hospital course was complicated due to sepsis, multiple DVTs, pulmonary embolism, NSTEMI and psoas/paraspinal abscesses. Patient eventually succumbed to his co-morbidities after 3+ month hospital stay.

DISCUSSION:
GOO can be due to metastatic or benign causes, but should always be considered malignant until ruled out otherwise.1 Patients usually present with nausea, vomiting, abdominal pain and weight loss. Also can have a succussion splash or in chronic cases of GOO could have a thickened stomach on physical exam.2 CT is the recommended imaging modality while EGD is often used to establish the diagnosis and cause. Initial management involves making patient NPO, IV fluids, daily PPI and decompression with a NG tube.2 Ultimately our patient may have benefited from chemotherapy if he was able to recover completely.
3238 Botulinum Toxin Therapy: A Novel Approach to Gastroparesis
Authors: Rashid Mamoon Ur , Sarvepalli Deepika , Ullah Waqas , Zafar Hammad , Hussain Ishtiaq , Hasan Badar , Khan Muzammil Muhammad , Ur Rehman FNU Asad , Hurairah Abu 
Published: October 2019

INTRODUCTION:
Gastroparesis is a dysmotility disorder characterized by symptoms of chronic dyspepsia and delayed gastric emptying including: nausea, vomiting, bloating and upper abdominal pain. One of the novel therapeutic approaches for gastroparesis is endoscopic botulinum injection. Here we report a case of post-surgical gastroparesis that responded well to botulinum toxin therapy.

CASE DESCRIPTION/METHODS:
A 43 years old gentleman with a past medical history of atrial fibrillation s/p cardiac ablation presented with complaints of chest pain and odynophagia. After MI was ruled out, patient was diagnosed with linear deep mid esophageal perforation, which was closed with 6 hemostatic clips. Patient was discharged on TPN, after being stable. Two weeks later, he presented for shortness of breath and chest discomfort again. Patient had loud pericardial friction rub and Stat Echo showed a pericardial effusion with early signs of cardiac tamponade. Patient underwent emergent pericardiocentesis. The patient became febrile with positive blood cultures and chest CT (pulmonary veins) revealed Atrio-esophageal fistula, pericardial effusion and left-sided pleural effusion with empyema. Patient underwent thoracotomy, decortication of empyema, and repair of inferior pulmonary vein/atrial margin, esophageal repair, G/J tube placements, and omental transfer. Patient developed gastroparesis likely due to vagal nerve injury postoperatively. Patient was then treated with intra-pyloric sphincter botulinum toxin injection. Patient responded well to the therapy and his gastroparesis improved by ≥60%.

DISCUSSION:
Gastroparesis is a complex disorder of delayed gastric emptying that impairs patient's quality of life. While diabetes (29%), postsurgical (13%), and idiopathic (36%) etiologies comprise the majority of cases, other causes include neuromuscular disease, medications, scleroderma etc. Postsurgical gastroparesis often occurs following vagus nerve injury or vagotomy. Diagnostic criteria include standard endoscopy, lab studies and CT of head and abdomen to exclude other causes of postprandial fullness and confirmation of delayed gastric emptying through gastric emptying scintigraphy. Treatment consists of dietary management, prokinetic drugs like metoclopramide and erythromycin, pyloric interventions, and innovative gastric electrical stimulation therapies. Botulinum toxin injection is an emerging pyloric intervention effective in the treatment of gastroparesis.
3240 Cytomegalovirus Gastritis in an Immunocompetent Patient
Authors: Mbonu Ikechukwu , Onwochei Jennifer , Nagarakanti Sandhya , Hudacko Rachel 
Published: October 2019

INTRODUCTION:
Cytomegalovirus (CMV) is a large enveloped virus of the Herpes virus family. CMV frequently infects humans and can establish latent infection after an acute infection. In immune-compromised patients, CMV can have neurological, cutaneous, gastrointestinal (GI), cardiac or ocular manifestations and can cause severe organ dysfunction leading to significant morbidity and mortality. The colon and the stomach are the common sites of GI infection.

CASE DESCRIPTION/METHODS:
54 year old female with no prior medical history presented to the hospital with complaints of shortness of breath for the last 3 days and was noted to be in rapid atrial fibrillation. Patient was admitted and subsequently found to have severe mitral valve stenosis and moderate to severe tricuspid regurgitation. The patient was seen by Cardio-thoracic surgery and underwent mitral valve replacement and tricuspid ring annuloplasty. During the post-operative period, the patient was found to have blood in her stool and was evaluated by the gastroenterology service. In evaluating her GI bleed, she underwent an upper endoscopy. Findings on upper endoscopy included, small hiatus hernia and a single small ulcer in the incisura of the stomach. An area of gastritis was found in the antrum/body of the stomach. The mucosa appeared nodular and edematous. Biopsies were taken from the antrum and showed gastric antral type mucosa with reactive gastropathy. CMV viral inclusions were present in the gastric pit epithelial cells, confirmed on immunostain for CMV. HIV and quantiferon gold tests were negative and the patient was not known to be on any immunosuppressive therapies. Serum CMV DNA PCR was tested on 2 subsequent days which showed 4858 IU/ml and 5548 IU/mL respectively.

DISCUSSION:
CMV infection of the GI tract is a common manifestation of CMV disease in the immunocompromised patients such as Acquired immunodeficiency syndrome, organ/ bone marrow transplantation and other condition requiring chronic immunosuppressive therapy. CMV of the GI tract is rare in an immunocompetent patient and only few cases have been reported so far. Presenting symptoms include odynophagia/dysphagia, epigastric pain, nausea/vomiting, GI bleeding. However, in up to 7% of cases it can be asymptomatic. Endoscopic features of CMV infection include macroscopic normal mucosa, diffuse erythema, nodules, pseudotumors, erosions and ulcers. Detection of intranuclear inclusions, also known as “owl's eye,” is the hallmark of CMV infection.