bluuebunny/crossref_metadata_2025_split huggingface dataset:
1727 Importance of DIETARY Modification in Successful Management of Eosinophilic Gastroenteritis
Authors: Kudaravalli Pujitha , Saleem Sheikh A. , Sapkota Bishnu 
Published: October 2019

INTRODUCTION:
Eosinophilic gastroenteritis (EGE) is an extremely rare inflammatory disorder with an estimated prevalence of 22-28/100 000. We herein, present a case of EGE in an elderly patient which was successfully managed with dietary restriction. We would like to stress that food allergy is the main culprit in certain cases of EGE and dietary modification should always be the first step in the management of these cases.

CASE DESCRIPTION/METHODS:
A 70-year-old male with a history of GERD, atopic dermatitis and asthma presented with 2 weeks history of foul-smelling non-bloody diarrhea associated with nausea, vomiting and weight loss. Physical examination was significant for dry oral mucosa and loss of skin turgor. Lab findings were significant for a Hb/Hct (g/dl/%) of 13.2/38.5, MCV of 86.3%, WBC count of 24,200/mm3, albumin of 2.2 g/L, stool fat of 70g, stool osmolar gap of 115, CRP of 1.47. ESR, HIV test, infectious stool work-up were unremarkable. CT abdomen was unremarkable. The mucosa appeared mildly inflamed on upper endoscopy and colonoscopy, and biopsies showed eosinophilic infiltration of the mucosal and muscular layers. A diagnosis of EGE was made after other causes such as parasitic infection, drug use and malignancy were ruled out. The patient was suggested a six-food elimination diet which successfully resolved his diarrhea. The patient did not have any relapses with dietary modification on follow-up.

DISCUSSION:
The prevalence of EGE is underestimated as it is under diagnosed given the rarity of the condition especially when it presents outside of the age spectrum. The pathogenesis of EGE remains unclear and it is hypothesized to be a hypersensitive response to certain allergens. The recurrence rate of EGE is 50% and a dietary trial could be a long-term solution. A six-food elimination diet or an elemental diet is recommended. Steroids improve symptoms in 90% of cases but the recurrence rates are high. The type, dose and duration of steroid therapy is unclear. Sodium cromoglicate, ketotifen, and Montelukast are other proposed treatments, the results being inconclusive. Bowel resection is performed in intestinal obstruction, but medical therapy is needed as recurrence in other segments in common. The clinical guidelines for the diagnosis of EGE is sparse and the treatment offered is low-evidence based. Dietary modification, a therapy with no side-effects should be the first line of treatment and can result in resolution sparing the patient of steroid induced side effects.
1731 Leukemic Infiltration Leading to Esophagitis: A Rare Initial Presentation of AML
Authors: Chung Jae , Richter Seth , Wazir Ali , Rahman Haider , Naseer Usman , Fitzpatrick Michael , Arslan Mustafa Erdem 
Published: October 2019

INTRODUCTION:
Acute Myeloid Leukemia (AML) is a group of blood cancers that arise from clonal proliferation of malignant hematopoietic precursor cells in bone marrow. We report a case of AML that presented as esophagitis secondary to leukemic infiltration of the esophagus.

CASE DESCRIPTION/METHODS:
A 60 year male who presented with 1 month history of worsening retrosternal pain, worsened with eating & drinking, leading to a 9 kg weight loss. Patient was taking increasing doses of NSAIDS to treat this pain unsuccessfully. Patient’s past medical history included hypertension, hyperlipidemia & Bell's palsy. Patient’s EKG & 3 troponins were normal. He had no melena, hematochezia but stool guaiac tested positive. Initial CBC showed a WBC 20.5 k/mm3, Hgb 7.7 g/dL, & Platelets 28 k/mm3 with peripheral smear revealing 86% blasts with rare Auer rods. Patient was diagnosed with AML with NSAID associated gastritis & was started on IV Proton pump inhibitor therapy. Patient underwent a bone marrow biopsy that showed 95% blasts and 5% erythroid. On flow cytometry 95% were myeloblasts. Fluorescence in-situ hybridizationtesting showed MLL mutation with 11q23 rearrangement. While awaiting induction 7 + 3 chemotherapy, patient underwent EGD due to continued odynophagia. It showed multiple discreet large non-bleeding ulcers in the proximal & middle third of the esophagus. CMV esophagitis was suspected & the patient received empiric ganciclovir for 3 days. The final biopsy showed no CMV and colonisation without invasion by Actinomycetes, but it also showed atypical mononucleated cells consistent with leukemic infiltrates in the ulcer bed. Patient received induction chemo 7 + 3 but had partial response based on day 14 bone marrow & was successfully reinducted. He is currently awaiting a bone marrow transplant on consolidation chemotherapy. He is symptom free of esophagitis.

DISCUSSION:
In AML, large numbers of immature myeloid cells are seen in the bone marrow & in peripheral blood resulting in a crowding out effect of other cell lines. Presentation is usually symptoms of anemia, bleeding from thrombocytopenia or immune deficiency. In previous autopsy series, gastrointestinal involvement of leukemia have been noted, with involvement of the esophagus being less common. There have been reports of leukemic infiltration of the esophagus developing during treatment for AML, but our case is a rare initial presentation with esophagitis from leukemic infiltration which led to the diagnosis and treatment of AML.
1741 Large Cell Neuroendocrine Carcinoma of the Esophagus Arising From Barrett’s Esophagus: A Rare Phenomenon
Authors: Shah Maulik , Truscello David , Lal Kailash , Kolnik John 
Published: October 2019

INTRODUCTION:
In this case report, we present an anomalous case of poorly differentiated large cell neuroendocrine carcinoma (NEC) arising in Barrett’s esophagus (BE). BE typically predisposes a patient to an adenocarcinoma of the gastroesophageal junction, although the incidence is low. Proximally, squamous cell carcinomas are a more likely finding in the esophagus. Esophageal large-cell NECs are rare and aggressive tumors and lead to a poor prognosis.

CASE DESCRIPTION/METHODS:
56-year-old male presented to the outpatient gastroenterology office with a history of gastroesophageal reflux disease (GERD) and unintentional 22 lb weight loss. He endorsed acid reflux refractory to long-term PPI therapy. Initial upper endoscopy revealed short segment Barrett’s esophagus and gastritis. Follow-up surveillance endoscopy performed six months later demonstrated a cratered ulcer within the segment of Barrett’s esophagus (Figure 1). Biopsies revealed large-cell neuroendocrine carcinoma in the setting of Barrett’s esophagus (Figure 2). Repeat biopsies taken during endoscopic ultrasound confirmed this. The biopsy stained positive for CDX2, CK7, CK20, chromogranin and synaptophysin. Following diagnosis, he was seen by Thoracic Surgery and had Ivor Lewis esophagectomy (ILE) performed. Given its aggressive biology and risk of recurrence, he was evaluated by oncology and started on carboplatin and etoposide chemotherapy treatment.

DISCUSSION:
Our patient is a middle-aged Caucasian male with a history of GERD, which are known risk factors for development of BE. BE is a precursor for esophageal adenocarcinoma (EAC), with the annual risk of transformation being 0.1-0.5%. Considering BE increases the risk of developing esophageal cancer, this case reminds gastroenterologists of the importance of surveillance endoscopy and biopsy. Although there are a few cases of esophageal large-cell NEC noted in literature, we found no others reporting this subtype in the setting of BE. Neuroendocrine collision tumors in the setting of BE have only been reported in one other case. Esophageal large-cell NEC are extremely rare, accounting for only 0.04-1.4% of GI NECs reported. Given the rarity of esophageal large-cell NECs, there are no definitive guidelines for diagnosis, staging and treatment. Surgery and platinum-based adjuvant chemotherapy have been the only effective treatments. Aggressive biology and high risk of recurrence means it is imperative that an accurate diagnosis is made and prompt treatment is initiated.
1751 A Rare Complication of a Common Finding: A Case of Iron Deficiency Anemia Secondary to an Ulcerated Inlet Patch
Authors: Curtis Stephen , Tritsch Adam 
Published: October 2019

INTRODUCTION:
Inlet patches are a congenital anomaly of the cervical esophagus which are comprised of heterotropic gastric mucosa and have been reported in 1-12% of patients on endoscopy. Typically, this finding is seen distal to the upper esophageal sphincter, and appears endoscopically as a salmon colored patch which contrasts against normal esophageal mucosa. Rarely, inlet patches become symptomatic due to mucosal changes leading to ulceration, neoplasia or stricturing. We present a case of an ulcerated inlet patch leading to iron deficiency anemia.

CASE DESCRIPTION/METHODS:
The patient was a 41 year old African American female, who was admitted with a cardioembolic stroke (CVA). On admission, hemoglobin was noted to be 5.8 g/dL with an MCV of 55 fl. Her iron panel was suggestive of iron deficiency anemia (TIBC 455 ug/dL, Ferritin 5 ng/ml, Iron Saturation 4.4%). She denied having gastrointestinal symptoms, overt bleeding and she endorsed only having light bleeding during menstruation. EGD and colonoscopy were performed to further evaluate her anemia. Colonoscopy with intubation of the terminal ileum was unremarkable however, EGD revealed an ulcerated gastric inlet patch with adherent clot at 20 cm from incisors. No other obvious bleeding source was identified on EGD. Given her recent initiation of anticoagulation for cardioembolic stroke and absence active bleeding, the decision was made to not perform any endoscopic interventions. She was started on a proton pump inhibitor and serology for Heliobacter pylori (HP) IgG obtained. When this returned was positive she was initiated on triple therapy.

DISCUSSION:
This represents a rare case of an ulcerated gastric inlet patch resulting in iron deficiency anemia. Literature suggests that there may be high concordance of Helicobacter pylori colonization of inlet patches in patients with colonization of the stomach. Potentially this could be a unifying diagnosis of her HP serology positivity and an ulcerated inlet patch. This case also highlights the importance of deliberate visualization of the esophagus during EGD where proximal esophageal lesions can be easily missed.
1760 A Tough to Swallow Diagnosis: Dysphagia as a Manifestation of Esophageal Pemphigus
Authors: Yang Grace H. , Apfel Tehilla , Peters Stephen , Jones Anja , Shulik Oleg 
Published: October 2019

INTRODUCTION:
Pemphigus is a rare group of autoimmune blistering disorders that affect mucous membranes and skin via acantholysis triggered by binding of circulating IgG autoantibodies to intercellular adhesion molecules. Pemphigus vulgaris (PV) is the most common, although paraneoplastic pemphigus in association with lymphoproliferative disorders exists as well. The esophagus is an uncommon site of involvement, but if present, may cause dysphagia and odynophagia or rarely, hematemesis.

CASE DESCRIPTION/METHODS:
A 76-year old man with a history of stable PV maintained on chronic steroids presented with several months of dysphagia with new oral ulcerations and bullous lesions on his upper and lower extremities. Patient also had a history of stage IIB (T2N1) squamous cell carcinoma of the distal esophagus. He underwent neoadjuvant chemotherapy and radiation with subsequent esophagectomy 2 years ago. Surveillance CT Chest/Abdomen/Pelvis immediately prior to admission showed no evidence of metastatic disease. Given dysphagia and history of esophageal cancer, patient underwent EGD, which revealed desquamating areas of the esophagus. Two small nodules in the areas of desquamation were biopsied. The esophageal biopsies were notable for squamous esophageal mucosa showing “denuded upper epithelial layers leaving one to several layers of suprabasal keratinocytes at the surface. The remaining keratinocytes show loss of cohesion consistent with involvement by the patient’s pemphigus.” New skin lesions continued to appear, most notably on the patient’s right hand. Biopsy of the skin lesion on his right thumb revealed PV, but it was noted that paraneoplastic pemphigus could not be excluded.

DISCUSSION:
Esophageal involvement of pemphigus is a rare finding in an already rare disease. It may be misdiagnosed or missed altogether if not on the differential. The presentation of dysphagia with concomitant oral ulcerations in a patient with a history of pemphigus should be further explored with EGD. Biopsies, brushings, and immunofluorescence of esophageal tissue will aid in diagnosis. Prognosis is poor despite therapy in refractory pemphigus, with mortality as high as 70-80% in 2 years. Despite high dose steroids, the patient's PV continued to worsen requiring rituximab and IVIG combination therapy as well as plasmapheresis.
1764 It’s Not Always Reflux: The Role of High-Resolution Manometry in Management of Patients With Sleeve Gastrectomy
Authors: Tran Victoria , Kuna Michael , Averbukh Leon D. , Singh Tejinder Paul , Tadros Micheal 
Published: October 2019

INTRODUCTION:
We present cases of esophageal motility disorders associated with sleeve gastrectomy and identify the role of high-resolution manometry (HRM) in perioperative diagnosis and management.

CASE DESCRIPTION/METHODS:
Case 1: A 44-year old female with history of morbid obesity and gastric reflux presented with persistent symptoms of regurgitation, vomiting, and refractory reflux after undergoing a sleeve gastrectomy two years prior. Upper endoscopy showed slight resistance to endoscope passage at the lower esophageal sphincter and HRM evaluation was consistent with Type II achalasia, a finding confirmed by barium esophagram. The patient underwent a Heller myotomy with conversion into gastric bypass. On follow-up, patient noted no further recurrence of her presenting symptoms. Case 2: 52-year old female with multiple comorbidities presented with refractory dysphagia. She had undergone sleeve gastrectomy 5 years prior and subsequently developed worsening postprandial chest pain and solid food dysphagia. Outside work up of her dysphagia including multiple endoscopies and an esophagram were negative. On present evaluation, a 13 mm Barium pill traversed the esophagus without delay, and HRM showed a hypercontractile esophagus with high normal integrated relaxation pressure. The patient was started on antispasmodic therapy with symptom improvement.

DISCUSSION:
Laparoscopic sleeve gastrectomy is a bariatric surgical procedure for rapid weight loss in those classified as morbidly obese. The procedure leaves patients with a narrow tubular stomach roughly the diameter of the esophagus. Post operatively, patients have been noted to experience dysphagia, odynophagia, and most commonly (19.7% of cases) reflux. In our cases, patients experienced severe esophageal dysmotility which may have been caused by post-operative alterations of gastric anatomy and pressures. The mechanism behind post-operative motility disorders is unclear, and some studies have suggested that the procedure may unmask previously latent or subclinical disorders rather than induce them. We believe that HRM should be used as part of high value care in evaluating gastric sleeve patients with esophageal symptoms, especially before surgical revisions. Braghetto, I., et al. OBES SURG (2010) 20: 357. https://doi-org.elibrary.amc.edu/10.1007/s11695-009-0040-3.
1766 Can We Avoid Esophagectomy in T1b Esophageal Adenocarcinoma?
Authors: Odah Tarek , Shafa Shervin 
Published: October 2019

INTRODUCTION:
Current guidelines recommend esophagectomy for Esophageal Adenocarcinoma stage T1b. There are limited data regarding multimodality therapy for Esophageal Adenocarcinoma T1b using endoscopic therapy instead of a surgical option. We present a case of EAC stage T1b patient who was successfully treated by multimodality treatments.

CASE DESCRIPTION/METHODS:
An 84 years old female with a history of Barrett’s esophagus underwent an endoscopy and was found to have esophageal adenocarcinoma with deep submucosal invasion (T1b) with no surrounding lymphadenopathy on EUS. She was recommended to have an esophagectomy but refused and requested a less invasive approach. She was offered endoscopic mucosal resection (EMR) and cryoablative treatments. Over the course of one year, the patient underwent several sessions of endoscopic EMR followed by cryoablative therapy. The fourth EMR specimen revealed positive deep margins involving the submucosa with lymphovascular invasion (LVI). Further sessions of cryoablation and EMR were done and she was also referred to oncology for adjuvant therapy. Oncology recommended both chemotherapy (with paclitaxel and carboplatin) as well as radiotherapy. However, the patient couldn’t tolerate more than two sessions of chemotherapy so it was discontinued while radiotherapy was continued. Few months after the patient finished radiotherapy she underwent a follow-up EGD with multiple biopsies which showed no evidence of dysplasia or malignancy.

DISCUSSION:
Endoscopic eradication therapy is the treatment of choice for early esophageal cancer. Surgical management for T1b is recommended given higher rates of LVI. Our case represents a successful case of eradicated adenocarcinoma using a multidisciplinary approach involving gastroenterology, thoracic surgery, medical oncology, and radiation oncology. More data will be helpful in assessing the effectiveness of a multimodality approach in treating T1b esophageal adenocarcinoma with LVI without invasive surgery.
1770 The Utility of Congo Red Staining in Grossly and Histopathologically Silent Gastrointestinal Amyloidosis
Authors: Zilberstein Netanel F. , Singh Sanmeet , Zilberstein Ashley T. , Carroll Robert 
Published: October 2019

INTRODUCTION:
Primary amyloidosis (AL) with gastrointestinal (GI) involvement is a rare disease with nonspecific clinic manifestations1. Patients with symptoms suggestive of GI amyloidosis undergo endoscopic evaluation with biopsy and up to 75% of patients with GI amyloidosis have non-specific gross findings on endoscopy2. H&E staining shows characteristic amyloid deposition, which is then followed up by confirmatory Congo red staining. If both endoscopic and histologic evaluations are unremarkable, it is not common practice for Congo red staining to be performed3. We present two cases of AL amyloidosis with gastrointestinal involvement diagnosed by Congo red staining despite normal endoscopic findings and non-specific histopathologic findings.

CASE DESCRIPTION/METHODS:
71-year-old female with history of smoldering myeloma and AL amyloidosis complicated by heart failure presented with several weeks of nausea, vomiting, abdominal pain and anorexia. Her symptoms were initially attributed to her chemotherapy regimen; however, they persisted despite reduction of her chemotherapy doses and addition of a protein pump inhibitor. She also developed new-onset dysphagia to solid foods. The patient was referred to gastroenterology for an esophagogastroduodenoscopy (EGD), which was grossly unremarkable. Biopsies showed only nonspecific chronic inflammation, yet Congo red staining was performed due to high clinical suspicion for amyloidosis and was positive. She was started on a dysphagia diet with eventual resolution of her symptoms. A similar case involved a 51-year-old female with history of AL amyloidosis complicated by gastroparesis with gastrostomy tube placement who presented for chronic diarrhea for 6 months. Workup including stool PCR studies, fecal fat, and stool alpha-1-antitrypsin were all negative. She was referred for EGD and colonoscopy which were grossly unremarkable. Histological evaluation of the biopsy was negative for significant pathologic changes (Figure 1A). However, she was found to have positive Congo red staining (Figure 1B). She underwent treatment with octreotide and psyllium with resolution of her symptoms.

DISCUSSION:
These two cases highlight the importance of performing Congo red staining in all cases in which there is high clinical suspicion for GI amyloidosis despite negative endoscopic and histopathologic evaluation. This method will allow for increased diagnosis and early treatment of the disease.
1774 Achalasia Presenting as a Complicated Lung Abscess
Authors: Vijayasekar Kavitha , Syed Umer , Ahmed Moiz , Walfish Aaron 
Published: October 2019

INTRODUCTION:
Achalasia is a rare motor disorder of the esophagus resulting from inflammation and degeneration of neurons and the interstitial cells of Cajal in the esophageal wall. Patients typically present with slow progressive dysphagia for solids and liquids, regurgitation, chest pain, cough, aspiration, and pneumonia. If patients are undiagnosed for an extended period of time, complications can arise. We report a case of how a complication can arise from achalasia, particularly in the form of lung abscess. The purpose of this report is to bring awareness of the increasing incidence of respiratory complications in patients with achalasia warranting further study.

CASE DESCRIPTION/METHODS:
A 44-year-old male came to the hospital with chest pain for one week. Shortly after, he began to experience severe pleuritic chest pain. The pain worsened with deep inspiration and coughing, preventing him from eating. A CT scan in the emergency room demonstrated infectious/inflammatory changes of the right upper lobe, concerning for abscess. His CT chest also showed a dilated esophagus, suggestive of achalasia. Further questioning revealed a several year long history of regurgitation symptoms. It was determined that the abscess was likely a complication of his suspected achalasia. IR guided drainage of the abscess was performed, and cultures were obtained, which grew multiple organisms found in oral flora. He subsequently underwent a VATS procedure for washout, decortication, chest tube placement, and bronchoscopy. An EGD to rule out pseudoachalasia caused by any mass lesions was performed showing a dilated esophagus. His EGD with manometry showed dilation of entire esophagus, notable for achalasia. A POEM procedure was performed with intra-operative real-time assessment using ENDOflip showed adequate myotomy.

DISCUSSION:
This case represents a rare complication of achalasia - lung abscess. Respiratory complications are common in patients with achalasia. Patients with achalasia experience respiratory symptoms with much greater frequency than previously thought, as shown in one study of 110 patients with achalasia where fifty-one patients (40%) reported the occurrence of at least one respiratory symptom daily, including cough in 41 patients (37%). Imaging obtained earlier in the hospital course may be beneficial to identify any respiratory processes that may be a result of the underlying achalasia. This case highlights the potentially severe complications of achalasia in patients with atypical clinical findings.