bluuebunny/crossref_metadata_2025_split huggingface dataset:
2575 A Rare Case of Extra-Gastrointestinal Stromal Tumor
Authors: Jiyani Rucha , Hirpara Kiran , Desai Jiten 
Published: October 2019

INTRODUCTION:
Gastrointestinal stromal tumors (GIST) are tumors of mesenchymal origin rising from the walls of gastrointestinal tract, stomach being most common site followed by small intestine. Those with the similar morphology identified outside the GI tract are termed as Extra-gastrointestinal stromal tumor (EGISTs) and their incidence is about 10%. They are often located in the mesentery, omentum, retro peritoneum, rectovaginal septum, and perivaginal soft tissue and very rarely in prostate. Due to their malignant potential, it is almost essential to diagnose such extra intestinal occurrence. Here, we report a very rare case of EGISTs.

CASE DESCRIPTION/METHODS:
61-year-old male with no past medical history presented with intermittent abdominal pain. Physical exam and vital were unremarkable. CT abdomen revealed multilobulated enhancing lesions in mesentery; largest one was approximately 10 × 9 × 8 cm in size. Bowel loops were unremarkable. Diagnostic laparoscopy showed multiple nodules approximately 800 to 1000 in number with size varying from 1 to 10 cm. Diagnosis of EGISTs was made based on immunohistochemistry (IHC). Gross findings: 1st mass: cut surface- creamish white 2nd mass: cut surface- lymph node structure seen Microscopic exam: Histology from 1st mass showed fascicles and solid sheets of round to oval shaped cells and vesicular nuclei with abundant eosinophilic cytoplasm. Mitosis with scanty lymphocytic infiltration and vascular proliferation were also seen. Histology from 2nd mass showed metastasis to lymph nodes. Patient was treated with Imatinib for 10 weeks and largest tumor was removed surgically. Imatinib therapy was continued post surgery as well.

DISCUSSION:
Due to lack of awareness that GIST can be present in extra intestinal location; they are likely to be misdiagnosed. Pathogenesis and prognosis of EGISTs have not yet been completely understood. Differential diagnosis includes mesothelioma, amelanotic malignant melanoma or metastasis; which can be confirmed out by IHC. (Positive CD117 & CD34 with CK 5/6, pankeratin, desmin, myogenin, s-100 and calretinin being negative in our case). IHC findings favored the diagnosis of EGISTs with metastasis to lymph nodes. As there are specific drugs available for treating EGISTs, it is important to differentiate it from other pathological conditions. This case serves best to promote awareness of GIST in unusual anatomical location and help early diagnosis and prompt subsequent management.
2581 Acute Lymphoblastic Leukemia Presenting With Mesenteric Ischemia
Authors: Baliss Michelle , Krill Timothy , Abdulla Hamza , Parupudi Sreeram 
Published: October 2019

INTRODUCTION:
Acute lymphoblastic leukemia (ALL) is a malignancy of B/T-cell lymphoid precursors that predominantly affects the pediatric population. Presenting symptoms are usually related to bone marrow and organ infiltration. Arterial thrombosis is extremely rare and seldom seen as a presenting manifestation of acute leukemia. To our knowledge, we present the first case of mesenteric ischemia due to complete occlusion of the superior mesenteric artery (SMA) as the first manifestation of T-cell ALL.

CASE DESCRIPTION/METHODS:
A 44-year-old male presented with severe upper abdominal pain, vomiting and diarrhea for 1 day. Physical examination was notable for diffuse abdominal tenderness and pain out of proportion to exam. Initial laboratory data showed WBC of 2.02 × 103/mL with 30% blasts. Lactic acid was within normal limits. CT of the abdomen revealed a thrombus in the SMA resulting in complete occlusion (Figure 1). An emergent open SMA thrombectomy was performed following failure of catheter-directed thrombolysis. Diffuse ischemic changes were visualized in the jejunum necessitating a partial small bowel resection (Figure 2). Intraoperative transesophageal echocardiogram was negative for intracardiac thrombus or valvular pathology. A peripheral blood smear revealed a large population of immature cells with fine chromatin and a high nuclear to cytoplasmic ratio (Figure 3). Flow cytometry showed a large population of blasts constituting about 22% of cells, positive for CD5, CD7, and CD10. The immunophenotypic appearance confirmed the diagnosis of T-ALL. He was referred to medical oncology for bone marrow biopsy.

DISCUSSION:
This is the first reported case of acute arterial occlusion in the SMA leading to mesenteric ischemia as the initial manifestation of T-cell ALL. SMA thromboembolism typically occurs in the setting of atherosclerosis or cardiac pathology, which were absent in this case. Venous thromboembolism is a well-documented complication of acute leukemia that negatively impacts mortality. The inhibition of anticoagulant proteins, production of prothrombotic factors, alteration of the vascular endothelium, and increased vascular adhesion of leukemic cells are all potential contributors. However, arterial occlusion is extremely unusual and almost exclusively seen in acute promyelocytic leukemia (APL). This report illustrates that an unexplained arterial or venous thrombotic event in a previously healthy patient could be a sign of an underlying malignancy.
2586 Renal Cell Carcinoma Presenting as Paraneoplastic Syndrome Involving the Gastrointestinal Tract
Authors: Attarha Barrett , Maharaj Satish , Harris Ciel , Schey Ron , Nassri Ammar , Sottile Elisa , Stemboroski Lauren 
Published: October 2019

INTRODUCTION:
We present a case of a patient who presented with abdominal pain and a small bowel obstruction and was found to have renal cell carcinoma causing a paraneoplastic vasculitis affecting his bowel.

CASE DESCRIPTION/METHODS:
A 57 year old Caucasian male with no significant past medical of family history presented to the Emergency Department complaining of a 2 day history of severe abdominal pain, nausea, vomiting and a bilateral non-blanching rash on his lower extremities that extended up towards his umbilicus (Figure 1). Initial XR Abdomen revealed a small bowel obstruction. A CT abdomen/pelvis was done which showed focal bowel wall thickening of distal duodenum and proximal jejunum with some mucosal edema and stranding of adjacent mesenteric fat concerning for duodenitis/enteritis. A CT renal mass protocol was ordered which revealed a 3.1 cm enhancing left renal mass highly suspicious for Renal cell carcinoma. An NG tube was inserted for decompression. On day three of admission patient had EGD performed which revealed multiple partially obstructing ulcerations throughout the second and third portion of the duodenum (Figures 2 and 3). Biopsy samples of the duodenum showed severe active duodenitis with erosions that was negative for CMV. A colonoscopy revealed an ulcer at the ileocecal valve which was biopsied and showed acute inflammation. There was non-specific erythematous mucosa throughout the colon. The patient began to experience swelling and pain in his wrist and the small joints of his hand and the rash continued to spread. Rheumatology performed an autoimmune workup which was normal save for mildly elevated C3, C4 and a high CRP. An extensive infectious disease workup was negative. Skin biopsy of the lesion was consistent with medium/large vessel vasculitis and the patient was started on high dose steroids. The patients clinical course improved drastically and he was discharged on a prolonged steroid taper. He underwent a nephrectomy 1 month from hospital discharge with pathology revealing clear cell renal cell adenocarcinoma with clear margins. He was continued on a steroid taper until resolution of his symptoms at 6 months follow up.

DISCUSSION:
Paraneoplastic vasculitis in patients with solid tumors has been described, and can very rarely affect the gastrointestinal tract. It can cause local or diffuse pathologic changes in the gastrointestinal tract, resulting in nonspecific paralytic ileus, mesenteric ischemia, submucosal edema, hemorrhage, or even bowel perforation.
2587 Never Too Old for Meckel's: A Unique Presentation of an Uncommon Source of Gastrointestinal Bleeding in Adults
Authors: Aggarwal Pankaj , Patel Harsh D. , Camero Alfredo , Wright Randy P. 
Published: October 2019

INTRODUCTION:
Meckel's diverticulum is a common gastrointestinal congenital malformation, affecting approximately 2% of the population. Related complications such as bleeding commonly occurs in the pediatric age group; although, in adults it is often missed. We present a case of recurrent obscure-overt gastrointestinal (GI) bleeding secondary to a Meckel's diverticulum which remained elusive after multiple diagnostic studies.

CASE DESCRIPTION/METHODS:
30-year-old male with history of recurrent GI bleeding, presents to the outpatient GI clinic for further evaluation after being admitted to the intensive care unit (ICU) 3 weeks prior with massive hematochezia requiring several blood transfusions for a drop-in hemoglobin from 14 gm/dL to <7 gm/dL. The patient had undergone endoscopy, colonoscopy, and video capsule endoscopy (VCE) three years prior for similar symptoms without an identifiable source. A nuclear tagged red blood cell scan was performed showing bleeding in the proximal colon. CT angiography following showed contrast extravasation in the distal jejunum and ileum which was treated with gel foam. The patient had no further episodes of hematochezia and was discharged. After the clinic visit, the patient underwent a Meckel's scan which did not show ectopic gastric mucosa but revealed colonic bleeding proximal to the hepatic flexure. Ileocolonoscopy was normal. Subsequent VCE showed abnormal mucosa in the distal small bowel. He finally underwent a retrograde balloon enteroscopy which revealed a distal small bowel diverticulum with a single adjacent, nonbleeding ulcer (Figure 1). Biopsies of the ulcer showed gastric foveolar metaplasia. Based on the findings, he was referred for a small bowel resection which revealed a jejunal Meckel's diverticulum with gastric oxyntic heterotopia on histology (Figures 2 and 3).

DISCUSSION:
This case highlights the potential morbidity and possible mortality of Meckel's diverticulum as a source of lower GI bleeding. Recent studies have recommended against prophylactic surgical resection in the absence of certain risk factors including age less than 40, male gender, and macroscopic mucosal alteration. Given this patient's significant hematochezia, transfusion requirements, and gross peri-diverticular ulceration, we opted for small bowel resection. Meckel's diverticulum should always be included in the differential for occult or overt GI bleeding, especially in young patients when no other sources of bleeding are readily identifiable.
2593 The Importance of Endoscopy in Diagnosis of Lupus Enteritis
Authors: Koldhekar Amol , Taborda Cesar , Barrett Amanda , Iskandar Heba , Xue Yue 
Published: October 2019

INTRODUCTION:
Lupus enteritis is defined as vasculitis or inflammation of the small bowel with supportive image and/or biopsy findings in patients with SLE. Symptoms such as abdominal pain (97% of cases) and vomiting (42%) are non-specific. These symptoms represent a wide differential, including vasculitis, medication reactions, and infection. This can cause diagnostic dilemmas in patients with multiple comorbidities.

CASE DESCRIPTION/METHODS:
A 28-year-old female with SLE, lupus nephritis, and ESRD after failed renal transplant presented with one day of abdominal pain and vomiting. Her medications included mycophenolate mofetil, prednisone, and hydroxychloroquine. Physical examination revealed periumbilical tenderness without rebound or guarding. CT abdomen showed small bowel wall thickening and hyperemia in the proximal jejunum with bowel dilatation and no transition point. Labs were remarkable for elevated CRP and decreased C3 complement. Given her symptoms and abdominal imaging, she underwent small bowel enteroscopy that showed severe inflammation in the proximal jejunum with purple discoloration (Figure 1). Initial jejunal biopsy was concerning for vasculitis. The patient was treated with methylprednisolone. Her symptoms improved within one day. A CTA abdomen two days later showed no vascular abnormalities with interval improvement of jejunal edema. Final pathology of the jejunal biopsy (Figures 2 and 3) showed mildly inflamed and injured small intestinal mucosa with fibrin thrombi in small vessels, lamina propria hemorrhage and patchy lymphangiectasia, consistent with lupus enteritis in this clinical setting.

DISCUSSION:
The clinical presentation of lupus enteritis is non-specific but often associated with abdominal pain and vomiting in SLE patients. The jejunum is involved in 80% of cases. The underlying cause is believed to be immune-complex deposition and complement activation that produce diffuse microvascular injury, thrombosis, and increased vascular permeability. This can result in intestinal necrosis and perforation. Timely diagnosis and treatment lead to excellent response within days. This patient achieved symptomatic improvement after one day of high-dose steroids. Due to her dialysis schedule, CT angiogram of her abdomen was delayed until after symptom resolution. The normal imaging reflected treatment response rather than lack of disease and led to initial non-diagnosis until final pathology resulted. Our case highlights the value of endoscopy in patients with a suspicion of lupus enteritis.
2602 Strongyloidiasis Presenting as Gastric Outlet Obstruction
Authors: Yazdanpanah Fariba , Abraamyan Sirush , Tin Kevin , Rahmani Rabin , Hindy Pierre 
Published: October 2019

INTRODUCTION:
Strongyloides Stercoralis is an intestinal parasite mostly seen in tropical areas. Commonly patients are asymptomatic with non-specific gastrointestinal manifestations. We present a case of strongyloidiasis presenting as gastric outlet obstruction.

CASE DESCRIPTION/METHODS:
Our patient is a 67-year- old woman, originally from Jamaica, recently diagnosed with Diabetes Mellitus who presented with 50 pounds weight loss, anorexia postprandial epigastric pain and recurrent episodes of vomiting. Her symptoms have been progressively getting worse and let her to doctor visits over the past several months. On physical exam she was afebrile but appeared cachectic. She did have minimal tenderness to palpation of the epigastric area and had minimal bilateral pedal edema. Laboratory testing revealed normocytic normochromic anemia, thrombocytosis, Hyponatremia and hypoalbuminemia. An Abdominal CT scan revealed dilatation of the second portion of duodenum and tapering of third portion of duodenum plus mild intrahepatic and extrahepatic bile ducts dilatation as well as dilation of the proximal pancreatic duct (Figures 1 and 2). The patient was admitted to the hospital for hydration and subsequently had an upper endoscopy. The procedure revealed marked retention of bilious fluid as well as evidence of severe duodenitis. Narrowing of the lumen of the duodenum was also seen (Figure 3). Biopsies from the duodenum were obtained and confirmed the presence of Strongyloides Stercoralis. Pt was given two days of Ivermectin with dramatic improvement of her symptoms and subsequent discharge.

DISCUSSION:
1. Stercoralis is a nematode with a complex life cycle. The parasite infects humans and replicates within its host for years or even decades (autoinfection). Patients would have positive serologies for S. Stercoralis but usually are asymptomatic. Immunosuppressive medications, HIV, HTLV1, Chronic diseases and in our case the new onset diabetes cause the parasite to replicate and leads to life-threatening dissemination of larvae to multiple internal organs called hyperinfection.
2603 Clostridioides difficile: Is Jejunum a New Reservoir?
Authors: Jha Samir , Thyagaturu Harshith , Aliyev Nurlan , Hyman Charles 
Published: October 2019

INTRODUCTION:
Clostridium difficile is the most common cause of healthcare associated infectious diarrhea. Normally inhabiting in the colon, this organism was found in jejunal aspirates, suggesting that the small bowel may act as reservoir. However, review of current literature showed C. difficile enteritis cases have occurred only in the presence of underlying surgical manipulation (resection/partial or total colectomy) or inflammatory bowel disease. Our patient is unique in not having any of the above-mentioned risk or predisposing factor, nor did he have any sign or symptom exhibiting any bowel disease.

CASE DESCRIPTION/METHODS:
A 35-year-old Caucasian male, presented to the hospital with complaint of severe acute abdominal pain, started as dull aching pain, about a week ago, associated with nausea and two episodes of loose stools, back pain and generalized body aches. He had a history of splenectomy due to ruptured splenic artery aneurysm and an episode of diverticulitis treated with intravenous antibiotics, 8 months ago. On the exam, he was found to have temperature of 38.1 deg. C with tachycardia and tachypnea. There was some tenderness to palpation over the epigastric region without any rebound tenderness. A white blood cell count showed leukocytosis of 34,000 cells/mm3. Intravenous Vancomycin and Piperacillin-Tazobactam were empirically started. A CT scan with intravenous contrast (without oral contrast) showed prominence of contiguous length of proximal and mid-jejunum in the left abdomen with concern for inflammation. Stool culture for Salmonella, Shigella, and Campylobacter was unremarkable, and Shiga toxin was negative. Two sets of blood culture obtained 15 minutes apart, didn’t grow any bacteria. Stool evaluation sent for C. difficile toxin Nucleic acid amplification Test (NAAT) was positive. He never had a C. difficile infection in the past. The intravenous antibiotics were discontinued and started on oral Vancomycin for 10 days. He significantly improved with the treatment; symptoms subsided and was discharged home.

DISCUSSION:
C. difficile, commonest cause for diarrhea in healthcare, can involve the small intestine, more so in surgically manipulated bowel or patients with IBD. As small bowel involvement is associated with a higher mortality than colonic involvement, it should be considered as a differential diagnosis for a patient presenting with enteritis, more so in patient with risk factors.
2609 Use of Dotatate Scan to Establish Diagnosis of a Neuroendocrine Tumor
Authors: Cooper John , Sadowski Brett , Tritsch Adam 
Published: October 2019

INTRODUCTION:
Neuroendocrine tumors (NETs) are rare malignancies, defined at a cellular level by the presence of somatostatin receptors, which has recently been exploited in the development of positron-emitting somatostatin analogs for use in the 68-Gallium DOTATATE PET scan (hereafter “Dotatate scan”). Compared to previously-used technology, the Dotatate scan has shown dramatic improvements in sensitivity for lesion detection. The Dotatate scan exposes patients to lower doses of radiation, and is completed much more quickly. We present a case of a new diagnosis of a neuroendocrine tumor that illustrates multiple benefits of Dotatate scan including improved lesion detection and characterization which quickly led to changes in the treatment plan for a patient who previously was given a presumptive diagnosis of advanced pancreatic adenocarcinoma.

CASE DESCRIPTION/METHODS:
A 52-year-old man with history of two episodes of pancreatitis presented with one day of acute-onset epigastric pain, diarrhea, and nausea. Initial ultrasound and computed tomography (CT) scan demonstrated numerous hypervascular lesions in the liver, a mesenteric mass with associated lymphadenopathy, and a possible pancreatic tail lesion, leading to clinical concern for pancreatic adenocarcinoma. Upon further questioning, the patient reported 12–18 months of intermittent flushing and rash. A Dotatate scan revealed increased avidity in the hepatic and mesenteric lesions suggestive of carcinoid malignancy. The improved lesion characterizations provided by the Dotatate scan were useful for identifying the larger small bowel lesion as the likely primary tumor, as well as for surgical planning for debulking. Subsequent serum and urine tests were consistent with carcinoid malignancy, and a biopsy of a liver lesion confirmed the diagnosis of metastatic carcinoid tumor. The pancreatic lesion also demonstrated uptake on the scan, most consistent with a metastasis to the pancreas, with a confirmatory biopsy via endoscopic ultrasound pending.

DISCUSSION:
We demonstrate the utility of the Dotatate scan to support the rapid diagnosis of a neuroendocrine tumor, to assist in identification of the likely primary lesion, and to better characterize the extent of disease. Dotatate scans have been infrequently used due to novelty and cost, but cases such as this demonstrate that the cost can be well-justified in the right clinical setting.
2626 A Curious Case of Gastric Outlet Obstruction!
Authors: Saini Mannat K. , Amarnath Shivantha , Ahmed Moiz , Syed Umer , Shankar Uday , Bansal Raghav 
Published: October 2019

INTRODUCTION:
The average lifetime risk of a woman developing breast cancer is 12%. Invasive lobular carcinoma (ILC), the second most common histologic type attributes to 10–15% of breast cancer diagnoses. Compared to invasive ductal carcinoma, ILC has a higher chance to metastasize liver, ovaries and even the gastrointestinal tract. We present a unique case of gastric outlet obstruction (GOO) as the initial presentation of metastatic ILC. Histologically, it can be challenging to delineate ILC from primary gastric adenocarcinoma. This was a rare case where the diagnosis was made via the comparison of the endoscopic biopsy with the patient’s previous lymph node pathology.

CASE DESCRIPTION/METHODS:
75-year-old female with history of type 2 diabetes mellitus, and lobular carcinoma treated with a bilateral mastectomy and Anastrozole hormone therapy for 8 years presented with confusion and non-bilious, non-bloody vomiting for two weeks. Vitals indicated orthostatic hypotension and abdominal exam revealed a tender epigastrium without rigidity or guarding. Laboratory findings demonstrated severe contraction alkalosis. Abdominal CT with contrast depicted wall thickening in the second and third portion of the duodenum. Endoscopy revealed an infiltrative circumferential mass that stemmed from the antrum extending through to the proximal duodenum causing GOO. The morphological features of the duodenal mass were consistent with biopsy findings of the patient’s previous sentinel lymph node and mastectomy specimen. The diagnosis was further confirmed with immunostains, which were positive for estrogen receptor and mammoglobin, and negative for progesterone receptor and E-cadherin. Patient received robotic gastrojejunostomy tube placement. Her nutritional status improved and was started on chemotherapy. She had a complete metastatic workup which was unrevealing.

DISCUSSION:
ILC can metastasize later in life to the brain, ovaries and gastrointestinal tract. Isolated duodenal metastasis is limited to only a few case reports. It is theorized in the literature that lack of expression of the adhesion molecule, E-cadherin, may facilitate ILC’s permeation into tissues. This may contribute to metastasis of ILC with a predilection to gastrointestinal and gynecological sites, which generally occurs after a mean duration of 7 years. Our case is rare in that, the patient presented with GOO as the only initial manifestation of duodenal metastasis within 8 years of treatment of ILC without any other evidence metastatic spread.