bluuebunny/crossref_metadata_2025_split huggingface dataset:
1493 Large Fecalith Obstructing the Cecum in a Patient With Rectal Bleeding and Iron Deficiency Anemia
Authors: Rivera Arturo Suplee , Rapoport Grigoriy , Castano Juan J. , Zamir Asif 
Published: October 2019

INTRODUCTION:
Fecal impaction as a result of fecalith formation can lead to rare but serious complications, such hemorrhage, perforation, intussusception and bowel obstruction. Fecaliths are stones made of feces and are a common finding in clinical practice. A fecaloma is a giant fecalith. Patients typically present with overflow diarrhea, constipation, and abdominal pain. Fecalomas are usually located in the sigmoid colon or rectum, but are rarely seen in the cecum. We present a case of a patient with a fecaloma obstructing the cecum, causing ischemic stricture.

CASE DESCRIPTION/METHODS:
The patient is a 79-year-old man without a significant past medical history who was referred to gastroenterology clinic for iron deficiency anemia, bloating, intermittent rectal bleeding, and chronic constipation. Home medications include ferrous sulfate. Patient's last colonoscopy was 7 years ago and was significant for internal hemorrhoids. No significant family history. Due to anemia and rectal bleeding he was scheduled for colonoscopy. Colonoscopy revealed the presence of a large, obstructing fecalith in the cecum, with evidence of luminal narrowing. After several attempts, it was removed endoscopically with a large 27 mm hexagonal snare. It was subsequently split into smaller pieces in the transverse colon due to concerns for obstruction. Iron supplementation was stopped. Follow-up colonoscopy revealed a smooth circumferential luminal narrowing of the right side of the colon likely due to ischemic changes from the pressure effect created by the fecalith. The patient was seen in clinic 2 weeks afterwards with significant improvement of his symptoms.

DISCUSSION:
Although fecaliths are a frequent finding in clinical practice, luminal obstruction and ischemic changes resulting in stricture formation are rare. The need for surgery in our patient was avoided due to successful removal of the fecalith. At this point we believe that iron supplementation caused the fecalith formation, resulting in obstruction and ischemic stricture. Our case illustrates an alternative non-invasive way to manage cecal fecaliths in symptomatic patients thus preventing the need for surgery.
1497 Signet Ring Cell Carcinoma of the Colon: A Rare Finding and Clinical Review
Authors: Law Jade , Singh Simi 
Published: October 2019

INTRODUCTION:
Colorectal primary signet ring cell carcinoma (PSRCCR) accounts for less than 1% of colorectal cancer cases. PSRCCR most commonly arises in the stomach, but it can arise in the colon, prostate, rectum, and breast. Prognosis is poor as this cancer is usually advanced upon presentation. We present a rare case of PSRCCR diagnosed early and treated with hemicolectomy.

CASE DESCRIPTION/METHODS:
A 72-year-old male with myelodysplastic syndrome and hemochromatosis presented with a positive stool DNA test. Though he was asymptomatic, colonoscopy revealed a 30 mm sessile polyp in the ascending colon. Pathology of the polyp showed poorly differentiated signet-ring cell adenocarcinoma without lymphovascular invasion. Full body computed tomography (CT) scan found no evidence of metastatic disease. Carcinoembryonic antigen (CEA) was elevated at 5.3. He was treated for stage IIA disease with a right hemicolectomy. Two months later, PET-CT showed no recurrence, and CEA level was normal at 2.7.

DISCUSSION:
PSRCCR of the colon is a rare malignancy that is typically diagnosed at an advanced stage due to the late manifestation of symptoms. Colorectal cancer screening tests can help identify some of these individuals with sensitivities of 79% for fecal occult blood tests, 92% for stool DNA tests, and >95% for colonoscopies.
1
A third of PSRCCR patients have metastasis on presentation. One hypothesis for the late presentation of PSRCCR is that the cancer spreads through the mucosa and spares mucosal surfaces, leading to fewer symptoms in the early stages.
2
Treatment is focused on surgical resection, neoadjuvant radiotherapy, and adjuvant radiochemotherapy. In our case, the patient was diagnosed early at stage IIA without lymph node involvement or metastases. His early diagnosis enabled him to have surgical resection that will likely be curative. This remarkable case showcases a rare circumstance of early detection and treatment of PSRCCR.
1501 Double Whammy: Checkpoint Inhibitor and CMV-Induced Colitis
Authors: Paniz Graziella Rangel , Sharkey Sarah O. , Dean James T. , Lopez Portillo Glenda M. 
Published: October 2019

INTRODUCTION:
Immune checkpoint inhibitors (ICIs) such as nivolumab have become a common treatment for several types of malignancies, especially metastatic disease. Diarrhea and enterocolitis are known side effects of these drugs. Here we present a case of a patient who developed ICI associated colitis who was later diagnosed with superimposed Cytomegalovirus colitis.

CASE DESCRIPTION/METHODS:
A 75-year-old male with past medical history pertinent for squamous cell carcinoma of the neck and base of tongue treated with nivolumab. His treatment was interrupted due to the development of chronic diarrhea possibly related to immune checkpoint inhibitor therapy (nivolumab). Immunotherapy was discontinued and the patient was started on a high dose of steroids with initial clinical response and symptom control. He was admitted to the hospital two months later with signs of shock with hematochezia and profound diarrhea. Computed Tomography (CT) of his abdomen upon admission showed severe colitis. Blood cultures were positive for Streptococcus infantarium (previously known as Streptococcus bovis) likely translocation from severe immunotherapy-induced colitis. His hemodynamics improved with fluid resuscitation and antibiotic therapy; however his diarrhea did not resolve. He then underwent colonoscopy which demonstrated circumferential, uninterrupted, extensive and severe inflammation (Figures 1 and 2) with the procedure terminated prematurely to avoid risk of perforation. Pathology of colonic biopsies showed positive immunostaining for Cytomegalovirus (CMV), and the patient tested positive for CMV DNA PCR, confirming acute active infection. He was started on valganciclovir and his steroid regimen was tapered with significant improvement of his diarrhea.

DISCUSSION:
Immune checkpoint inhibitors are monoclonal antibodies that target downregulators of the anti-neoplastic immune response. There are currently seven FDA approved ICIs, including Nivolumab. Immune-mediated colitis and diarrhea are the most common side effects associated with these drugs. One third of patients treated with ICIs will experience gastrointestinal adverse effects and 1-2% of patients on nivolumab will experience diarrhea. Although is not common, infection can coexist and in the setting of persistent and recurrent diarrhea it has to be ruled out.
1504 Case Report: A Rare Case of Community-Acquired Clostridium difficile Infection After Colonoscopy
Authors: Xu Binghong , Xie Bingru 
Published: October 2019

INTRODUCTION:
Clostridium difficile (C.diff) infection (CDI) is commonly related to recent antibiotic use, usually occurring in hospitals and other health care facilities where a significantly higher percentage of people carry the bacteria. Here we reported a rare case of community acquired C.diff 3 days after colonoscopy in a low risk patient without a history of antibiotic use or recent hospitalization.

CASE DESCRIPTION/METHODS:
A 50-year-old healthy female with no past medical history presented for screening colonoscopy. She tolerated the bowel preparation regimen with polyethylene glycol well. The colonoscopy was unremarkable with one small tubular adenoma removed by snare polypectomy. Patient tolerated the procedure well without any complications. She ate raw blueberry from the local supermarket one day after colonoscopy. Then she presented with watery diarrhea up to 10 times per day with nocturnal symptoms 3 days after colonoscopy. Stool studies were ordered. Diarrhea gradually resolved with hydration and clear liquid diet after 3 days without antibiotics treatment. Stool studies came back with positive C. diff toxins. Patient has no risk factors include recent hospitalization, antibiotic use. She took proton pump inhibitor intermittently a few months prior to colonoscopy. All the other patients had procedures done on the same day in the endoscopy suite had no complications.

DISCUSSION:
The risk factors of CDI include antibiotics use, advanced age (>65), gastrointestinal surgery, IBD and immunosuppression, etc. The effect of anti-acid use remains unsure because the C. diff spores are acid resistant. Recent studies reported a 7-fold and 13-fold increase in C. diff infection rate after colonoscopy for patients with Crohn's disease and ulcerative colitis compared with non-IBD patients. Another study reported the preoperative use of mechanical bowel preparation was not associated with increased risk of C. diff infection after colectomy. Generally, mechanical bowel preparation and colonoscopy are not risk factors of CDI for a healthy population. This is a rare case with no traditional risk factors acquired CDI by eating raw blueberry 3 days after colonoscopy. Bowel preparation might be a risk factor to disturb the normal gut flora, which increases the risk of CDI. The use of probiotics afterward to prevent C. diff colonization could be a safe and easily adoptable control strategy, but the routine use for prevention or treatment of active infection is not recommended.
1507 A Rare Case of Intestinal Endometriosis Mimicking Acute Appendicitis and Sigmoid Malignancy in a Five Year Time Span
Authors: Miao Chuan Long , Khuri Nadeem , Roberts Marigny , Broadwell Ronald 
Published: October 2019

INTRODUCTION:
Endometriosis is characterized by implantation of endometrial epithelium outside the uterus. The prevalence is about 10-15% in women of reproductive age. The most common extra-pelvic site is the GI tract, affecting 4–37% of women with endometriosis. The sigmoid colon and rectum are the most common sites followed by the ileum, appendix and cecum.

CASE DESCRIPTION/METHODS:
Here we present a very rare case of severe intestinal endometriosis involving multiple GI sites including the terminal ileum, appendix and recto-sigmoid colon in the past 5 years. 4.5 years ago, the then 27 year old otherwise healthy female presented with worsening RLQ pain. She had leukocytosis of 15K WBC with CT scan showing a dilated and thickened distal appendix consistent with appendicitis. She underwent laparoscopic appendectomy without complications. Pathology reported endometriosis (Figure 1). After appendectomy, she continued to have diffuse abdominal pain with nausea and constipation. As part of GI workup, she underwent EGD and colonoscopy about 3 years ago with findings of two recto-sigmoid strictures with biopsies showing endometriosis. The patient was then lost followup until she was readmitted with multiple GI complaints including nausea/vomiting, abdominal pain, with alternating diarrhea and constipation. It appears that she had been treated for IBS and also received hormonal treatment for endometriosis in the past two years. On admission, she had leukocytosis of 16K and a CT scan showing a 3 cm focal apple-core lesion in the distal sigmoid colon. Colonoscopy showed a very severe stricture at the distal sigmoid colon with nodular mucosa in the proximal rectum. Pathology was negative for malignancy or endometriosis. She then underwent laproscopy with findings of 2 strictures in the recto-sigmoid colon together with another stricture 5 cm proximal to the IC valve in the distal ileum. Partial resection of the recto-sigmoid colon together with a right hemicolectomy was performed. Pathology of both TI and recto-sigmoid colon showed endometriosis (Figure 2). During the one-month post-op followup, she reported resolution of constipation.

DISCUSSION:
Our patient represents a rare case of symptomatic multi-focal gastrointestinal endometriosis with mucosal involvement at different times mimicking appendicitis and sigmoid malignancy. Endometriosis should be considered in the differential diagnosis in any young woman with lower GI symptoms.
1509 81 Colonic Polyps—An Incidental Finding and Clinical Dilemma
Authors: Franco Quintanilla Jose A. , Camero Alfredo , Patel Harsh D. , Schindler Amy E. 
Published: October 2019

INTRODUCTION:
Colorectal polyposis syndromes are rare but, when present, can increase someone's risk of colorectal cancer up to 100%, such as in the setting of familial adenomatous polyposis. Advances in genomics have identified several well-established hereditary cancer syndromes; however, with ongoing research, many patients are left without a formal diagnosis. Clinical presentations vary widely. We present a case of a 62-year-old man with a polyposis syndrome found incidentally during workup for multiple myeloma and the clinical dilemma it presented.

CASE DESCRIPTION/METHODS:
A 62-year-old man undergoing staging workup for newly diagnosed multiple myeloma had abnormal computerized tomography (CT) and positron emission tomography (PET) imaging of the gastrointestinal (GI) tract. His CT scan demonstrated intraluminal densities in the rectosigmoid region and his PET scan showed increased FDG avidity of these lesions along with others in the descending colon (Figures 1 and 2). The patient had no symptoms related to the GI tract. He had no relevant surgical history, and there was no family history of colon cancer or other GI disease. He had a 46 pack-year smoking history. A colonoscopy was performed, which showed marked left-sided colonic polyposis. Two additional colonoscopies were performed over the next week, and a total of eighty-one polyps were removed. Most left-sided polyps were between 1-3 cm, and many had large pedunculated stalks (Figure 3). Pathology showed all polyps to be tubular adenomas with six of them having high-grade dysplasia. Genetic testing using a 17-gene panel for colorectal cancer predisposing mutations was negative.

DISCUSSION:
Our patient had clinical signs of a colorectal polyposis syndrome but was in a clinical conundrum, as he was only recently diagnosed with widespread multiple myeloma and was due to start potentially cytotoxic chemotherapy. Our decision to perform such extensive polypectomy was to decrease polyp burden, evaluate for high-risk features, and potentially diagnose early adenocarcinoma. Genetic testing did not identify a culprit gene, but with his clinical features and high-grade dysplasia colectomy was recommended. A multidisciplinary approach between hematology and colorectal surgery is being pursued after initial rounds of chemotherapy. This case highlights the variety in which polyposis syndromes can present, discussion of extent of polypectomy at time of colonoscopy, and importance of a multidisciplinary approach.
1511 Epiploic Appendagitis After Rigorous Exercise in a Woman: An Easily Misdiagnosed Cause of Acute Abdomen
Authors: Zhao Weidan , Sanchez Antonio J. 
Published: October 2019

INTRODUCTION:
Acute abdominal pain can be a surgical emergency. However, benign etiologies, such as epiploic appendagitis (EA), can present with similar symptoms. We report a case of an otherwise healthy woman, on oral contraceptives (OCP), presenting with severe abdominal pain related to epiploic appendagitis. Timely recognition of this condition is important to avoid misdiagnosis and unnecessary surgical interventions.

CASE DESCRIPTION/METHODS:
A 44-year-old woman with a past medical history of ovarian cyst and BMI 25 presented to the Emergency Department with a three-day history of sharp left lower quadrant (LLQ) pain. Patient reported that she started a vigorous aerobic exercise regimen 6 weeks before. Only medication was norgestimate-ethinyl estradiol for contraception. Vital signs normal. Physical exam showed tender LLQ without rebound tenderness or rigidity. Initial testing including complete blood count, basic metabolic panel, pregnancy test, urinalysis, and vaginitis panel were unremarkable. Given worsening pain, CT scan of abdomen and pelvis with contrast was obtained showing an encapsulated oval, pericolonic fatty nodule adjacent to the sigmoid colon, with surrounding fat stranding consistent with EA. Patient was discharged home with conservative pain management. Her OCP was discontinued. She had no symptom recurrence within a 3-year period.

DISCUSSION:
EA is an uncommon cause of acute abdominal pain that mimics serious medical or surgical emergencies such as acute diverticulitis, appendicitis, or, gynecological emergencies such as ruptured ectopic pregnancy. It is, generally, a self-limited ischemic infarction involving the epiploic appendices, which are normal outpouching fat of the lower colon and rectum. EA can be divided into primary versus secondary. The primary form is caused by either torsion or spontaneous venous thrombosis of an epiploic appendage central draining vein. It commonly occurs in men aged 20–50. Risk factors include obesity, hernia, and rigorous exercise. Secondary form is related to inflammation of adjacent organs. Although our patient does not match the typical profile for EA, rigorous exercise and probably OCP usage, a risk factor for thromboembolic phenomena, may have triggered this episode. Diagnosis of EA is by imaging via ultrasound or CT scan, and complete resolution typically occurs within two weeks with conservative management. Prompt identification of EA is essential in patients at risk, to avoid unnecessary surgical procedures.
1519 Portal Vein Thrombosis as an Initial Presentation of Crohn's Disease
Authors: Nguyen Minh , Helmstetter Nicholas J. , Sieloff Martin , Tariq Tooba 
Published: October 2019

INTRODUCTION:
Inflammatory bowel diseases (IBD) are chronic and progressive conditions that can increase the risk of thromboembolism, including portal vein thrombosis (PVT). PVT are exclusively described in cases with confirmed IBD diagnosis and are more commonly related to ulcerative colitis. This report highlights a case of PVT as an initial manifestation of Crohn's disease.

CASE DESCRIPTION/METHODS:
A 38-year-old gentleman presented with worsening abdominal pain, watery diarrhea and weight loss of the last three months. His initial diagnosis was diverticulitis and a course of oral ciprofloxacin was prescribed. As symptoms persisted, a colonoscopy was performed and showed diverticulitis in the descending colon. The pathology demonstrated acute cryptitis from rectum to cecum. Due to ongoing symptoms, a computed tomography (CT) of the abdomen without contrast was obtained and showed wall thickening and inflammatory changes in the small bowel. Despite another course of antibiotics with the addition of oral steroids, his pain worsened and thus repeat imaging was performed as an abdominal CT with contrast. He was found to have a chronic PVT extending into the superior mesenteric vein (SMV) and was transferred to our institution for further management. Physical exam was notable for mild tenderness in upper abdominal quadrants. Laboratory studies revealed mildly elevated CRP and ESR but his liver function was normal. Hematologic workups including hypercoagulability and clonal disorders were noncontributory. He endorsed a history of tobacco abuse, but no history of abdominal surgery nor family history of IBD. A CT enterography showed skip lesions suggestive of Crohn's enteritis along with thrombus in the right main portal vein and SMV. The pathology report from a repeat colonoscopy showed chronic active colitis. The patient then improved with high dose oral steroids and he was discharged on a tapered steroid regimen with oral anticoagulation. Follow-up appointments were scheduled with hematology and gastroenterology.

DISCUSSION:
In summary, this case represents one of the handful reported cases of PVT being the initial presentation of Crohn's disease. In those with an established IBD diagnosis, PVT should be considered with persistent abdominal pain in the absence of active inflammation. Early recognition of portal vein thrombosis may expedite treatment and prevent the consequences of portal hypertension.
1523 Unintended Discovery of Enterobius vermicularis During Colonoscopy: An Uncommon Visualization
Authors: Randhawa Tejinder , Attar Bashar M. , Mutneja Hemant , Agrawal Rohit , Omar Yazan Abu , Vohra Ishaan 
Published: October 2019

INTRODUCTION:

Enterobius vermicularis (pinworm) is the most common helminthic infection in the United States with an estimated prevalence of nearly 40 million people. Transmission of E. vermicularis occurs when its infective eggs, carried on contaminated hands, food, or environmental surfaces, are ingested. The eggs travel to the jejunum and hatch, maturing throughout the remainder of the gastrointestinal tract, until they reach their residence in the cecum. Females exit through the rectum and lay their eggs on the perianal skin. Though most infections are clinically silent; occasionally patients present with perianal itching, sleeplessness, hyperactivity, weight loss, abdominal pain and/or vomiting. Diagnosis is classically made by collecting the characteristic eggs from the perianal region using an adhesive coated surface and viewing the eggs microscopically. Here we present an unusual diagnostic finding of incidental pinworms during colonoscopy.

CASE DESCRIPTION/METHODS:
A 36-year-old male was admitted with a three-day history of bright red blood per rectum and an intermittent history of melena over the past six months. History was remarkable for active alcohol abuse and alcoholic Childs A cirrhosis. On examination, the patient was hemodynamically stable, abdomen was soft and non-tender, rectal exam was without blood. Patient underwent upper endoscopy and colonoscopy for bleeding site identification. During colonoscopy a white serpiginous organism was found attached to the mucosa of the ascending colon (Figures 1 and 2). It was actively moving around over the colonic mucosa. The specimen was collected, and after pathology it was confirmed that the parasite was E. vermicularis. The remainder of the endoscopic investigation revealed both large esophageal varices and large internal hemorrhoids as likely culprits for the gastrointestinal bleed.

DISCUSSION:
Direct visualization of pinworm eggs collected from the perianal region of suspected infected individuals has been essential to the diagnosis of intestinal parasite infections. Routine screening for pinworms in asymptomatic patients is not standard practice. Nevertheless, as an increasing number of colonoscopies are performed each year, we may encounter more incidentally diagnosed pinworm infections.