bluuebunny/crossref_metadata_2025_split huggingface dataset:
1999 Jejunal GIST: An Unusual Cause of Acute Massive Gastrointestinal Bleeding
Authors: Liu Yingheng , Shah Suraj , Weisberg Ilan 
Published: October 2019

INTRODUCTION:
Gastrointestinal stromal tumors (GISTs) are rare, making up 0.1–3% of all gastrointestinal (GI) tumors. While most commonly found in the stomach, GISTs in jejunum are among the rarest subtypes. The majority of GISTs present with occult GI hemorrhage. Here we present a case of massive GI bleeding due to a jejunal GIST in a young woman with BRCA2 gene mutation.

CASE DESCRIPTION/METHODS:
A 30-year-old woman presented with 1 day of melena and symptomatic anemia. Medical history was notable for BRCA2 gene mutation. Family history was significant for colon cancer in her maternal grandfather and breast cancer in her maternal aunt. On admission, there was melena in the rectal vault and her abdomen was soft, non-tender with no palpable masses. She was anemic with hemoglobin 6.8 g/dL. Emergent EGD revealed no blood or source of bleeding identified. After a rapid bowel preparation, an urgent colonoscopy showed melena in the entire colon and examined terminal ileum, however no culprit lesion was identified. Patient was hemodynamically unstable subsequently so an urgent computed tomography angiogram was performed and revealed active GI bleeding from the jejunal artery. A 3.1 × 2.2 cm mass with peripheral hemorrhage in the left upper quadrant was seen. The patient then underwent emergent embolization of two jejunal branches. An exploratory laparotomy was subsequently performed with resection of a proximal jejunal mass. Histology confirmed a spindle-cell GIST with positive staining for c-kit (CD117). Given the size, low-grade, and mitotic rate of 1/50 high-power field, no adjuvant therapy was needed. Magnetic resonance imaging surveillance was recommended.

DISCUSSION:
Bleeding jejunal GIST is a rare cause of acute massive GI bleeding. GISTs can be particularly difficult to diagnose because of their endoscopic inaccessibility. The majority of GISTs are thought to be a result of activating mutations of proto-oncogenes c-KIT (CD117) or PDGFR-alpha. These then increase tyrosine kinase receptor activity and result in the proliferation of stem cells. No reports yet suggest a direct association between a BRCA2 germline mutation and small bowel neoplasms. This case highlights a dramatic presentation of massive hemorrhage from a GIST, especially when confined to the small bowel. Further studies are needed to establish whether an association exists between BRCA mutations and GIST as well as other small bowel neoplasms.
2001 Mastocytosis Complicated by Upper and Lower GI Bleeding
Authors: Khamis Alia , Richards David , Chen Ellie 
Published: October 2019

INTRODUCTION:
Mastocytosis is a rare disease caused by the abnormal proliferation and accumulation of mast cells in 1 or more organs of the body and is divided into cutaneous and systemic disease. Patients have increased susceptibility to urticaria, pruritis and anaphylactic shock. GI manifestations are thought to be related to direct mast cell infiltration and release of mast cell mediators.

CASE DESCRIPTION/METHODS:
A 39-year-old woman with a history of cutaneous mastocytosis intolerant to cromolyn sodium, Roux-en-Y gastric bypass, gastritis, celiac disease and hemorrhoids presented with melena and hematemesis following a mastocytosis flare and concurrent pneumonia. She had no prior history of GI bleeding, PUD, H. Pylori infection, NSAID or anticoagulation use, liver disease, or family history of GI malignancies. Prior EGDs and colonoscopies were unremarkable. She was on a chronic high-dose of famotidine and prednisolone taken as needed. Physical exam showed mild epigastric and left upper quadrant tenderness, bilateral rhonchi, and hemodynamic stability. Initial laboratory findings were insignificant. She was given IV pantoprazole BID and continued to have melena while remaining stable; with Hb down-trending to 11.6 gm/dL. EGD revealed a large gastric pouch with Roux-en-Y anatomy and 2 non-bleeding cratered ulcers near the congested, erythematous gastrojejunal anastomosis. The larger ulcer (9 mm) had a visible vessel and was clipped. Pathology revealed reactive gastropathy, mild chronic inflammation without H. pylori. Jejunal biopsies showed congestive mucosa and mild acute on chronic inflammation. The patient resumed IV continuous infusion of pantoprazole for 48 hours then transitioned to oral PPI with her usual famotidine.

DISCUSSION:
Up to 80% of patients with systemic mastocytosis can present with a variety of GI symptoms, with the most common being diarrhea and abdominal pain. Though the etiology of diarrhea is not well understood, abdominal pain is largely attributed to dyspepsia and gastroduodenal ulcers resulting from acid hypersecretion. Symptomatic treatment for GI symptoms largely depends on anti-mediator therapy where H1 and H2 receptors are typically combined. PPIs are added to treat gastric involvement. Cromolyn sodium is a highly effective treatment for GI manifestations (100-200 mg PO up to 4 times/day). Oral corticosteroids may relieve malabsorption and ascites in the rare cases of liver involvement. Lifestyle modifications include avoidance of triggers and stress management if possible.
2002 Oh My Lipoma: An Unexpected Cause of a Gastrointestinal Hemorrhage
Authors: Rao Shanti , Basilio Carlo , Baddour Nabil , Nakanishi Yukihiro , Gaspard Gregory 
Published: October 2019

INTRODUCTION:
Gastrointestinal (GI) lipomas are benign tumors made of adipose tissue that are usually asymptomatic and slow-growing. Lipomas of the GI tract are uncommon, and even less common to find in the gastric region. Around 220 cases of gastric lipomas are reported in the literature. Of these cases, very few have shown a gastric lipoma that leads to symptomatic anemia and hemorrhage.

CASE DESCRIPTION/METHODS:
A 48-year-old man with a history of hypertension presented to the emergency room with shortness of breath and was found to have a hemoglobin of 6.0 g/dl, with a baseline of 15 g/dl. Gastroenterology was consulted, and the patient had an esophagogastroduodenoscopy (EGD) performed. The EGD showed a large, 4 cm, polypoid, submucosal, ulcerated mass with active oozing of blood on the lesser curvature of the gastric body. Biopsies were taken, and computed tomography (CT) imaging was performed as there was concern this was a malignant mass. Pathology showed the mass to be a gastric lipoma, and the patient was taken for a partial gastrectomy to remove the lipoma due to risk for bleeding. The surgery was performed without complications.

DISCUSSION:
Interestingly, gastric lipomas account for less than 1% of tumors in the stomach. This case displays a rare finding of a large gastric lipoma that led to symptomatic anemia and gastrointestinal hemorrhage. Most gastric lipomas are asymptomatic, but can ulcerate depending on the size and location. Ulceration can occur as a result of pressure necrosis of overlying mucosa, causing large volume bleeding. Lipomas can be diagnosed with endoscopic ultrasound, EGD, and CT scan. Treatment modalities include aspiration lumpectomy, strip biopsy, endoscopic unroofing technique, or surgical removal with partial gastrectomy. Rarely are gastric lipomas removed surgically, but in the case of large volume blood loss or active bleeding, they are removed surgically rather than endoscopically. Of note, it is important to rule out any evidence of malignancy or metastatic disease with imaging prior to surgical removal of a lipoma. If malignancy is ruled out, oftentimes endoscopic removal of the lipoma can be performed rather than undergoing a large surgical resection.
2008 Fundic Gland Polyps: Not Always an Innocent Bystander
Authors: Mosier Evan , Imbertson Erick 
Published: October 2019

INTRODUCTION:
Fundic gland polyps (FGP) are often found incidentally on endoscopy in 1.9% of patients, with most being asymptomatic. However, as in this case, FGP have been a source of upper gastrointestinal bleeding (UGB) leading to hospitalization.

CASE DESCRIPTION/METHODS:
An 81-year-old male with GERD and non-dysplastic Barrett’s Esophagus, presented to the emergency department with coffee ground emesis for 2 weeks. He denied NSAID, steroid, or alcohol use. GERD is well controlled on Omeprazole 40 mg daily which he has taken for the past 10 years. He denies dysphagia, abdominal pain or weight loss. No family history of gastric or colon cancer or familial polyposis syndromes. Patient with normal heart rate and blood pressure however with orthostatic hypotension. Physical exam without abdominal tenderness and rectal vault without stool on exam. Hemoglobin 11.1 on presentation with last hemoglobin 13.3 four months ago. Last EGD 2 years ago revealed non-dysplastic Barrett’s Esophagus, along with a few sub centimeter non-bleeding FGP, confirmed with biopsy. A colonoscopy 4 years prior had one tubular adenoma. Patient underwent EGD and was found to have multiple gastric body polyps; several of the largest polyps had active oozing blood. The bleeding polyps measured 12 mm in size and were removed via hot snare polypectomy. Normal remainder of exam. Afterward he remained clinically stable with no further bleeding and was discharged with Omeprazole daily. Histology revealed FGP with low grade dysplasia. H.pylori was negative on biopsies. Repeat EGD 8 weeks later removed the remaining polyps and gastric mapping was performed. Histology revealed FGP without dysplasia and no gastric intestinal metaplasia was noted. Patient has done well since with no further bleeding.

DISCUSSION:
Bleeding gastric FGP are rarely considered in the differential of UGB, however in this case, led to the patient’s hospitalization. Long-term (>5 years) proton-pump inhibitors (PPI) have been associated with fourfold increased risk of FGP, with regression often seen upon withdrawal of PPI. This patient brings a unique case in which guidelines recommend long-term daily PPI for his Barrett’s Esophagus, however has already had complications from his growing FGP on Omeprazole. FGP can also be associated with polyposis syndromes. Malignancy is rare in sporadic and PPI induced FDG but can be seen in up to 4.2% of patients with familial adenomatous polyposis. The removal of FGP can potentially limit the risk of future bleeding as seen in this case.
2009 Bleeding Intestinal Lymphangiectasia Diagnosed and Treated by Using Double Balloon Enteroscopy in a 41-Year-Old Female: Case Report and Review of Literature
Authors: Gopalakrishnan Ravikumar Naveen Prasad , Shahab Danish , Bain Andrew 
Published: October 2019

INTRODUCTION:
Intestinal lymphangiectasia (IL) is a rare disease characterized by dilated lymphatic vessels in the intestinal wall and small bowel mesentery, which induce loss of protein and lymphocytes into the bowel lumen. Gastrointestinal bleeding (GIB) rarely has been described as the only symptom of IL. We describe a case of obscure GIB in a young female caused by lymphangiectasia localized to the distal jejunum by antegrade double balloon enteroscopy.

CASE DESCRIPTION/METHODS:
A 41-year-old African American female who initially presented to her PCP with chronic fatigue and intermittent episodes of melena. The patient was subsequently placed on iron supplementation and referred to gastroenterology for further work up. Physical examination finding were largely unremarkable. On laboratory tests, her hemoglobin declined to 5.8 g/dL (from a baseline of 10 g/dL). Initial Esophagogastroduodenoscopy (EGD) showed 2 cm hiatal hernia but was otherwise unremarkable. A subsequent colonoscopy showed mild internal hemorrhoids and a 3 mm solitary ulcer in the distal rectum but no other obvious sources of GI bleeding. Magnetic resonance enterography (MRE) was unremarkable. Next, a video capsule endoscopy was done which showed a site of active bleeding from the mid-small bowel and was associated with nodular mucosa and prominent lacteals. A subsequent double balloon enteroscopy (DBE) showed an oozing fold in the distal jejunum with white speckled appearance consistent with a bleeding lymphangiectasia. A total of seven clips were placed on the lesion and during application of clips, a white milky substance was noted coming from the lesion suggesting the diagnosis of lymphangiectasia.

DISCUSSION:
IL is most commonly found in the small bowel, making its diagnosis difficult by EGD or colonoscopy. DBE and video capsule endoscopy (VCE) are the two most important diagnostic modalities available to evaluate the entire small intestine.The noninvasive nature of VCE and its capability to visualize the entire small bowel has made it a first-line tool in many centers. However, DBE is preferred over video capsule endoscopy because of higher sensitivity from better endoscopic visualization and ability to perform biopsies for pathologic diagnosis. In this report, we present an extremely rare case of primary intestinal lymphangiectasia in causing obscure GIB and successful intervention using DBE. We believe this is the second case to report small bowel bleeding from jejunal lymphangiectasia, which was successfully treated using DBE.
2012 Metastatic Merkel Cell Carcinoma Presenting With Upper GI Bleeding and Obstructive Jaundice
Authors: Elkafrawy Ahmed A. , Numan Laith , Zafar Yousaf , Elkhouly Mohamed A. , Bahaj Waled , Liu Cynthia , Hamid Fadi 
Published: October 2019

INTRODUCTION:
Merkel Cell Carcinoma (MCC) is a rare and aggressive skin cancer that was first described in 1972. Lymph node metastases are common in MCC and distant metastases occur in 8.4% of cases. We present a case of MCC complicated by melena and obstructive jaundice from GI metastases. To the best of our knowledge, less than 20 cases were reported with a similar presentation.

CASE DESCRIPTION/METHODS:
The patient is a 67-year-old male with a history of CAD, COPD and metastatic MCC who was admitted with melena and severe blood loss anemia. He was diagnosed with MCC of the right eyebrow 2 years ago and had a recurrence in the parotid gland that was treated with resection, radiotherapy (RT) and chemotherapy. PET CT scan 3 months prior to admission showed no evidence of distant metastases. After resuscitation and initiation of appropriate medical therapy, the patient underwent an EGD that showed multiple (1 cm) lesions scattered in the stomach and a large (4 cm) ulcerated mass in the lesser curvature with stigmata of recent hemorrhage. Hemospray was applied successfully for hemostasis. Biopsies of the gastric lesions confirmed metastatic MCC. The patient was discharged home and was started on palliative immunotherapy (Atezolizumab) and RT. Repeated PET CT scan showed the progression of the disease with widespread lymphatic, pancreatic, right perinephric, diffuse gastric and bony metastases. Four weeks later he was admitted with jaundice. Bilirubin was 2.5 gm/dl, ALP 458, ALT 457 and AST 441. Abdominal ultrasound showed dilated intra and extrahepatic ducts. An ERCP was performed and it showed a distal CBD stricture. An uncovered metal stent was successfully placed. The patient continued to have recurrent melena and a repeated EGD showed a new friable 4 cm ulcerated periampullary duodenal mass that was not amenable to endoscopic intervention. Mesenteric arteriogram was performed and active bleeding from the duodenal mass with tumor blush in the third part of duodenum was seen. Coil embolization of the GDA and PDA was successfully performed with the cessation of the bleeding. The patient was discharged home to resume palliative RT and immunotherapy.

DISCUSSION:
Merkel cell carcinoma is rare and aggressive skin cancer. GI metastases are very uncommon. Close surveillance with PET CT scan is important and high suspicion of GI metastases should be exercised when clinically appropriate.
2018 Occam’s Diverticula: Multiple Causes of Significant Lower GI Bleeding in a Young Man
Authors: Powell Charleston , Lindholm Phillip C. 
Published: October 2019

INTRODUCTION:
Meckel’s Diverticulum (MD) is the most common congenital malformation of the gastrointestinal tract. MD is difficult to diagnose as it presents with intermittent symptoms or none at all. Lower gastrointestinal bleeding (LGIB) is the most common presentation. The diagnosis is made even more difficult when there are other plausible causes of bleeding on endoscopy. We present a case of severe LGIB in a young man with right sided diverticulosis found to have symptomatic MD after a prolonged work-up.

CASE DESCRIPTION/METHODS:
A healthy 23-year-old male presented with several episodes of bright red blood per rectum and crampy abdominal pain relieved by defecation. He denied taking any NSAIDs. He was hemodynamically stable with mild, lower abdominal tenderness. During admission, his hemoglobin decreased from 14.4 to 8.6 and he became hypotensive, pale and diaphoretic requiring two units of packed red blood cells. CT of abdomen and pelvis was unremarkable. EGD did not reveal a cause of bleeding. Colonoscopy showed scattered, small-mouthed diverticula in the ascending colon with no active bleeding and he was discharged with a presumptive diagnosis of diverticular bleeding. Video capsule endoscopy (VCE) performed for a second admission for hematochezia found blood clots throughout the distal small bowel without active bleeding. After much delay, a 99mTc pertechnate scan showed MD. He underwent surgery and had an ectopic gastric mucosa-containing diverticulum resected. He sustained no additional bleeding following surgery.

DISCUSSION:
Gastrointestinal bleeding is a major cause for hospitalization in adults. Less than 5% of cases are attributed to small-bowel sources. Diagnosis is more difficult when there are more common explanations for bleeding available. Diverticula located in the right colon are more likely to bleed despite being less common than left-sided ones, making them a plausible explanation for our patient’s symptoms. Even with the advent of non-invasive techniques to visualize the small bowel, diagnosing a small bowel bleed can prove to be a challenging feat. Diagnosis is affected by the features associated with a MD to include active bleeding, inversion or presence of heterotopic mucosa. Sensitivities for 99mTc pertechnate scan, CT and VCE are low at approximately 60, 48 and 8%, respectively, leaving much room for undiagnosed MD. High index of suspicion and multiple imaging modalities are required for diagnosis of MD, especially when more common explanations are present.
2023 A Unique Presentation of GI Bleeding as First Presentation of AML
Authors: Raborn Erik , Kelts Andrew , Stiemle Cassandra , Ali Farhan , Valvano Gary , Jeng Jennifer , Mazza Bruno 
Published: October 2019

INTRODUCTION:
Acute Myelogenous Leukemia (AML) is a heterogenous group of cancers of blood cells associated with many dysfunctions due to monoclonal expansion of blood marrow. AML typically presents with symptoms of pancytopenia, including general fatigue, weakness, infections, ecchymoses, epistaxis, or menorrhagia. Overt GI bleeding is not a common initial presentation for AML.

CASE DESCRIPTION/METHODS:
Our patient was an 85-year-old female with a past medical history of gastrointestinal bleed while taking DOAC for pulmonary embolism, gastroesophageal reflux disease, hypertension, and uterine adenoma with subsequent hysterectomy and bilateral oophorectomy. She presented with complaint of “jet black” stools for 12 hours and accompanying weakness. She had no other alarm symptoms including pallor, bruising, neurological complaints, weight loss, hematochezia, or night sweats. She was known to have a hiatal hernia on previous EGDs and a bleeding distal rectal mucosal lesion concerning for a Dieulafoy lesion, both of which were two years prior to admission. Her initial labs were significant for hemoglobin 8.4, platelets 24, INR 1.0, and white blood cell count 5.1 with normal differential. Upper GI bleed was suspected, despite her previous lower GI bleeding, and the first upper endoscopy was performed; this revealed a possible Dieulafoy lesion that was hemoclipped. Her anemia and melena continued to worsen and Hematology performed a bone marrow biopsy. In the intervening time, two more upper endoscopies were performed yielding no further evidence of bleeding. Given her continued symptoms, colonoscopy was performed showing blood in the terminal ileum and right colon with no obvious lesion; there was, however, discrete mucosal bleeding sites in the rectum with no lesions noted after extensive cleaning. Multiple hemoclips were placed in the rectum but,ultimately, none of the endoscopic interventions proved durative. Shortly after colonoscopy, bone marrow biopsy revealed AML.

DISCUSSION:
Our case highlights a unique presentation of AML, where gastrointestinal bleeding is the first major presenting symptom. Bruising, epistaxis, and vaginal bleeding are the most typical types of bleeding in AML, none were found in this patient. AML is due to dysfunctions due to monoclonal expansion blood marrow that can lead to preferentially nonfunctional blood lines. This patient had significant thrombocytopenia with cells that were dysfunctional, leading to diffuse gastrointestinal hemorrhage without the presence of bleeding lesions.
2025 Rare Obscure Cause of Upper Gastrointestinal Bleeding: Bleeding Duodenal Lymphangiectasia
Authors: Sorathia Sufian , Cantave Rulz T. , Choksi Vivek , Dave Kairavee , Kaplan Steven R. 
Published: October 2019

INTRODUCTION:
While ulcerative and erosive mucosal changes are more commonly the culprit lesion of upper gastrointestinal bleeding, bleeding can also occur from traumatic, malignant or vascular lesions. An unusual and infrequent vascular cause of bleeding is from a focal intestinal lymphangiectasia (IL). We describe a patient who presented with bleeding from a duodenal IL.

CASE DESCRIPTION/METHODS:
A 94-year-old female was sent by her nursing home for witnessed melena and new onset normocytic anemia with a hemoglobin of 7 g/dl. She was unable to provide a reliable history due to her advanced dementia. Her medical history was unknown. She was hypotensive on presentation which she responded to fluid resuscitation and one unit of blood transfusion. Her physical examination revealed conjunctival pallor, benign abdominal exam and melanotic stool on rectal exam. EGD was performed. The esophagus and stomach was normal. In the second portion of the duodenum, there was a five millimeter white plaque-like lesion, consistent with IL, and with a central red erythematous spot, appearing eroded [Figures 1 and 2]. In the view of bleeding and absence of other potential sources of bleeding, three hemostatic clips were placed to the lesion for hemostasis and prevent further bleeding [Figure 3]. Patient was followed clinically over the next several days and her bowel movements became brown in color. She required no further blood transfusions and hemoglobin levels stabilized. She was discharged with a hemoglobin of 8.7 and determined to have had bleeding from a duodenal IL.

DISCUSSION:
IL is characterized by dilated lymphatic vessels, which can be focal or diffuse. Generally asymptomatic, IL can be associated with malabsorption. Acute gastrointestinal bleeding is rare. An obstructed normal efferent lymphatic flow could subsequently open a latent lymphatic-venous/arterial connection, which could potentially explain its association with bleeding. Unless actively bleeding or with recent stigmata of bleed, definite diagnosis of bleeding from a focal IL is difficult. Endoscopic treatment is amendable to the same therapeutic interventions available of any bleeding gastrointestinal lesions, which includes injection of epinephrine, thermal therapy and/or placement of hemostatic clips. In conclusion, focal type of IL may rarely present with acute obscure gastrointestinal bleeding. Physicians should remain cognizant of this infrequently-described-in-literature etiology and should include it in their differential diagnosis.