bluuebunny/crossref_metadata_2025_split huggingface dataset:
1897 Endoscopic Closure of GastroColoCutaneous Fistula: A Rare Complication of Percutaneous Endoscopic Gastrostomy Tube Placement
Authors: Zia Hassaan , Hayat Maham , Guild Ralph 
Published: October 2019

INTRODUCTION:
Percutaneous endoscopic gastrostomy (PEG) tube placement is an indispensable method for enteral nutrition. The incidence of complications ranges from 0.4% to 40% .These include buried bumper syndrome, infection, tube dislodgement, malfunction, peristomal leakage, bleeding and colonic perforation. We report a rare complication of colonic perforation presenting as a gastrocolocutaneous fistula.

CASE DESCRIPTION/METHODS:
55-year-old male with Stage IV gastroesophageal junction neuroendocrine carcinoma with ongoing chemoradiotherapy had a PEG tube placed for dysphagia. There were no post procedural complications. Two months post procedure, patient presented with pancytopenia and a two-week history of persistent diarrhea, malodorous peristomal drainage and weight loss. Computerized tomography (CT) imaging with intravenous (IV) contrast confirmed the presence of a gastrocolocutaneous fistula (Image A, left) with internal bolster located in the transverse colon. Due to immunocompromised status, endoscopic closure was pursued with a colonoscopy and esophagogastroduodenoscopy (EGD). A pediatric colonoscope with distal cap attachment was used, an internal bolster with colocutaneous fistula with no cologastric fistula was seen. (Image B). The site was tattooed with 6mL of Spot (carbon black). The gastrostomy tube was removed, and three hemostatic clips were used for closure (Image C, left). No air leak was noted over the exterior abdominal wall. This was followed by EGD, the residual gastrocolic fistula was closed by a mini over the scope clip (OTSC) OVESCO 10/3t (Image C, right). A CT scan with oral contrast demonstrated no residual leak/fistula. (Image A, right) Total parenteral nutrition (TPN) was initiated. Patient continued to do well, and post-procedural hospital stay was uneventful.

DISCUSSION:
Gastrocolocutaneous fistula after PEG placement has an incidence of 0.5%–3%. Risk factors include lax mesentery, prior abdominal surgery leading to adhesions and improper insufflation of the stomach. Peritoneal signs represent acute presentations, delayed presentations manifest as feculent peristomal leakage, persistent diarrhea and weight loss. Diagnosis can be made with oral and IV enhanced imaging. Conservative management includes removal and allowing fistula healing. Surgical intervention is warranted when systemic signs or persistent fistulous tract is present. Endoscopic closure with OTSC is described as a treatment option for uncomplicated patients.
1898 Successful Endoscopic Removal of a Long Lost Toothbrush: 15 Years Later!
Authors: Khalid Nida , Kothari Truptesh , Kaul Vivek , Kothari Shivangi 
Published: October 2019

INTRODUCTION:
Toothbrush ingestion is uncommon and can sometimes be seen in patients with eating disorders or underlying psychiatric illness. Although some foreign bodies can pass spontaneously, due to its shape, spontaneous passage of toothbrush can be difficult and if left untreated can lead to abdominal pain, mucosal ulceration, bleeding and perforation. We report one such case of a toothbrush accidentally ingested 15 years ago and impacted in the gastric wall that was successfully removed endoscopically.

CASE DESCRIPTION/METHODS:
A 37-year-old female with past medical history of bulimia and accidental ingestion of tooth brush 15 years ago reported to her PCP with worsening abdominal pain. She had never reported or sought help for her ingested toothbrush all these years due to fear of being labelled mentally ill. Labs were relevant for mild anemia with Hb of 10.5 gm/dl. Initial attempt at endoscopic removal at outside center was unsuccessful. At repeat EGD at our center, a 20 cm long toothbrush was seen in the gastric body covered with significant debris (Figure 1). The distal end of the toothbrush was seen embedded in the proximal gastric wall (Figure 2). Attempts to free the distal end with a snare were not successful. A long overtube was then placed and gastroscope passed through it. Then using a rat tooth forceps the bristle part of the tooth brush was grasped and the brush was pulled into the antrum and the distal end was freed from the gastric wall. No frank perforation was seen at the site of impaction. The tooth brush was then grasped with a snare and brought into the overtube. The endoscope and overtube with the toothbrush were successfully removed (Figure 3). The patient was continued on PPI for 4 weeks and her abdominal pain resolved post procedure.

DISCUSSION:
Up to 80% of the ingested foreign bodies may pass through the gastrointestinal tract spontaneously. However long objects (>5 cm) cannot pass through the duodenum and need to be removed by endoscopy and rarely by surgery. Those that remain in gastrointestinal tract can be associated with serious complications such as perforation, bleeding, pressure necrosis or obstruction. Toothbrush ingestion is uncommon and requires prompt removal. However our patient sought help after 15 years of ingestion only after it caused abdominal pain. To the best of our knowledge this is the longest time period a toothbrush has been reported retained in the stomach and subsequently successfully retrieved by endoscopy.
1903 Esophageal Squamous Papilloma: A Rare Epithelial Tumor of Undetermined Significance
Authors: Takkouche Sahar , Hutton Anneka , Barakat Mohamed , Quintero Eduardo , Reddy Madhavi 
Published: October 2019

INTRODUCTION:
Esophageal squamous papilloma (ESP) is an uncommon lesion with less than 200 cases described. Although typically a benign lesion, the etiology remains uncertain. Currently, no guidelines exist for the management of esophageal squamous papilloma.

CASE DESCRIPTION/METHODS:
A 59-year-old woman presented with dysphagia; she reported symptoms of acid reflux and globus sensation. One year prior, esophagogastroduodenoscopy (EGD) was performed for these symptoms and revealed atrophic changes consistent with gastritis. Biopsy at that time was negative for H. Pylori infection. She was treated with PPI therapy, however her symptoms persisted. She endorsed intermittent dysphagia but denied weight loss or poor appetite. Physical exam revealed no palpable thyromegaly or epigastric tenderness. Repeat upper EGD revealed a white, 7 mm frond-like pedunculated polyp located 20 cm from the incisors (Figure 1). Endoscopic ultrasound (EUS) was performed, the origin of the lesion appeared to be within the superficial mucosa. The endosonographic borders were well defined, intact interfaces between the mass and adjacent structures suggested a lack of submucosal invasion (Figure 2). No was lymphadenopathy seen. The polyp was excised endoscopically (Figure 3), pathological review identified the specimen as an esophageal squamous papilloma, positive for Ki67 and HPV marker P16. The patient tolerated the procedure well and had no recurrence of symptoms after polypectomy.

DISCUSSION:
Often an incidental finding on endoscopy, ESP are most commonly found in adults over age 50 and typically involve the middle and distal thirds of the esophagus. ESP may be associated with dyspepsia but rarely cause obstruction. Purported etiologies include mechanical, chemical and viral insult to mucosa but is likely multifactorial. The malignant potential of ESP remains uncertain; although rare, several reported cases have been complicated by carcinoma. Studies to detect HPV DNA in ESP show variable percentage of HPV positivity. If HPV infection predisposes to ESP, this may explain cases of malignant conversion as HPV is a known cause of squamous cell cancer. ESP should be considered in patients over 50 years old presenting with dysphagia or GERD resistant to medical therapy. We recommend early recognition and removal of esophageal squamous papilloma due to ambiguity regarding malignant potential.
1904 Multiple Facets of CMV-Related Gastrointestinal Disease: From Top to Bottom
Authors: Magrath Melissa , Chauhan Kirtan , Vargas Alejandro , Tzimas Demetrios , Villanueva Gerald , Malter Lisa 
Published: October 2019

INTRODUCTION:
Cytomegalovirus (CMV) primarily affects immunocompromised patients, and has multiple manifestations in the gastrointestinal (GI) tract. The incidence of CMV-related GI disease has decreased since the advent of antiretroviral therapy (ART) for HIV. This, along with varied and nonspecific symptoms, makes it difficult to diagnose.

CASE DESCRIPTION/METHODS:
We report a 34-year-old man with AIDS (CD4 count 114 cells/µL) on ART presenting with five days of fevers. He was admitted to the ICU for sepsis and stabilized. His course was complicated by pulmonary embolism, recurrent fevers, and development of biopsy proven pyoderma gangrenosum. He also reported odynophagia, and was empirically treated for candida esophagitis with fluconazole. On hospital day 37, he developed massive hematochezia. An urgent esophagogastroduodenoscopy (EGD) did not reveal the source of bleeding, but showed a 5-cm linear esophageal scar, which appeared to be a healing tear. Sigmoidoscopy revealed a solitary rectal ulcer with a visible vessel, which was clipped for hemostasis. His bleeding resolved. The patient’s odynophagia persisted, significantly limiting his ability to tolerate oral intake. Repeat EGD revealed a large, cratered, non-bleeding esophageal ulcer which was biopsied. The same day, the patient developed hematochezia; repeat sigmoidoscopy showed a deeply cratered rectal ulcer with a visible vessel successfully treated with hemostatic clips. Esophageal biopsies returned positive for CMV; valganciclovir was initiated. His odynophagia improved after starting treatment and he had no further GI bleeding. Given the clinical response, the rectal ulcers were presumed to be due to CMV, making this a case of extensive CMV-related GI disease.

DISCUSSION:
This is a case of extensive CMV-related GI disease which eluded diagnosis during a prolonged and complicated hospitalization. CMV-related GI disease has varied presentations, most commonly affecting the esophagus, but has also been noted to manifest with gastritis, duodenitis, pancreatitis, and colitis. The most common endoscopic findings for esophageal involvement are discrete, shallow, punched-out ulcers surrounded by normal appearing mucosa. Clinical manifestations of colonic CMV include abdominal pain and diarrhea, while discrete ulceration causing bleeding is less commonly reported. This case highlights the importance of a high index of suspicion for CMV in immunocompromised patients with multiple, unexplained GI symptoms to avoid a delay in diagnosis and management.
1909 A Case of Severe Pseudomelanosis Duodeni
Authors: Zivari Kaveh , Yakubov Stanley , Iswara Kadirawelp , Rahmani Rabin 
Published: October 2019

INTRODUCTION:
Melanosis in the gastrointestinal tract consists of black pigmentation of the mucosa. It is generally seen in colon, and extracolonic melanosis is rare. Duodenal Melanosis is a rare benign condition caused by idiosyncratic metabolism of benzene-ring-containing drugs resulting in the accumulation of pigment in the duodenal mucosa. It is thought to be related to folate deficiency, gastric ulcer, intestinal bleeding, hypertension, chronic heart failure, chronic renal failure, consumption of sulfur-containing antihypertensive agents, drugs containing cyclic compounds, anthracene laxatives, and ferrous sulfate.

CASE DESCRIPTION/METHODS:
80-year-old man with history of hypertension, chronic heart failure, chronic renal failure, and chronic anemia on iron supplementation, presented to the hospital with weakness, palpitations, and melena. He was found to have acute blood loss anemia. The patient had normal folate level of 16 ng/ml. Gastroduodenoscopy revealed 2 cm gastric ulcer with no active bleeding, and melanosis of duodenum. Pathology confirmed aggregates of macrophages in the lamina propria with CD 68 positive immunostaining, contain black granular material consistent with Pseudomelanosis Duodeni (PD). Iron stain and Melan-A were both negative.

DISCUSSION:
Pseudomelanosis Duodeni was first described in 1976. Although there has been increased reports of this condition, its pathogenesis and clinical significance are not yet known. It is postulated that iron deposition secondary to intramucosal hemorrhage or impaired intramucosal iron transport after oral ferrous sulfate supplementation, or impaired macrophage metabolism of drugs is to be blamed. PD does not require any specific treatment or recommended follow-up; However, in our patient a 1 year follow up showed the progression of his melanosis.
1912 Chronic Non-Healing Gastric Ulcer Caused by Eosinophilic Gastroenteritis
Authors: Mavilia Marianna , Perelman Alexander , Sao Rahul , Sachdev Rishabh , Curran Matthew , Rossi Lisa 
Published: October 2019

INTRODUCTION:
Eosinophilic gastroenteritis (EG) occurs when eosinophils (eos) infiltrate the gastrointestinal (GI) tract leading to GI dysfunction. The prevalence of EG is 2.5 cases per 100,000 people in the US. The diagnosis is confirmed by histology with >20 eos per HPF. Common manifestations include abdominal pain, nausea, vomiting, and malabsorption. Ulcers are rarely seen in EG.

CASE DESCRIPTION/METHODS:
We describe a case of a 23 year old female with history of asthma presented with one month of severe epigastric pain, nausea and vomiting. Her pain was constant and exacerbated by eating. She took NSAIDs for 14 days without relief but denied melena, hematochezia, and hematemesis. She had no history of food intolerances, travel, smoking or alcohol use. Vitals and exam were unremarkable except for epigastric tenderness without rebound or guarding. Initial work up revealed WBC 8.0 K/UL with 16.7% eos, Hb 11.9 g/dL, MCV 80.6 fL, and ferritin 3 ng/mL. EGD revealed LA Grade A esophagitis, duodenitis, and a non-bleeding cratered antral ulcer, measuring 20 mm (Figure 1). Pathology revealed chronic gastritis without H. pylori. Pantoprazole 40 mg BID and sucralfate 1 g QID were initiated, but she continued to have symptoms and new onset hematemesis. Repeat EGD showed persistent 20 mm ulcer after 2 months of medical therapy. Biopsies showed marked eos in the esophagus, stomach, and duodenum, with >50 eos/HPF at the ulcer (Figure 2). Biopsies from a colonoscopy done at the time same revealed increased eos at the ileocecal valve. A workup for eosinophilia was negative for autoimmune or parasitic etiologies, gastrin level was normal, but serum IgE level was 1862 IU/mL. She was treated with prednisone and repeat EGD 2 months later revealed resolution of mucosal eosinophilia and decrease in ulcer size to 10 mm.

DISCUSSION:
Our patient was found to have diffuse eosinophilic infiltration throughout the GI tract as well as significant peripheral eosinophilia. While the ulcer may have been initially caused by NSAID use, it was refractory to treatment due to eosinophilic inflammation. Only after initiation of corticosteroids, did it begin to heal. The primary management for EG is elimination diet and avoidance of triggers. Systemic corticosteroids are effective in controlling symptoms if dietary modification is unsuccessful. There is limited evidence for the use of other medications including antihistamine, leukotriene, or IgE antagonists. In patients with ulcers refractory to conventional therapies, EG should be considered.
1917 Fatal Gastrointestinal Hemorrhage Secondary to Rare Aortoesophageal Fistula in a Patient With Esophageal Adenocarcinoma
Authors: Ratra Atul , Flannery Christopher 
Published: October 2019

INTRODUCTION:
Aortoesophageal fistula (AEF) is a rare cause of upper gastrointestinal bleeding which is associated with extremely high mortality despite timely intervention. We present a fatal case of gastrointestinal hemorrhage from AEF in a patient with esophageal adenocarcinoma who had recently undergone esophageal stent placement and chemoradiation therapy.

CASE DESCRIPTION/METHODS:
A 77 year-old Caucasian man with a past medical history of cirrhosis and TNM stage IIIA hepatocellular carcinoma, status post Yttrium-90 radioembolization in April 2017, presented with progressive dysphagia in January 2018. Patient underwent esophagogastroduodenoscopy (EGD) revealing a partially obstructing, non-bleeding mass at the gastroesophageal (GE) junction (Figure 1) and placement of an esophageal stent. Dysphagia improved post stent placement. Biopsy was consistent with primary adenocarcinoma of the esophagus. He received concurrent chemoradiation therapy with paclitaxel and carboplatin. In April 2018, patient presented to the emergency department with presyncope, hematemesis and epigastric pain. He was hyptotensive with a blood pressure of 88/56 mm Hg and anemic with a hemoglobin of 7.6 g/dL. Repeat EGD was performed with unintentional migration of stent into stomach, revealing friable and ulcerated mucosa in the lower esophagus (Figure 2). Retrieval of the dislodged stent caused the ulcerated mucosa to bleed. Hemostatic clip could not adhere to inflamed mucosa and a stent was placed to minimize bleeding. Interventional radiology was consulted. Fluoroscopy revealed presence of a small aortoesophageal fistula at the site of active bleeding (Figure 3). Hemostasis was achieved with coil embolization. Unfortunately, a few hours later, patient had a recurrence of massive re-bleed and expired.

DISCUSSION:
Esophageal malignancy is one of the primary causes of AEF. Thoracic radiation as a standalone cause has also been documented in non-esophageal malignancies. Several reports also document that aortic grafts and esophageal stents increase the risk of AEF development in patients who undergo radiation. This case adds to the growing literature that presence of esophageal stent and subsequent radiation compounds risk of AEF development in patients with esophageal tumors. Further studies are warranted for risk stratification. Such patients presenting with hematemesis and syncope need immediate AEF evaluation and emergent intervention.
1920 Superior Mesenteric Arteriovenous Fistula Mimicking Hepatic Cirrhosis With Spontaneous Bacterial Peritonitis
Authors: Haddad Ibrahim , El Kurdi Bara , Babar Sumbal , Alomari Mohammad , El Iskandarani Mahmoud , Young Mark 
Published: October 2019

INTRODUCTION:
Arteriovenous fistula of the superior mesenteric vasculature is a rare entity that was reported for this first time by Movitz and Finne in 1960. The majority of these cases are iatrogenic after surgical bowel resection. We present a 52-year-old male patient who had a spontaneous AFV of the superior mesenteric vasculature that presented as a chronic portal vein thrombosis.

CASE DESCRIPTION/METHODS:
A 52-year-old male patient with a past medical history significant for active hepatitis C infection. The patient presented to our institution complaining of progressive abdominal distention and chronic abdominal pain for 3 months. He had been diagnosed with cirrhosis two months prior to admission and was started on furosemide and spironolactone for ascites and underwent multiple therapeutic paracentesis. At presentation, the patient was found to have a normal platelet count and INR which were not consistent with cirrhosis calling the diagnosis into question. Further workup with ultrasound examination of the liver revealed portal vein thrombosis with extension to the proximal part of the splenic vein. This was followed by CT of the abdomen and pelvis with IV contrast which showed smooth liver surface, enlarged portal, superior and inferior mesenteric veins with clot seen in the left portal vein extending into the main portal vein (Figure 1).it also showed a fistula of the mid superior mesenteric artery with the superior mesenteric vein (Figure 2) which explained the prominence and the enlargement of the portal venous system. Upon diagnosis, the patient was transferred to a tertiary center for endovascular closure of the fistula.

DISCUSSION:
Arteriovenous fistula of the superior mesenteric vasculature is a rare entity. Most cases are iatrogenic in origin occurring after bowel resection. The most common presentation is gastrointestinal bleeding due to portal hypertension and resulting variceal changes. Treatment with endovascular with coil embolization is often preferred over surgical repair. In summary, we discuss an unusual presentation of idiopathic arteriovenous fistula of the superior mesenteric vasculature with portal vein thrombosis, abdominal pain and ascites mimicking hepatic cirrhosis with spontaneous bacterial peritonitis.
1922 The Use of a New Hemostatic Powder in Refractory Pseudocyst Wall Bleeding
Authors: Cortez Nathaly , Berzosa Manuel , Mahfouz Mahmoud 
Published: October 2019

INTRODUCTION:
Despite multiple endoscopic hemostatic devices available, GI bleeding can still be difficult to treat. A new hemostatic device was recently approved by the FDA as an non-surgical treatment option of upper and lower GI bleeding. The hemostatic powder forms a mechanical and adhesive barrier by absorbing water and promotes thrombus formation by concentrating and activating platelets and coagulation factors with high primary hemostasis rates. It has been reported as a successful hemostatic technique for common causes of GI bleed, but not for pseudocyst bleeding.

CASE DESCRIPTION/METHODS:
84-year-old male admitted to our institution ten days after a surgical cystgastrostomy with one day history of abdominal pain associated with nausea and vomiting. Hemoglobin decreased from 11 to 8 mg/dl after the surgery and occult blood in stool was positive. Initial CT angiogram revealed no active bleeding but a large complex fluid collection 13.1 × 11.6 × 12.9 cm from the pancreatic tail and involving the stomach. Gastroenterology was consulted to assess the cystgastrostomy patency and evaluate for GI bleeding as the cause of anemia. Endoscopy was performed and revealed that the pseudocyst gastrostomy in the proximal gastric body had stenosed to 0.5 cm from 6 cm and the pseudocyst cavity was filled with large clots but no evidence of active bleeding. Due to the stenosis, double pig tail plastic stents were placed. Patient developed melena and hemoglobin decreased again from 9 to 7 mg/dl. Repeated endoscopy revealed active bleeding within the pseudocyst wall near the anastomosis. The tissue was very friable. Epinephrine injection, coaptive coagulation with bipolar cap and hemostatic clip placement were all unsuccessful to stop the bleeding. Finally, hemostasis was achieved using a new hemostatic powder through endoscopic delivery catheter. The powder was sprayed successfully to the anastomosis and proximal cavity of the pseudocyst without complication or further bleeding. Follow up a month later did not showed any evidence of active bleeding. Repeat CT abdomen revealed decreased in size of the pancreatic pseudocyst with plastic stents still in place.

DISCUSSION:
To our knowledge, this is the first report of the use of hemostatic powder delivered via endoscopy outside the GI tract to achieve hemostasis from pancreatic pseudocyst wall bleeding. This device can be considered as a rescue modality for those cases where the standard treatment has failed. Further studies are needed to assess its safety in this setting.