bluuebunny/crossref_metadata_2025_split huggingface dataset:
1952 Safety of Capsule Endoscopy During Pregnancy
Authors: Siddiqui Mohammad A. , Haq Khwaja F. , Schairer Jason 
Published: October 2019

INTRODUCTION:
Currently there is limited literature on the safety of Video Capsule Endoscopy (VCE) during pregnancy. There is a theoretical risk of the growing uterus compressing the GI tract. Moreover the gastrointestinal transit is prolonged in the second and third trimester which may jeopardize VCE procedure. We hereby report a case of a pregnant patient who safely underwent a VCE without retention.

CASE DESCRIPTION/METHODS:
A 30 years old female who was 18 weeks pregnant with a history of myeloproliferative disorder and splenic vein thrombosis presented with hematemesis. She underwent an EGD that demonstrated type 1 isolated gastric varices without active bleeding that was doubted as the source. Colonoscopy found old blood in the terminal Ileum and the ascending colon. She was started on a beta-blocker for variceal bleeding prophylaxis. The patient was informed that there is limited literature on safety of VCE in pregnancy with a theoretical risk of capsule retention. As such pregnancy is deemed a relative contraindication to VCE. Therefore patient decided to pursue clinical monitoring. One week later the patient returned with similar symptoms. During this admission the manufacturer of the capsule was unable to provide any safety data as it had not been studied in pregnant patients. The Obstetrics (OB) service discussed the risks and benefits of VCE during pregnancy. The risk of a retained capsule is that it may require an x-ray of the abdomen and/or surgery. The patient was currently in the 2nd trimester which is the usual recommended trimester for any necessary surgery. Moreover the gestational age was beyond embryogenesis and per ACOG recommendations x-ray should be completed for maternal well-being. Since there were no safer alternatives and maternal wellbeing supersedes fetal health, VCE was performed. It found a small duodenal erosion but otherwise passed into the colon and was a normal examination of the small bowel. Hence recurrent bleeding was attributed to known gastric varices. She is now in her 30th week, following up with OB and per their review the fetus is doing well. She has had no more admissions for gastrointestinal bleeding.

DISCUSSION:
Elective VCE in pregnant patients should ideally be postponed until after delivery due to a lack of safety data. Nevertheless, VCE may be considered in indications related to maternal symptoms that put the mother or child at risk, such as small bowel bleeding. Accordingly, the FDA has assessed pregnancy as a relative contraindication to VCE.
1953 Blue Rubber Bleb Nevus Syndrome: A Diagnostic and Therapeutic Conundrum in Patients With Gastrointestinal Involvement Causing Chronic Anemia
Authors: Rashid Mamoon Ur , Inayat Faisal , Amjad Waseem , Khan Muzammil Muhammad , Ullah Waqas , Zafar Hammad , Munir Ahmed , Hussain Ishtiaq , Hurairah Abu 
Published: October 2019

INTRODUCTION:
Blue rubber bleb nevus syndrome (BRBNS) is a rare vascular anomaly syndrome consisting of multifocal venous malformations. It frequently presents a diagnostic and therapeutic challenge in patients with gastrointestinal involvement.

CASE DESCRIPTION/METHODS:
A 55-year-old male presented with symptomatic anemia. Physical examination showed paleness and tachycardia. Laboratory studies showed hemoglobin 5.8 g/dL with normal white cell count. Peripheral blood smear showed microcytosis and hypochromia. Coagulation studies and routine biochemistry values were normal. He received packed-red cells and iron supplementation. He underwent upper and lower endoscopies. Colonoscopy showed multiple scattered venous blebs throughout the colon. They ranged in size from 2 mm to 8 mm. None of these blebs were actively bleeding. These lesions were not amenable to endoscopic treatment. Treatment was conservative with PPIs, blood transfusions and iron replacement.

DISCUSSION:
BRBNS is a rare, multifocal vascular malformation. According to a PubMed search, a total of around 200 cases are reported to date. Although data is sparse, it more commonly occurs in the skin (93%) and gastrointestinal tract (76%). A thorough physical examination and diagnostic workup for any symptomatic site should be performed in all suspected cases. Gastrointestinal involvement is a great masquerader as these patients experience severe anemia for years without diagnosis. In these patients, bleeding from the gastrointestinal tract is the most important clinical feature of BRBNS owing to the risk of excessive bleeding. Antiangiogenic agents such as interferon, corticosteroids, or sirolimus may be an effective treatment option for gastrointestinal BRBNS. In future, more cases should be reported in order to understand the etiological factors and treatment approaches.
1958 An Unusual Ca(u)se of Upper Gastrointestinal Bleeding
Authors: Pisipati Sailaja , Abdalla Abubaker , Harrison Clark A. 
Published: October 2019

INTRODUCTION:
Duodenal varices (DVs) represent 17% of ectopic varices (EVs), have a 4-fold increased bleeding risk when compared to esophago-gastric varices (EGVs), and mortality rate up to 40%. There are no guidelines on the ideal management of DVs. We report a case of massive hemorrhage secondary to DV managed successfully with transjugular intrahepatic portosystemic shunt (TIPS).

CASE DESCRIPTION/METHODS:
A 69-year-old gentleman presented with hematemesis, hematochezia, dizziness and near-syncope. He was diagnosed with cryptogenic cirrhosis, non-alcoholic steatohepatitis in the past after negative autoimmune and infectious work-up. Prior doppler ultrasound showed elevated portal flow velocity; esophagogastroduodenoscopy (EGD) a month prior revealed portal hypertensive gastropathy (PHG) but no EGVs, and normal duodenum. Given prior hepatic encephalopathy, TIPS was not performed. He had abdominal surgeries in the past. He was hemodynamically unstable with benign abdominal exam. Labs revealed acute blood loss anemia with Hgb 9.1 (baseline 13), thrombocytopenia and coagulopathy. Following initial resuscitation with fluids, blood products, octreotide and pantoprazole infusion, urgent EGD was performed. There were no EGVs, but features of diffuse PHG, as well as a compressible mucosal bulge with a nipple sign representing a varix in the second portion of the duodenum were seen. Given the insufficient evidence to support endoscopic therapy in ectopic varices, interventional radiology was consulted. CT angiogram demonstrated patent portosystemic veins. TIPS was performed with a decrease in portal gradient from 16 to 2 mmHg. Rifaximin, lactulose and zinc were commenced. He remained hemodynamically stable following this and did not require further intervention. A year later, he remains free of further bleeding episodes or hepatic encephalopathy.

DISCUSSION:
Bleeding DVs are rare and potentially life-threatening. Diagnosis should be suspected in all cases of gastrointestinal hemorrhage, particularly in the absence of EGV or another source. Standard management has not yet been established. TIPS is a relatively safe and effective means of controlling acute DV bleeding. EVs may re-bleed despite a reduction of portosystemic pressure gradient < 12 mmHg or by 25–50% of baseline; hence the “12 mmHg rule” does not apply. Our patient recovered successfully following TIPS without needing additional therapy. Reducing the pressure gradient to very low values can result in successful outcomes with TIPS in DVs.
1959 A Case of Gastrointestinal Hemorrhage Due to Sevelamer-Induced Colonic Ulceration
Authors: Cheong Janice , Sahay Tanya 
Published: October 2019

INTRODUCTION:
Lower gastrointestinal bleeding is a common reason for gastroenterology consultation in hospitalized patients. Many medications lead to gastrointestinal tract injury, yet not often are these definitively recognized as the etiology of bleeding. In dialysis patients, noncalcium phosphate binders including sevelamer are used for management of hyperphosphatemia. Many adverse effects are reported, but gastrointestinal ulceration is only reported in the literature in case reports. We describe a case of rectal ulceration caused by sevelamer presenting as acute lower gastrointestinal bleed.

CASE DESCRIPTION/METHODS:
A 59-year-old Caucasian man with coronary artery disease with history of drug eluting stents on dual antiplatelet therapy, congestive heart failure, hypertension, diabetes mellitus and end stage renal disease on hemodialysis was admitted for a traumatic subdural hemorrhage after a car accident. He also reported a history of constipation and had previously experienced intermittent low-volume hematochezia attributed to hemorrhoids. He had no other prior history of gastrointestinal bleed. During hospitalization, while undergoing rehabilitation, he developed brisk hematochezia with associated hemodynamic instability. On exam, he was hypotensive with systolic blood pressure in the 80s. Physical examination revealed dark red blood in the rectal vault. Laboratory results showed hemoglobin of 7.9 g/dL (baseline of 9 g/dL), platelets of 145,000/μl and an international normalized ratio of 1.1. Upper endoscopy was normal. Colonoscopy showed scattered punched-out ulcerations in the rectum with firm and adherent clot overlying a large ulceration in the 6 o’clock position. No endoscopic intervention was indicated. The patient clinically stabilized and was discharged home several days later. The histology from rectal biopsies showed colonic mucosa with ulcer and granulation tissue, associated with crystalline debris. Findings were consistent with sevelamer induced colitis. In discussion with the patient’s nephrologist, sevelamer was stopped. Hematochezia has not recurred.

DISCUSSION:
Here, we present another case of sevelamer induced colitis this time with ulceration leading to gastrointestinal hemorrhage. Literature is lacking on rates of sevelamer inducing ulceration. However, given the large number of dialysis patients on this medication, gastroenterologists should be aware of and consider this etiology for gastrointestinal hemorrhage in this patient population.
1977 A Rare Cause of Small Bowel Bleeding From a Duodenal Varix
Authors: Ali Mohammed Fahad , Brennan Gregory T. , Samarasena Jason , Lee John 
Published: October 2019

INTRODUCTION:
Ectopic varices are rare and by definition occur outside of the esophagus and stomach. They can be found in the rectum, duodenum or be peristomal. An estimated 2–5% of variceal bleeds are due to ectopic varices with the majority occurring either in the rectum or duodenum. The diagnosis of ectopic duodenal varices can be challenging given their location. There is a paucity of data regarding optimal diagnosis and management of bleeding duodenal varices.

CASE DESCRIPTION/METHODS:
A 46 year old woman with a history of cirrhosis from alcohol and nonalcoholic steatohepatitis was referred to our center for ongoing small bowel bleeding. Previous endoscopic evaluation included an unremarkable EGD, colonoscopy revealed blood through the colon without lesions, and capsule endoscopy showed blood in the proximal small bowel (at less than 30% small bowel transit time). We performed a push enteroscopy which showed a submucosal bulge with overlying ulceration and intermittent active bleeding in the third portion of the duodenum. Hemostasis was achieved with two hemoclips and the location was marked with tattoos. On initial discovery, the lesion was most consistent with a submucosal tumor such as a GIST (Figure 1) and she was referred for surgical resection. However, surgery was unsuccessful because of dense adhesions from a prior unrelated surgery. A repeat examination of the lesion 6 weeks later with endoscopic ultrasound showed a large varix (Figures 2 and 3). The patient has otherwise been doing well without any recurrent GI bleeding.

DISCUSSION:
Varices typically appear as bluish enlarged vessels or bulges and are commonly tortuous and easily compressed with instrumental pressure. Ectopic varices can be confused with thickened folds or submucosal lesions as in this case. Differentiation of these lesions is paramount in choosing appropriate management. It is important to consider ectopic varices on the differentials of both GI hemorrhage and submucosal lesions. EUS is the preferred test to characterize such lesions. Varices typically appears as round anechoic structures arising from the lamina propria or submucosa. Color Doppler is used to detect blood flow, which will confirm the vascular nature of the structure. Options of endoscopic hemostasis of bleeding duodenal varices include hemoclips, sclerotherapy, TIPS, balloon-occluded retrograde transvenous obliteration or surgical resection.
1979 GI Bleed Secondary to Gangliocytic Paraganglioma Treated With Radiation Monotherapy
Authors: Van Jeremy , Esteban Marcus Juan , Oikonomou Ioannis 
Published: October 2019

INTRODUCTION:
Gangliocytic Paraganglioma (GP) is a rare, usually benign tumor typically found in the 2nd part of the duodenum. The rarity of the tumor hasn’t allowed development of treatment guidelines. Mainstay of treatment involves endoscopic or surgical resection. Adjuvant chemotherapy or radiation has been utilized in a few cases. The case described is of a patient with GP presenting with hematochezia. The patient’s gastrointestinal (GI) bleed was treated with radiotherapy alone, which is the first case to our knowledge in the literature.

CASE DESCRIPTION/METHODS:
A 78 year old male with past medical history of multiple comorbid cardiovascular conditions and Multiple Myeloma presented with a six month history of hematochezia. Complete Blood Count showed a hemoglobin (hgb) of 8.6 g/dL with a baseline hgb of 11 g/dL four months prior. Esophagogastroduodenoscopy (EGD) showed a 3 cm ulcerated, friable periampullary mass. Biopsies demonstrated epithelioid, spindle and “large” cells associated with GP. Computed Tomography (CT) scan of the abdomen showed a 5.1 cm soft tissue density appearing to originate from the pancreatic head and abutting the duodenum with no regional lymphadenopathy or distant metastasis (mets). Due to the patient’s comorbidities and high perioperative mortality risk, radiation monotherapy was pursued for treatment. After fourteen radiotherapy sessions, the patient’s GI bleed resolved. Repeat EGD showed decreased vascular markings in the duodenal mass.

DISCUSSION:
GP is a rare tumor composed of epithelioid, spindle and ganglion cells. Tumor behavior is usually benign with rare invasion of nearby structures and lymph node mets. CT scan and endoscopic ultrasound (EUS) are generally recommended for staging. Our patient underwent CT Scan, but EUS was deferred due to little utility with an increased perioperative mortality. Local surgical resection is the most common treatment, but endoscopic resection has shown lower morbidity and mortality in selected cases. The size of the tumor and invasion depth dictates treatment modality. Our patient’s tumor size (>5 cm) and pancreatic head origin would have necessitated pancreaticoduodenectomy in a healthy patient. Due to his comorbid conditions and positive literature data on adjuvant radiotherapy for benign paragangliomas of the pancreatic head and neck, our patient underwent successful monotherapy with radiation for control of bleeding. This case shows benefit of radiotherapy alone for control of bleeding due to GP in high risk surgical patients.
1980 A Case of Downhill Esophageal Varices Secondary to Metastatic Disease From Renal Cell Carcinoma and Resultant Superior Vena Cava Syndrome
Authors: Van Jeremy , Singh Shubha 
Published: October 2019

INTRODUCTION:
Downhill esophageal varices (DEV) are a rare form of varices associated with superior vena cava (SVC) obstruction. Obstruction leads to retrograde blood flow through collateral channels, including the esophageal venous plexus. This case describes a patient with hematemesis due to DEV from an enlarged paratracheal lymph node (PLN) secondary to metastatic disease (mets) from renal cell carcinoma (RCC).

CASE DESCRIPTION/METHODS:
A 65 year old male with past medical history of RCC s/p right nephrectomy with mets to the brain and mediastinum presented with a one day history of hematemesis and significant drop in hemoglobin. Esophagogastroduodenoscopy (EGD) was remarkable for large DEV in the proximal to mid-esophagus with white nipple sign. Band ligation was deferred given no active bleeding. Liver function tests were normal, vascular duplex of the abdomen was unremarkable, and CT chest with IV contrast showed extrinsic compression of the distal brachiocephalic veins (BV) and proximal SVC from a 4.6 cm necrotic right PLN. Radiotherapy was used to decrease the lymph node size and resultant extrinsic venous compression.

DISCUSSION:
DEV are a rare entity compared to uphill varices (UV) found in the distal esophagus due to portal hypertension. Hematemesis is more common with UV because of their location in the superficial sub-epithelium and increased acid exposure. DEV are located proximally in the submucosa, have more protection against acid, and have less than a 0.1% chance of causing hematemesis. After diagnosis with EGD, there are no clear guidelines on management. In this patient, banding was deferred given high risk of bleeding and perforation due to weakness in the proximal esophageal posterior wall and lack of serosa. After diagnosis on EGD, CT chest revealed the underlying cause of bleeding: SVC obstruction. The gold standard imaging study is direct venography but CT chest is an adequate alternative study. No surgical intervention was performed given the precarious nature and location of the lymph node and stenting of the SVC was deferred given the risk for re-bleed if placed on anticoagulation. Thus, radiotherapy was ultimately determined to be the next best step to decrease the extrinsic compression of the SVC from the lymph node. Chakinala RC, Kumar A, Barsa JE, et al. Downhill esophageal varices: a therapeutic dilemma. 2018 Nov 1. 1–6. Gebreselassie A, Awan A, Yaqoob H, Laiyemo A. Superior Vena Cava Obstruction: A Rare Cause of Recurrent Esophageal Variceal Bleeding. 2018 Feb 26. 2226.
1984 Helicobacter pylori-Negative MALT Lymphoma Presenting as Massive Recurrent Gastrointestinal Hemorrhage
Authors: Harne Prateek , Mukherjee Samiran , Lowe Dhruv , Manocha Divey 
Published: October 2019

INTRODUCTION:
Extranodal marginal zone lymphoma or low-grade B cell lymphoma of mucosa-associated lymphoid tissue (MALT), an uncommon type of non-Hodgkin lymphoma (NHL), accounts for 5–10% of NHL in the US (18.3 cases per 1 million person-years1). It usually presents as gastro-esophageal reflux, nausea, anorexia, weight loss or occult GI bleeding2. Massive GI bleeding is unusual and rare.

CASE DESCRIPTION/METHODS:
Here we present a 68-year-old woman who presented with weakness and syncope after large volume hematemesis. Physical exam showed tachycardia, hypotension and conjunctival pallor. Her hemoglobin and hematocrit on admission were 8.5 g/dL and 25.6 %. She was managed with IV fluids, packed RBC transfusion and Pantoprazole and Octreotide infusions. An EGD within 24 hours showed erythematous, friable, spontaneously oozing mucosa with neovascularization in gastric fundus which was treated with bipolar cautery. A biopsy was not obtained due to recent bleeding. She was discharged on oral Pantoprazole. Two days later she was readmitted due to severe recurrent hematemesis with similar findings on repeat EGD. Bleeding was controlled with APC and biopsies were obtained from the gastric fundus. Due to the recurrent bleeding, an angiogram was performed. Active bleeding could not be seen. Prophylactically, left gastric artery was embolized. Biopsies revealed low-grade B cell MALT lymphoma with negative H.pylori. She was treated with 20 fractions of radiotherapy with the intention to cure. She did not experience further episodes of bleeding and has remained in remission since.

DISCUSSION:
Studies show the indolent nature of GI MALT lymphoma3, but our case illustrates the life-threatening presentation of a rare low-grade B cell MALT lymphoma as massive and recurrent hematemesis with negative underlying H.pylori infection or autoimmune process45. H.pylori positive localized MALT lymphoma is treated with the eradication of infection. H pylori negative, localized and recurrent disease is treated with radiotherapy6. Chemotherapy and/or immunotherapy is given when patients fail to respond to radiotherapy or develop metastasis. Long term endoscopic and laboratory follow up is needed as gastric MALT lymphoma is associated with a significant risk of gastric adenocarcinoma8 and increased incidence of gastric cancer and residual NHL. Our case emphasizes the importance of early diagnosis and timely intensive radiotherapy of a localized but aggressive gastric MALT lymphoma which induced remission and cessation of GI bleeding.
1990 The Successful Treatment of a Gastroduodenal Artery Rupture With Extravasation Into the Duodenal Lumen
Authors: Drame Awa 
Published: October 2019

INTRODUCTION:
Gastroduodenal artery (GDA) aneurysms are rare, accounting for about 1.5% of all visceral arterial aneurysms. Two main entities of aneurysms exist: pseudoaneurysms occuring secondary to chronic pancreatitis and true aneurysms, less common and associated with artherosclerotic risk factors. The most serious complication of aneurysms is rupture with mortality rate of up to 70%. Early diagnosis is paramount to patient’s survival. GDAs may rupture into the superior mesenteric vein causing bleeding esophageal varices or into the peritoneum causing hemorrhagic shock or into the gastro-intestinal tract (GIT) causing hematemesis, melena or hemobilia. We herein report the case of a GDA rupture into the gastro-intestinal tract (GIT) which presented with sudden onset of abdominal pain and hypotension. Melena and hematochezia, typical clinical presentation associated with GIT bleed were absent secondary to severe opioid-induced fecal impaction. Despite this, high suspicion and early angiographic intervention helped in saving the patient’s life.

CASE DESCRIPTION/METHODS:
A 72-year-old male with a remote history of ulcerative colitis and active metastatic stage IV prostate adenocarcinoma to the brain, spine and bladder presented to the hospital with abdominal pain, hematuria and hypotension. He was admitted a week prior with similar complaints (right-sided flank pain and hematuria). In the ED, BP 94/46 with a leukocytosis of 11 and hemoglobin of 6.8. Foley catheter was placed with return of 400 cc of frank blood. He received 2 units of blood and was admitted to the ICU. Physical examination on admission was significant for abdominal distention, tenderness and hypoactive bowel sounds. He rapidly decompensated despite aggressive fluid resuscitation and vasopressors. He went into PEA arrest and ROSC was obtained after multiple ACLS rounds. CT A/P showed contrast extravasation at the posterior wall of the gastric body. Our GI service performed emergent EGD. There was a single deep, cratered and punched-out ulcer measuring 4 cm that was spurting blood. 3 clips were applied to control the bleeding. The following day, IR successfully embolized the GDA. Blood pressure stabilized and the patient was weaned off the ventilator and extubated. He was discharged hemodynamically stable.

DISCUSSION:
Giving the rarity of GDA rupture, there are no clear screening or follow-up guidelines. Decisions about diagnostic and therapeutic procedures should be prompt and made on an individual basis.