bluuebunny/crossref_metadata_2025_split huggingface dataset:
2028 Here’s the GIST: Expand Your Differential of an Acute Upper GI Bleed
Authors: Bergagnini Isabella , Nguyen Andrew , Robbins David 
Published: October 2019

INTRODUCTION:
While gastrointestinal stromal tumors (GIST) are among the most common mesenchymal malignancies affecting the gastrointestinal (GI) tract, they are considered rare entities comprising a mere 1-3% of all GI tumors. The vast majority are detected incidentally. We report a case of a small bowel GIST presenting as a severe acute upper GI bleed.

CASE DESCRIPTION/METHODS:
A 38-year-old female with a history of Henoch Schonlein Purpura presented with melena, lightheadedness, and dyspnea for one week. She was orthostatic on admission and her exam notable for conjunctival pallor and melena in the rectal vault. Her hemoglobin was 7.0 mg/dl on admission with labile measurements throughout her stay. An EGD revealed heme within the gastric body with active oozing in the proximal duodenum but with no identifiable source. Subsequent EGD revealed an actively spurting Dieulafoy lesion in the duodenum. Hemostasis was achieved with epinephrine and deployment of four hemoclips. Hemoglobin levels continued to fluctuate raising concern for re-bleeding. CT angiography of the abdomen was negative for an active bleed, but incidentally demonstrated a 5.8 × 4.7 × 3.7 cm enhancing mass adjacent to the proximal jejunum. She was taken to the OR for diagnostic laparoscopy and underwent en bloc resection of the 4th portion of the duodenum and proximal jejunum. The pathology revealed a low-grade GIST (positive for cKIT proto-oncogene, mitotic index < 5). The patient underwent a follow-up CT nine months after discharge which demonstrated no evidence of recurrent disease.

DISCUSSION:
Though GISTs are most commonly found in the stomach as well as the small bowel, the duodenum is an uncommon site of proliferation, comprising approximately 3-5% of all cases. Presentation varies, dependent on tumor size, with overt GI bleeding (hematemesis or melena) as the leading complaint in approximately 40-65% of cases. The presence of bleeding is associated with a high probability of tumor necrosis and ulceration and portends a poor prognosis. CT angiography has proven to be an effective imaging modality for the detection of GI bleeds, with sensitivities ranging from 63-90%. Surgical resection is preferred with or without the presence of a bleed. For larger tumors and those with chronic bleeding, oral imatinib is recommended to decrease tumor size. While GISTs commonly present with acute GI bleeding, they are rarely found in the small bowel, making this an important consideration when evaluating acute GI bleeds.
2032 Push Enteroscopy in the Diagnosis of a Gastrointestinal Bleed Caused by Diffuse Large B-Cell Lymphoma
Authors: Amine Mukarram , Srivastava Amit 
Published: October 2019

INTRODUCTION:
Only 5-10% of gastrointestinal bleeding is from the small intestine, and in these cases, video capsule endoscopy (VCE) is considered as a first line procedure for small bowel investigation. The most common causes of small intestinal bleeding in patients older than 40 years include angioectasias and NSAID-induced ulcers. In younger patients, its is more common to see bleeding events as a result of Crohn disease, Meckel diverticula, Dieulafoy lesions, and tumors. Celiac disease can cause bleeding in both age groups. Our case reports on an uncommon presentation of a rare gastrointestinal malignancy, and the utility of push enteroscopy in the diagnosis thereof.

CASE DESCRIPTION/METHODS:
A 77-year-old female with a past medical history of gastric carcinoid, iron deficiency anemia, and history of pulmonary embolism now on rivaroxaban had presented after a syncopal episode. Upon review of systems, the patient did report dark stools, which she attributed to her iron pills. On presentation, the patient was found to have severe iron deficiency anemia and heme-positive stools. EGD and colonoscopy were performed, which did not reveal an active source of bleeding. She was taken off of rivaroxaban and her hemoglobin subsequently stabilized and she had no further episodes of melena. She was discharged with instructions to follow up for an outpatient VCE. Ten days later, before the scheduled VCE, the patient returned to the hospital with another episode of melena, and was again found to have a substantial decline in her hemoglobin. The patient then underwent push enteroscopy, which revealed multiple actively bleeding, cratered ulcers ranging in size from 10 mm to 20 mm in the distal duodenum and proximal jejunum which were endoscopically ablated. Biopsy of these ulcers was positive for non-germinal center derived diffuse large B-cell lymphoma. The patient was subsequently transferred to a tertiary care center for further staging and possible treatment.

DISCUSSION:
This case demonstrates the utility of push enteroscopy for both diagnosis and treatment in clinically significant, obscure, occult gastrointestinal bleeds. In this patient in particular, it also enabled the early diagnosis of a rare and morbid malignancy for which survival without treatment is measured in months. While small bowel tumors are among the most common causes of obscure GI bleed in young patient, this is a rare finding in the elderly. As this case demonstrates though, the possibility of malignancy should not be overlooked.
2039 Invasive "Intracholecystic Papillary-Tubular Neoplasm" (ICPN) Presenting as Hemobilia in a Jehovah's Witness Patient
Authors: Iyer Divya G. , Siddappa Pradeep K. , Aujla Amreet K. , Selden Michael A. 
Published: October 2019

INTRODUCTION:
Hemobilia is a rare cause of upper gastrointestinal bleeding, which requires high index of suspicion for diagnosis. In various case series, hemobilia due to neoplastic disease of the hepatobiliary system ranges from 6% - 15%. ICPNs are rare neoplasms of the gallbladder that are usually detected incidentally. This is a case of a Jehovah’s Witness patient with severe symptomatic anemia secondary to hemobilia due to invasive ICPN.

CASE DESCRIPTION/METHODS:
71-year-old Jehovah’s Witness patient with a 4 month history of anemia, suspected to be due to multiple small intestine angioectasias seen on prior enteroscopies, presented with a 3 day history of fatigue, dyspnea on exertion, and melena. Patient’s hemoglobin/hematocrit at presentation was 6.4/23.4. She underwent gastroduodenoscopy which showed blood in the second part of the duodenum which prompted a side viewing duodenoscopy examination which showed blood oozing from the ampulla (Figure 1). Abdominal MRI showed markedly distended gallbladder with polypoid appearing wall thickness and blood (Figure 2). Patient received iron infusions to improve hemoglobin and hematocrit. She then underwent open cholecystectomy, and intraoperatively the surgeons did not appreciate any mass lesion in the gallbladder. Surgical pathology found invasive mucinous adenocarcinoma (1.0 cm) arising from a large (14.5 cm) ICPN with high-grade dysplasia (Figures 3a,b). The tumor invaded the muscularis propria and had negative cystic duct margins for carcinoma or dysplasia. Two lymph nodes were positive for malignancy. It was staged as III-b and pT1b, pN1, pMx. After discussion in the tumor board, she was recommended to have surveillance imaging in 3 months because her comorbidities precluded chemotherapy.

DISCUSSION:
To the best of our knowledge this is the only reported case of ICPN presenting as hemobilia. Residual changes of ICPN are seen in only 6.4% of the patients with invasive GB carcinomas. The presence of angioectasias in the small intestine acted as a red herring in this patient. The fortuitous timing of endoscopy to visualize bleeding from the ampulla clinched the diagnosis of hemobilia. The presence of blood in the gallbladder made it difficult to identify the mass lesion which was eventually confirmed on surgical pathology. Hemobilia should always in the differential diagnosis for patients presenting with upper GI bleed and should be actively investigated when no obvious bleeding lesions are noted from the gastric or intestinal mucosa.
2040 Where Can the Lesion Be? A Pelvic GIST With Both a Normal Upper and Lower Endoscopy
Authors: Arroyo-Mercado Fray Martin M. , Likhtshteyn Michelle , Alshal Mohamed , Reka Safak 
Published: October 2019

INTRODUCTION:
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumor of the GI tract; the age-adjusted incidence is 6.8 per million in the SEER data collected from 1992-2000 [1].

CASE DESCRIPTION/METHODS:
An 80-year-old female with history of CVA, hypertension, diabetes, hyperlipidemia, diverticulosis, and mild antral gastropathy with negative H.Pylori presented to the hospital with syncope and two episodes of dark stools mixed with bright red blood. Physical exam revealed normoactive bowel sounds and tenderness to palpation in the left lower quadrant without rebound tenderness. A rectal exam was positive for melena but negative for any palpable masses or hemorrhoids. Initial laboratory workup showed a hemoglobin of 4.8 and elevated BUN to 60 from a baseline of 40. Patient was fluid resuscitated and given packed red blood cells with appropriate response to transfusion; the patient remained hemodynamically stable and had no further episodes of hematochezia. On endoscopic investigation, both upper and lower endoscopy were unremarkable and did not reveal any lesions; colonoscopy showed old blood but no active bleeding. An Abdominopelvic CT scan was performed which showed a 9.5 × 9.8 cm soft tissue mass in the right abdomen inferior to the liver and a 12.5 × 12.4 cm conglomerate soft tissue mass in the right pelvis as well as a 1.3 cm left hepatic hypodensity concerning for liver metastasis (Figure 1). Core biopsy of the pelvic mass revealed spindle cells and positive KIT (CD 117) consistent with GIST (Figures 1 and 2).

DISCUSSION:
GISTs are commonly are found in the stomach and proximal small intestine, but they can be found in any part of the gastrointestinal tract. GISTs are composed of spindle (70%) or epithelioid (30%) cells, and 10%-30% are malignant showing intra-abdominal spread or liver metastases. Most GISTs will be positive for a KIT protooncogene mutations leading to uncontrolled activation of KIT (CD 117), a receptor tyrosine kinase (RTK) [2]. The likelihood of metastasis increases when the tumor reaches a size of 10 cm. Tumors located in the small intestines have more potential of metastasis than gastric tumors due to delay in onset of symptoms. While endoscopic investigation is a significant diagnostic method, some cases may yield unremarkable findings. Our case highlights the importance of obtaining further imaging studies when no source of gastrointestinal bleed or mass can be identified on initial endoscopy.
2042 A Therapeutic Misadventure With Helminth Therapy for IBD
Authors: Meluban Lee , Spinnell Mitchell K. 
Published: October 2019

INTRODUCTION:
Intestinal colonization by helminths has decreased in the developing world coinciding with an increased prevalence of inflammatory bowel disease (IBD) in these regions. This has raised the question of the protective role these parasites play in attenuating intestinal inflammation. Trichuris suis ova (TSO), porcine whipworm, has been evaluated as a possible therapy for IBD, but the most recent meta-analysis of efficacy and safety of this treatment showed no clinically significant benefit in inducing remission. We describe a case of a patient with Crohn’s disease whose symptoms were exacerbated by self-administered helminth therapy.

CASE DESCRIPTION/METHODS:
A 24-year-old male with a longstanding Crohn's disease presented with active colonic inflammation. Patient learned of a clinical trial involving ingestion of TSO, and failing to qualify, independently obtained T. trichiura, human whipworm, and hookworm products from an online vendor marketing themselves as a safe alternative to standard IBD therapy. Following a protocol under advisement from the vendor, the patient ingested whipworm ova and applied hookworm ova to his arm regularly for six months, in the meantime refusing standard IBD therapy. Failing to improve, the patient was eventually started on infliximab infusions and obtained clinical remission. Stool studies for Ova and Parasites negative prior to starting biologic therapy. Five years later while still on biologic therapy, the patient presented with worsening abdominal pain and diarrhea. Colonoscopy was performed and showed quiescent Crohn's colitis with live helminth seen in the cecum. Stool studies confirmed Trichuris trichiura worm and eggs. Patient was treated with mebendazole 100 mg and clinical remission was restored. Patient has been asymptomatic since parasite treatment and continues to be maintained on infliximab.

DISCUSSION:
This case illustrates the risk associated with the vast naturopathic products marketed for the treatment of IBD. Patients have an arsenal of products at their disposal, many sold based on loose or inconclusive data, not overseen by federally guided regulatory supervision. Through an internet search, we identified several vendors marketing helminths for the treatment of IBD and other illnesses. The availability of these products needs to be recognized when treating patients with IBD, and the presence of parasites needs to be tested when diagnosing and treating such patients, even those from regions of the world where these infections are uncommon.
2045 Linear IgA Bullous Dermatosis Is an Unusual Skin Extra-Intestinal Manifestation in IBD
Authors: Williams Kathy N. , Nocerino Angelica , Rivas Shelly , Ivanina Elena , Swaminath Arun 
Published: October 2019

INTRODUCTION:
Linear IgA bullous dermatosis (LABD) is a rare extraintestinal manifestation of inflammatory bowel disease (IBD). This autoimmune subepidermal disease presents with bullae, erosions and vesicles. LABD is characterized by the immunopathologic finding of linear IgA deposits in the basement membrane along the dermo epidermal junction. There is an uncommon association of LABD with IBD and PSC.

CASE DESCRIPTION/METHODS:
A 36-year-old male, with a history of Ulcerative Colitis (UC) presented for initial evaluation. For 6 years, the patient has been treated for UC with combinations of steroids and mesalamines. He always discontinued therapy due to what he perceived were adverse drug reactions: pruritic blisters affecting his chest, abdomen, back, and arms. He describes multiple bloody bowel movements, pain with defecation, and a 12-pound weight loss over 2 months. His most recent colonoscopy revealed pancolitis. He has never been in clinical remission. He was referred to a dermatologist for evaluation of his skin lesions, to determine if the dermatitis reaction was a true adverse drug reaction. Hyperpigmentation on his chest and back were noted and appeared to be due to a resolved bullous dermatosis (Figure 1). Skin biopsies identified Linear IgA bullous dermatosis. Dapsone 100 mg daily resulted in resolution of the rash. He was subsequently treated for UC with infliximab and achieved a deep remission. Persistently elevated alkaline phosphatase was investigated with MRI. This revealed intrahepatic duct dilation, and liver biopsy confirmed comorbid PSC.

DISCUSSION:
LABD is defined by three criteria: vesicles/bullae, subepidermal vesicles with a neutrophil predominance and the linear pattern of IgA basement membrane deposits. This case identifies a rare extra-intestinal skin manifestation of IBD. The exact pathophysiology of the association between these distinct, yet inter-related diseases, has yet to be elucidated.
2047 Insidious Onset of Crohn's Disease During Pregnancy
Authors: Prabakaran Sabrina , Patel Krishen 
Published: October 2019

INTRODUCTION:
Inflammatory bowel disease (IBD) affects 1.3 million people in the United States. The typical age of onset is at 15-30 years, thus affecting women during their childbearing years. Symptoms can often be mistaken for other conditions, especially in pregnant individuals. This case shows an interesting presentation of IBD occurring immediately after childbirth.

CASE DESCRIPTION/METHODS:
A 21-year-old female with no significant past medical history presented to the ER with GI discomfort and diarrhea. Her symptoms began 1 month prior, immediately after an uneventful vaginal delivery of her first child. She developed abdominal pain and cramping, which she was initially told was normal after her delivery. However this persisted and she also developed diarrhea with 5-7 loose bowel movements per day, hematochezia, as well as inability to tolerate PO intake. She had presented to an outside hospital 5 times for further evaluation, and was diagnosed with endometritis, a UTI, and most recently infectious colitis for which she was on ciprofloxacin and flagyl with no improvement. On presentation to our hospital, she was tachycardic with abdominal distension and tenderness on exam. Labwork was notable for hemoglobin of 7.7 with MCV 80.3, ESR 79, and CRP 2.34. CT abdomen/pelvis was performed with concerning findings of mucosal hyperenhancement and bowel wall thickening throughout the colon. Infectious colitis work up was negative and the patient proceeded to undergo a colonoscopy, which revealed severe colitis with apthous ulcers within the ileum and throughout the colon, with sparing of the rectum. Biopsies confirmed a diagnosis of severe rectal sparing ileocolonic Crohn’s disease (CD). She was immediately started on steroids with the plan to transition to a biologic medication as an outpatient.

DISCUSSION:
Inflammatory bowel disease first manifesting in pregnancy is a unique presentation that is not well described or discussed in the literature. It has been estimated that approximately 4.1% of women diagnosed with CD are diagnosed while pregnant. This case is especially interesting as the patient’s symptoms were initially attributed to her recent pregnancy and delivery, despite her relatively classic IBD symptoms. Thus, CD and IBD should be considered in the differential diagnosis of abdominal pain in a pregnant patient, especially as early diagnosis and treatment may affect maternal and neonatal outcomes.
2050 NUDT 15 C415T Variant as a Cause of Azathioprine-Induced Pancytopenia With Severe Sepsis
Authors: Debnath Prasanta , Jain Shubham , Nair Sujit , Udgirkar Suhas , Rathi Pravin 
Published: October 2019

INTRODUCTION:
Thiopurines (i.e. azathioprine [AZA] and mercaptopurine exert a glucocorticoid-sparing effect for patients with inflammatory bowel disease (IBD) who cannot maintain remission when glucocorticoids are tapered and withdrawn. However, side-effects like leucopenia, pancytopenia limit its use in several conditions where immune suppression is required.

CASE DESCRIPTION/METHODS:
17-year-old female presented with abdominal pain for 10 months with acute deterioration for 1 month with intermittent episodes of low-grade fever, loose stools on and off non-bloody, with nausea and multiple episodes of vomiting for last 5 days. She was diagnosed to have Crohn’s disease and was started on Azathioprine 50 mg OD which was increased to 100 mg within next 7 days, along with with with Prednisolone 30 mg and Mesalamine 1500 mg for last 3 weeks. Her baseline investigations showed normocytic normochromic anemia (Hb 9 g/dl) with thrombocytosis. When she presented to us she had pancytopenia Hb-6.6, TLC 900/µL (DLC- N20% L77% M3%), Platelet count of 1,64,000/µL, ESR 31, CRP 140 with normal liver chemistries, Normal Vitamin B12 & Folate level. Patient also started developing alopecia. Azathioprine and steroids were stopped. Initial blood and urine cultures were sterile. She was started on broad-spectrum antibiotics along with G-CSF. Despite antibiotics, patient went on having high fever with falling leucocytes (TLC 300) with Absolute Neutrophil Count of 120/µL. Bone marrow biopsy revealed hypoplastic marrow. Repeat blood culture grew ESBL Escherichia coli sensitive to Tigecycline. After change in antibiotics, there was resolution in her symptoms. Genetic analysis for TPMT mutation and NUDT 15 was considered, which revealed wild type TPMT genotype and homozygous NUDT 15 C415T variant. In the meantime, the patient developed symptoms of intestinal obstruction. CT enterography revealed stricturing Crohn’s disease and was posted for surgery.

DISCUSSION:
In this report, we present a case of Azathioprine toxicity with pancytopenia with severe sepsis in a young patient with homozygous NUDT 15 variant and wild type TPMT genotype. This case, along with recent researches, enlightens us to consider NUDT 15 variant analysis before starting thiopurines in any patient, particularly in Asian population.
2057 Refractory Fulminant Ulcerative Colitis With Concurrent Clostridioides difficile Colitis Challenging Modern Guideline-Directed Medical Therapy to Failure
Authors: Ghanim Marcel , Javaid Toseef , Ghazaleh Sami , Nehme Christian , Nawras Ali 
Published: October 2019

INTRODUCTION:
Guidelines on treatment of ulcerative colitis (UC) follow a stepwise approach of escalating medical therapy. Similarly, treatment guidelines for Clostridioides difficile infection (CDI) are well-established based on severity. The combination of fulminant UC & CDI especially patients with treatment naïve pancolitis is challenging with concerns for safety & efficacy of various therapies in concurrent conditions.

CASE DESCRIPTION/METHODS:
A 21-year-old male presented with 3 weeks of diarrhea, hematochezia & abdominal pain. Stool cultures & CD were negative & antibiotics were started. Subsequent colonoscopy showed pancolitis & UC on biopsy. IV steroids & probiotics were initiated with modest improvement & he was discharged. However, he was readmitted with worsening symptoms, started on IV steroids. Repeated colonoscopy with biopsies confirmed moderate active chronic colitis with focal ulceration & no granulomas or dysplasia. CD testing was positive. Hence, PO vancomycin was started. He had IBD-related arthritis & was started on sulfasalazine then methotrexate (MTX). Response to IV steroids (10 days) & PO vancomycin (14 days) was limited, therefore with infliximab was started. Vancomycin was switched to fidaxomicin with IVIG (3 doses). Colonoscopy was repeated revealing ongoing severe pancolitis with pseudomembrane, Mayo grade 3. Fecal microbiota transplant (FMT) was done. Biopsies were negative for CMV. Follow up CD testing was negative, yet, he progressed to fulminant UC within 6 weeks of initial diagnosis despite 4 doses of infliximab & steroids. He remained hemodynamically stable with supportive care. He was reluctant to have colectomy & hence tofacitinib was started. Despite IV steroids, infliximab, & tofacitinib; sulfasalazine & MTX; parallel PO vancomycin, fidaxomicin, IVIG & FMT, along with lactobacillus acidophilus, bloody diarrhea continued; patient was dependent on fluid support & blood transfusions. Finally, total colectomy was done as a last resort.

DISCUSSION:
Guidelines are lacking on treatment of concurrent refractory fulminant UC with CDI especially in patients who do not want colectomy. Potential success of biologic therapy & risk of progression to fulminant CDI in this setting is unknown. Safety & efficacy of the various treatments including immunosuppressants & FMT in cases of concurrent UC & CDI is a grey zone. Further case-reports & studies are needed to establish the optimal stepwise approach & guide therapeutic choice & decision making.