bluuebunny/crossref_metadata_2025_split huggingface dataset:
1819 The Black Esophagus in the Renal Transplant Patient
Authors: Yu Michael , Mulki Ramzi , Massaad Julia 
Published: October 2019

INTRODUCTION:
Acute esophageal necrosis (AEN) is an uncommon disease characterized by gastrointestinal bleeding and endoscopic findings of circumferential black-colored necrosis of the distal esophagus. Patients at risk include elderly males over the age of 65, who typically have multiple chronic medical issues including vascular disease and diabetes. Mortality is reported to be 32%. Here, we present a case of AEN in a renal transplant patient and describe potential inciting factors such as immunosuppression and opportunistic diseases.

CASE DESCRIPTION/METHODS:
A 35-year-old male with ESRD from hypertensive nephrosclerosis s/p kidney transplant presented with worsening chronic right foot pain. He was found to have right lower extremity limb ischemia was started on heparin. On hospital day 3, he underwent successful revascularization of his R lower extremity. Post-procedural WBC and Hb were 20,000/mL and 12.5 g/dL, respectively. On postoperative day (POD) 3, WBC worsened to 25,400/mL and Hb decreased to 9.6 g/dL. On POD4, he had 3 episodes of melena and his HB dropped to 7.3 g/dL. EGD showed LA Grade D esophagitis in the mid and distal esophagus with necrotic appearing mucosa in the distal esophagus. A CT chest/abdomen with oral contrast performed after the EGD showed circumferential thickening of the distal esophagus. Patient was treated with sucralfate and pantoprazole. He was bridged to warfarin and discharged. On follow up, his Hb improved to 10.9 g/dL.

DISCUSSION:
Our patient was admitted for limb ischemia likely aggravated by peripheral vascular disease of renal disease. He underwent revascularization of his right lower limb which added a component of hemodynamic compromise. As a renal transplant patient, he has multiple comorbidities placing at risk for developing AEN. First, kidney disease gives a higher chance of developing vascular disease. Next, as a transplant patient, he was receiving various immunosuppressing agents like corticosteroids and MMF which also reduce the protective function of the gastrointestinal mucosa. Other risk factors include opportunistic infections and transplant rejection. Caution is needed when caring for renal transplant patients, and following major procedures with significant hemodynamic insult, an EGD should be considered.
1821 Post-Fundoplication Esophageal Bezoar Resolved With Endoscopic Instillation and Oral Ingestion of Cola
Authors: Padhya Kunjali , Dhamija Ankit , Carlson Christopher , Farivar Alexander 
Published: October 2019

INTRODUCTION:
We present a difficult bezoar-like esophageal food impaction which occurred 6 months after repair of a giant Type IV hiatal hernia.

CASE DESCRIPTION/METHODS:
The patient is an active 90-year-old female who had a giant Type IV paraoesophageal hernia containing stomach and colon for many years. She underwent repair with mesh and a loose Nissen fundoplication (58 Fr). Pre-operative esophageal manometry was not performed. Post-operative esophagram showed intact wrap, with “3 mm minimum diameter central luminal channel through the fundoplication.” Preserved esophageal motility was also noted. Recovery was uneventful. Six months later, she presented to the ED complaining of sensation of food stuck in her throat. She was tolerating secretions and tiny sips of water. Barium esophagram revealed “dilated distal esophagus, with contrast pooling above retained material at the GE junction”. EGD was performed under general anesthesia. The distal esophagus was completely obstructed with food. Despite use of multiple tools including net, rat-tooth forceps and pronged graspers, it could not be cleared. Using small instillations of cola through a 60 cc syringe, we were able to “tunnel” through the impaction and create a lumen into the stomach. Retroflexion showed a small hiatal hernia. After more than 2 hours, there was still a significant amount of food adherent to the walls of the esophagus. The patient was extubated and admitted to the hospital. She was instructed to drink small sips of cola and ice chips upright in bed. She ingested 2 L of cola over the next 8 hours without difficulty. EGD the next day noted complete passage of food. There was no frank ring or stricture. Fundoplication was intact with a small(2 cm) hiatal hernia. She was discharged the same day on soft diet. At follow up with thoracic surgery she had no further dysphagia episodes. She was instructed to drink cola once a day for maintenance.

DISCUSSION:
Although the patient had a loose wrap and no known dysmotility, post-op diameter of the esophageal lumen was fairly small (3 mm). If patient was not adhering to post-fundoplication diet, this likely precipitated “packing” of food into the distal esophagus and remnant small hernia. Removal of esophageal food impaction is most commonly done by pushing food into the stomach, or removing it mechanically. The use of proteolytic enzymes e.g. papain is not recommended due to perforation risk. One can consider adding cola to the arsenal of tools for safely treating difficult esophageal food impactions.
1832 Adenocarcinoma Arising From a Cervical Esophageal Inlet Patch: The Malignant Potential of a Small Lesion
Authors: Dziadkowiec Karolina N. , Szu Eric , Delaflor-Weiss Eduardo , Proenza Jose 
Published: October 2019

INTRODUCTION:
Inlet patches (IP) are heterotopic lesions consisting of gastric mucosa. Commonly located in the cervical esophagus, it is believed that they are remnants of fetal columnar epithelium. A rare complication of IP is the development of esophageal adenocarcinoma. We report a case of a 59-year-old male with intractable cough and dysphagia that was found to have a malignant transformation of an IP.

CASE DESCRIPTION/METHODS:
A 59-year-old white male, with heart failure, obesity, and smoking history, presented with 5 months of cough, bilateral neck pain, globus sensation, and progressive dysphagia. Barium swallow noted an irregularity at the distal cervical esophagus and esophagogastroduodenoscopy (EGD) revealed a stricture extending 17 to 20 cm from the incisors. Pathological analysis from random biopsies returned negative for dysplasia or malignancy. Routine laboratory analysis was unremarkable. The patient returned two years later, complaining of progressive dysphagia. Repeat EGD was performed and immunohistochemical staining on repeat biopsy revealed adenocarcinoma that was: CK7+, CK20-, and variable for CDX2. Pathology revealed adenocarcinoma of the cervical esophagus, invading at least the lamina propria, arising from ectopic gastric mucosa (a cervical IP). The patient was deemed a poor surgical candidate and was treated with palliative carboplatin and paclitaxel with adjuvant radiation therapy.

DISCUSSION:
Most IPs are asymptomatic and are discovered incidentally during EGD, but rarely they may present with reflux, esophagitis, stricture or ulcer formation and produce symptoms of throat pain, dysphagia and globus esophagus. Their prevalence varies from less than 1% to 14%. The incidence of adenocarcinoma arising from a cervical IP is reported to be 1.5% or less. Our patient developed proximal esophageal adenocarcinoma from a cervical IP. EGD images showed no continuity of non-malignant mucosa with the stomach. In addition, the absence of goblet cells indicates a high likelihood that this malignancy originated from the cervical IP. Currently, there are no guidelines to guide the management of incidentally discovered IPs. Some studies recommend routine endoscopic surveillance, although prospective data have failed to demonstrate long-term benefits. With mounting evidence, it is clear that IPs carry significant clinical importance due to their malignant potential. This case demonstrates the need for increased awareness in identifying and managing these lesions discovered during routine endoscopy.
1833 Utilization of EndoFLIP to Diagnose Achalasia in a Patient With Chronic Dysphagia Previously Attributed to Dysphagia Lusoria
Authors: Hundt Melanie A. , Sharma Prabin , Pourmorady Jonathan , Masoud Amir 
Published: October 2019

INTRODUCTION:
Dysphagia lusoria is a rare cause of dysphagia resulting from compression of the esophagus due to an aberrant right subclavian artery. Less than 2% of the population have this anatomic variant and the majority are asymptomatic. An aberrant right subclavian artery may not be clinically significant in a patient with concurrent esophageal pathology.

CASE DESCRIPTION/METHODS:
An 87-year-old woman with a twenty year history of chronic dysphagia complicated by recurrent food impactions presented with poor oral intake and weakness. Previously attributed to paraesophageal hernia, the dysphagia persisted despite partial fundoplication surgery. Prior CTA abdomen was suggestive of dysphagia lusoria, identifying an aberrant origin of the right subclavian artery traversing behind a dilated esophagus with associated mass effect. Achalasia was previously suspected but never confirmed as the patient could not tolerate the manometry procedure. EGD with EndoFLIP revealed a distensibility index of 0.6, a diameter of 5 mm, and a balloon pressure of 29 mm Hg with no appreciable peristalsis, consistent with type I achalasia. EUS revealed an aberrant right subclavian artery without extrinsic esophageal compression. EGD with pneumatic dilatation was performed after which the distensibility index was 6 with a diameter of 12.5 mm. The patient was placed on clear liquids and successfully transitioned to a pureed diet with significant symptomatic improvement. Outpatient follow up is pending.

DISCUSSION:
The EndoFLIP and EUS results confirmed the diagnosis of achalasia while simultaneously showing that the aberrant right subclavian artery represented an incidental finding rather than the true etiology of dysphagia. Moreover, it was the esophageal dilatation caused by achalasia that likely led to the discovery of the previously undetected aberrant subclavian vessel. Given the rarity of clinically significant dysphagia lusoria, it is important to consider alternative diagnoses in the evaluation of dysphagia. Molz G, Burri B. Aberrant subclavian artery (arteria lusoria): Sex differences in the prevalence of various forms of the malformations. Evaluation of 1378 observations. Virch Arch A Pathol Anat Histol 1978;380:303–15.
1844 A Case of Idiopathic Esophageal Ulceration as Initial Presentation of Acquired Immune Deficiency Syndrome
Authors: Din Hassieb , Fasanella Kenneth 
Published: October 2019

INTRODUCTION:
Esophageal ulceration (EU) is most frequently caused by gastroesophageal reflux disease. However, immunocompromised individuals are particularly susceptible to EU caused by infections including herpes simplex virus (HSV), cytomegalovirus (CMV), and candida species. Furthermore, patients with acquired immunodeficiency syndrome (AIDS) can also develop idiopathic EU even in the absence of infection.

CASE DESCRIPTION/METHODS:
A 30-year-old male with no significant past medical history presented with 6 months of profound weight loss, odynophagia, dysphagia, and chest pain. He had no history of NSAID use. Symptoms had persisted despite trials of proton pump inhibitors, H2 antagonists, and sucralfate. His physical exam was notable for cachexia and bi-temporal wasting. Esophagogastroduodenoscopy revealed two large hemi-circumferential cratered distal esophageal ulcers separated by a mucosal bridge. Endoscopic ultrasound demonstrated an isoechoic mass in the lower third of the esophagus measuring 1.2 cm in thickness, obliterating the wall layer architecture, along with three enlarged gastro-hepatic lymph nodes. Pathology demonstrated granulation tissue with fibro-inflammatory debris and was negative for malignancy, HSV, and CMV. Fine needle aspiration of one of the enlarged lymph nodes was also negative for malignancy. A contrasted computed tomography scan of the chest, abdomen, and pelvis did not reveal any additional findings. Laboratory evaluation was most notable for worsening leukopenia (WBC count: 3000 cells/μL) and anemia (Hgb: 9.9 g/dL). Further history revealed unprotected sexual encounters with multiple females in the last 10 years. Subsequent workup demonstrated a positive human immunodeficiency virus (HIV) antibody screen with a CD4 count of 44 cells/µL. Patient was ultimately diagnosed with idiopathic EU from AIDS and was initiated on highly active antiretroviral therapy.

DISCUSSION:
While EU is a common complication in patients with AIDS, it is normally associated with infections such as CMV and HSV. Idiopathic EU in these patients are rarer and typically found in those with CD4 cell counts less than 100 cells/µL. Our case was unique in that the patient's development of large EU was his initial presentation of AIDS. In these cases, establishing the correct diagnosis and ruling out malignancy is important as misdiagnosis can significantly alter treatment plan and prognosis. This case further highlights the necessity for HIV testing in patients who present with idiopathic EU.
1850 Intestinal Tuberculosis in an Immunocompetent Patient
Authors: Vaze Reema , Buckshaw Ricky , Malik Anam , Kloska Michal , Aleem Abdul , Stelzer Frederic 
Published: October 2019

INTRODUCTION:
Intestinal tuberculosis (TB) is a rare disease in western countries usually only affecting immigrants from endemic areas and those that are immunocompromised. Diagnosis is challenging especially when pulmonary symptoms are absent as it can mimic other abdominal pathologies, notably Crohn’s disease. It is especially important to distinguish between Crohn’s and TB since treatments greatly differ. Intestinal TB favors the small bowel, particular the small ileum due to its affinity for Peyer’s patches. Biopsies positive for acid-fast bacilli confirms the diagnosis. Our case describes an immunocompetent patient diagnosed with intestinal TB that was initially thought to be Crohn’s disease.

CASE DESCRIPTION/METHODS:
A 79-year-old male with a history of TIA, seizure disorder and achalasia presented to the hospital with acute encephalopathy and sepsis. Chest x-ray revealed bilateral infiltrates and the patient was treated for pneumonia. Incidental finding on CT chest, abdomen and pelvis revealed terminal ileitis and an ileocecal valve mass. The patient underwent colonoscopy which showed a terminal ileum and ileal cecal valve lesion with sigmoid stricture and severe left sided diverticulitis. Biopsies were taken that were significant for non-necrotizing granulomas concerning for infectious etiology or Crohn’s disease. The patient was referred to Colorectal Surgery and underwent laparoscopic right hemicolectomy. Surgical pathology revealed extensive granulomas positive for acid-fast bacilli (AFB) secondary to Mycobacterium tuberculosis (TB). Prior to these findings, the patient denied prior TB exposure, travel to TB endemic countries, previous incarceration, pulmonary symptoms, fevers, weight loss, diarrhea, constipation, melena, hematochezia, alcohol or illicit drug use. The patient underwent bronchoscopy with cultures positive for AFB. The patient then began treatment for active TB with a four-drug regimen.

DISCUSSION:
Though rare, intestinal tuberculosis should be kept on the differential when evaluating chronic intestinal diseases. Proper knowledge and anticipation of intestinal manifestations of systemic disease should be mandatory due to the vast differences in treatment. Though diagnosis is difficult in the absence of active symptoms, intestinal tuberculosis should be considered especially in metropolitan areas. Endoscopic evaluation is the mainstay of diagnosis and should be promptly considered to differentiate it from other abdominal pathologies.
1851 The Ever-Mysterious Cyclical Vomiting Syndrome (CVS) and Abdominal Migraine: Recognition and Successful Management Strategies Illustrated by a Case Report
Authors: Yuridullah Ruhin , Yudi Camacho , Botros Youssef , Kapoor Ashima , Melki Gabriel , Baddoura Walid 
Published: October 2019

INTRODUCTION:
Cyclical vomiting syndrome (CVS) is a medically and socially disabling, idiopathic disorder characterized by recurrent, stereotypical bouts of vomiting with periods of normal health, occurring in children, adolescents, and recognized in adults. CVS is associated with substantial morbidity. Lack of awareness and recognition leads to tremendous anxiety, cost burden, and delay in diagnosis. Recently updated, Rome IV classification has attempted to highlight the issue to promote early recognition and diagnosis. We present a case of CVS and abdominal migraine in a 27-year-old female whose illness went unrecognized for 8 years and discuss successful management strategies.

CASE DESCRIPTION/METHODS:
A 27-year-old female with an 8-year history of recurrent episodic abdominal pains, nausea, vomiting, incidental superior mesenteric artery syndrome, status post laparoscopic duodenojejunostomy at 24, after which she had an apparent 6-month relief of symptoms, and history of anxiety and depression was seen for persistent diffuse abdominal pain, nausea, and 7-8 daily episodes of emesis for 3 weeks. Family history was significant for migraines in her mother. Since her initial symptoms at the age of 19, she experienced episodes of incapacitating nausea, vomiting, and abdominal pain lasting 3-4 weeks followed by symptom-free periods of 2-3 months. She had visited many hospitals, primary care physicians, psychiatrists, and gastroenterologists, and undergone repeated work-ups from basic to complex. Treatment with SSIRs, anti-emetics, valproic acid and even marijuana showed no or minimal benefit. Following thorough history and obtainment of records from other institutions, she was diagnosis and started on a combination of amitriptyline, propranolol, and Co-enzyme Q/L-Carnitine. She has been followed by monthly phone calls for about 1-year, remains symptom-free, and compliant with the regimen.

DISCUSSION:
Cyclic vomiting syndrome (CVS) is characterized by recurrent bouts of nausea and vomiting with periods of normal health. The pathogenesis is multifactorial, with multiple genetic, autonomic, and environmental factors. Often a great delay in diagnosis, on average 2.6 years in children and 8 years in adults leads to unnecessary testing and cumbersome procedures. In the case of our patient, her illness was unrecognized for many years and her symptoms often dismissed, pushing her into anxiety and depression. A multidisciplinary approach as well as prophylactic and abortive pharmacotherapy is needed to address the issue.
1861 Duodenal Gangliocytic Paraganglioma in Patient With Rectal Adenocarcinoma
Authors: Villavicencio Jaimy , Disiena Michael , Elkhattib Ismail , Birk John 
Published: October 2019

INTRODUCTION:
Gangliocytic paragangliomas are a rare subclass of neuroendocrine tumors that usually appear in the periampullary region of duodenum. They are generally benign, although may have potential for metastases depending on size and extension. They most commonly present with bleeding or abdominal pain, but cases with obstructive jaundice and pancreatitis have also been reported. They are often misdiagnosed as GISTs or other neoplasms, but with histologic examination, an accurate diagnosis can be reached. However, intraoperative diagnosis with FNA and frozen section analysis are often inaccurate and could affect surgical decision.

CASE DESCRIPTION/METHODS:
62-year-old male with past medical history of diverticulitis, internal hemorrhoids, and iron deficiency anemia presented with syncope and gastrointestinal bleeding. During evaluation with colonoscopy, a mass was found in the rectum, which was later confirmed to be an adenocarcinoma. An FDG-avid duodenal segment was incidentally found while undergoing workup with PET-scan. He had neoadjuvant chemoradiation, with resection of rectal cancer and temporal ileostomy. Biopsy of duodenum with endoscopic ultrasound revealed normal duodenal mucosa on 2 separate occasions. Ultimately, the duodenal tumor was excised via exploratory laparotomy. Intraoperative frozen biopsy of mass revealed a GIST and a Whipple procedure was performed due to proximity to ampulla. Final pathology report revealed a gangliocytic paraganglioma, after staining positive with synaptophysin (as well as S-100 and neuron specific enolase) and negative for antibody to CD117, which is a sensitive marker for GISTs.

DISCUSSION:
Duodenal gangliocytic paragangliomas remain to be rare entities. There is yet no clear consensus in regards to appropriate workup, treatment or follow-up, especially in patients with metastases or concurrent adenocarcinoma. It is uncertain if coexistence with a rectal adenocarcinoma (as seen in this case) was coincidental or due to similar pathogenesis. Diagnosis with FNA and frozen section biopsies can be useful, but are often inaccurate. The success largely relies on the operator and clinical suspicion, but it is especially hard when there are no symptoms or relevant history. The recommended management is margin-free resection endoscopically, with local surgical excision or Whipple procedure. Studies have shown that some molecular markers can predict malignant potential. Yet, whether they are useful for management or surveillance has not been determined.
1862 Novel Endoscopic Repair of a Percutaneous Endoscopic Gastrostomy Tube Malpositioned Through the Transverse Colon
Authors: Campbell John P. , Klein Daniel , Gupta Vipin 
Published: October 2019

INTRODUCTION:
Malpositioning of a PEG tube on placement has been well documented in the medical literature. This case outlines a novel approach to repairing a malpositioned PEG tube in a patient that was not a surgical candidate.

CASE DESCRIPTION/METHODS:
This is a 60-year-old male with a past medical history of gastroparesis, end-stage renal disease, and diabetes mellitus who was admitted for influenza and severe acidosis. Soon after admission he underwent cardiac arrest and had return of spontaneous circulation after 20 minutes of resuscitation. Following a prolonged hospital course, tracheostomy and PEG tube placement with Soldinger technique were performed. Over the subsequent days, he experienced melenic stools and declining hematocrit. Colonoscopy showed a foreign body suspicious for a feeding tube crossing the transverse colon. He was found to not be a surgical candidate due to his comorbidities, and a contrast enema showed no extravasation of contrast. Repeat endoscopy was therefore performed to attempt correction. Our novel approach began with colonoscopy. Once the foreign body was visualized, the tubing was cut from the outside and pulled by forceps into the lumen of the transverse colon. Hemostatic clips were applied to the colonic mucosa to close the first perforation. The team then transitioned to gastroscopy. The PEG tube hub was visualized in the stomach and removed. Additional clips were used to close this gastric perforation. The team then turned attention to the second colonic perforation. Once located, clips were used to close this final perforation. Subsequent plain films did not show free air, and abdominal exam remained generally benign. Upper GI series was without evidence of extra-luminal contrast material. CT showed no abscess or fluid collection. He was soon able to be fed through a nasoduodenal tube. Later, he was weaned from the ventilator and able to resume a solid diet without complication.

DISCUSSION:
This case was unique in its endoscopic approach to repairing a malpositioned PEG tube in a patient that could not be taken to surgery. Without this novel endoscopic approach, this patient would have likely experienced significantly increased morbidity. Although these methods have not been extensively documented in the literature, this approach may be warranted in some patients who could not proceed to traditional surgery. We hope to start discussion about future research into the area of endoscopic repair of a malpositioned PEG tube.