bluuebunny/crossref_metadata_2025_split huggingface dataset:
2634 Small Bowel Lymphoma Presenting With Perforation: A Case Report
Authors: Karim Syed S. , Singh Davinder , Bhatt Ruchi , Prasa Jarin , Rizvon Kaleem , Mustacchia Paul , Esackimuthu Venkatesh S. 
Published: October 2019

INTRODUCTION:
Lymphoma account for only 1 to 4 % of neoplasms in the gastrointestinal tract (GIT), with the stomach being the most common location (68 to 75%) and the small bowel as the second most common (30 %). Among the possible presentations of GIT lymphomas, small bowel perforation is one of the most lethal and rare. Here we present a case of a patient that had a perforated jejunum secondary to lymphoma.

CASE DESCRIPTION/METHODS:
57 year old female with history of diabetes, presented with 2 days of severe abdominal pain and vomiting. Physical exam revealed peritoneal signs and absent bowel sounds. CT showed multifocal small bowel thickening, pneumoperitoneum and extraluminal contrast indicating perforation. The patient was rushed to have explorative laparotomy which revealed multiple masses along the small bowel and had resection of a perforated jejunum. Pathology revealed lymphoma. Immunohistochemical staining was positive for CD20 and CD5, and was negative for Bcl-6 and CD10. FISH analysis was negative for translocation t(11,14), t(14,18), and MYC. The patient’s wounds healed and she was eventually treated with cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP) along with rituximab for 6 cycles and Intrathecal (IT) chemotherapy.

DISCUSSION:
The WHO classify small bowel lymphomas (SBL) into B-cell subtypes (90 % of cases), T-Cell subtypes and Hodgkins Lymphoma.The most common symptoms are abdominal pain (70% of cases), ileus, and weight loss. Perforation was only found in approximately 16% of cases. CT may show polypoid lesions, multiple masses, and small bowel thickening. Usually, SBL is surgically resected for both diagnosis and treatment. Historically, endoscopy has been difficult because of the location. However, with the advent of capsule endoscopy and double balloon techniques, endoscopy can potentially avoid invasive surgeries. Our patient had an acute abdomen and therefore underwent surgical evaluation. Presence of CD20 and CD5, indicated a CD5 positive B-Cell lymphoma. FISH did not show any genetic rearrangements for Cyclin D- t(11,14), a marker for Mantle cell lymphoma, nor Myc and Bcl, markers for Burkitt’s and Follicular cell lymphomas, leading to the diagnosis of DLBCL. Localized tumors undergo surgical resection followed by radiation. TNM stage IIIE or higher is treated with combination chemotherapy, CHOP and rituximab, as was our patient. SBL is a rare entity; this case provides some insight and we hope such knowledge can only improve the management of patients to come.
2642 Diffuse Large B-Cell Lymphoma Presenting as Partial Small Bowel Obstruction and a Fistula
Authors: Gajjar Bhavesh A. , Gabriel Joseph , Minhas Ahmed , Schmidt Lawrence 
Published: October 2019

INTRODUCTION:
Non-Hodgkin lymphoma (NHL) is one of the most common cancers in the United States, accounting for 4% of all cancers. Diffuse Large B-Cell Lymphoma (DLBCL) the most common type of NHL. Gastrointestinal (GI) tract is a significant site of extranodal NHL and accounts for 30%–40% of all extranodal NHL. Out of this, 44 % are due to DLBCL. Ileocecal DLBCL accounts for 9.7% to 15% of total GI DLBCL. They lack specific symptoms and diagnosed when complications occur. We report a case of elderly male hospitalized for partial small bowel obstruction and a possible fistula due to DLBCL involving the ileocecal valve extending to the ileum.

CASE DESCRIPTION/METHODS:
A 75-year-old male presented with complaints of abdominal pain, nausea, and nonbilious vomiting for a day. He denied any fever, chills, sick contact, night sweat, or weight loss. On physical exam, he had moderate lower abdomen tenderness without palpable masses. CT scan of the abdomen and pelvis showed partial small bowel obstruction with a transition point at an ileocecal junction with amorphous soft tissue at the level of the terminal ileum and possible stricture or neoplastic involvement (Figure 1). Three days later, he had a colonoscopy which showed a large mass behind the ileocecal valve with a fistula (Figures 2 and 3). We were unable to intubate the ileocecal valve. Multiple biopsied taken from the mass that confirmed the diagnosis of DLBCL. PET scan showed cecal mass without any distal involvement. As recommended by surgery and oncology consultations, he had right hemicolectomy.

DISCUSSION:
Ileocecal region is a rare place for DLBCL occurrence. Majority of the cases are diagnosed incidentally or when complication like obstruction, perforation, or bleeding occurs like our patient who had bowel obstruction on presentation. We also found a fistula in cecum during colonoscopy. Clinically we suspect fistula as the patient was able to tolerate diet and complete bowel preparation easily in spite of having complete closure of ileocecal valve on colonoscopy. Due to the lack of oral contrast, it was not identified on the initial CT scan. Endoscopic features of DLBCL are nondiagnostic. The only way to confirm a diagnosis is, immunohistopathology staining specific for DLBCL. Majority of ileocecal DLBCL are at stage I or II diseases at the time of diagnosis. Surgical resection followed by chemotherapy had shown prolongation of survival. In conclusion, ileocecal DLBCL should be considered as a differential diagnosis for bowel obstruction or fistula.
2650 Severe Celiac Disease Presenting With Intussusception Without Lead-Point in an Adult Male
Authors: Paz Sandra Gomez , Jiyani Rucha , Jacob Bobby , Rizvon Kaleem , Mustacchia Paul 
Published: October 2019

INTRODUCTION:
Adult celiac disease is an autoimmune disorder that usually presents with abdominal pain and diarrhea. We present the case of an adult man who presents with chronic diarrhea and intussusception, who was diagnosed with severe celiac disease.

CASE DESCRIPTION/METHODS:
38 year old male with history of depression, presents with three months of abdominal pain and intermittent watery diarrhea, associated with thirty-pound weight loss, fatigue, nausea, diffuse joint stiffness and mild swelling, and tingling and numbness that started two weeks prior. Physical exam was remarkable for thin body habitus, hyperactive bowel sounds and diffuse abdominal tenderness with guarding. Laboratory testing was significant for microcytic anemia and INR 2.7, work up for infectious causes of diarrhea was negative. Liver and renal function tests were normal. CT of the abdomen showed fluid filled colon as well as entero-enteric intussusception of approximately 10 cm in left mid abdomen. Further investigation included tissue transglutaminase (TTG) antibodies of more than 100 U/mL and IgA 227. Colonoscopy with random biopsies was performed, pathology revealed partial villous atrophy negative for increased intraepithelial lymphocytes, suggestive of celiac disease. Patient was diagnosed with severe celiac disease, associated with multiple vitamin deficiencies secondary to malabsorption and peripheral neuropathy. Patient was managed conservatively and eventually discharged with follow up of Gastroenterology and Rheumatology practices.

DISCUSSION:
Intussusception is well described in patients with previously diagnosed celiac disease, in which small intestinal lymphoma or adenocarcinoma may represent the “lead point” causing the intussusception. Much rarely seen is intussusception as the presenting symptom of previously undiagnosed celiac disease, particularly in the absence of a lead point. Theories of its development include presence of flaccid, dilated small bowel, fold abnormalities, lymphadenopathies and fluid excess. Intussusception in celiac disease is often multiple, transient and repetitive, so surgical intervention should be avoided. In our case, the presence of intussusception without a lead point was suggestive of celiac disease, confirmed by serologic and histologic testing. Intussusception without a lead point should prompt investigation for celiac disease as it may represent initial presentation, in order to avoid unnecessary surgical intervention.
2655 A Unique Case of Polyarteritis Nodosa Involving the Gastrointestinal Tract
Authors: Bergenstock Marika , Tufail Kashif , Tariq Umar , Confer Bradley 
Published: October 2019

INTRODUCTION:
Polyarteritis nodosa (PAN) is a rare, systemic necrotizing vasculitis that affects medium-sized arteries and leads to inflammation resulting in vessel narrowing, thrombosis, and aneurysms. It can involve multiple organs and therefore presents with a range of non-specific symptoms. Gastrointestinal (GI) involvement of PAN is uncommon and may manifest as abdominal pain and rectal bleeding. Herein we describe an unusual case of PAN involving the small bowel in a patient presenting with abdominal pain.

CASE DESCRIPTION/METHODS:
A 49 year old man presented with acute onset left upper quadrant abdominal pain associated with nausea, vomiting, constipation, and multiple episodes of rectal bleeding. Vitals were unremarkable. Physical exam notable for abdominal tenderness and external hemorrhoids. Lab work revealed WBC 25, hemoglobin 11.6, platelets 476, and BMP unremarkable. Autoimmune markers revealed CRP 200, ESR 76, and ANA, ASMA, p-ANCA, c-ANCA, and acute hepatitis panel was negative. CT revealed splenic infarcts with no evidence of acute bowel ischemia. Arteriogram revealed multiple abnormalities including focal narrowing and irregularities of renal artery, distal splenic artery, as well as ileal and jejunal arteries (Figure 1a). Small bowel enteroscopy revealed jejunal erosions with biopsies showing focal erosive jejunitis and small caliber arteries without evidence of vasculitis. Colonoscopy positive only for large external hemorrhoids. Video capsule identified partial loss of villi, mucosal flattening, and multiple areas of ulceration throughout the small bowel (Figure 2) concerning for ischemia. Due to the high degree of concern for PAN with small bowel involvement, high dose prednisone and cyclophosphamide were initiated with improvement of symptoms. Follow-up angiogram revealed improvement in previous focal narrowing and segmental stenosis (Figure 1b).

DISCUSSION:
Diagnosing PAN is challenging and involves biopsy of an affected organ to identify medium-sized artery vasculitis. As in this case, establishing PAN with GI involvement is difficult due to the low likelihood of identifying medium-sized artery vasculitis on endoscopic biopsy of the GI tract. Invasive small bowel resection is oftentimes unrealistic. Untreated PAN can lead to devastating outcomes including ischemia of multiple organs as ongoing inflammation of vessels results in progressive narrowing. Thus, consideration should be given to initiating aggressive therapy based on imaging findings and clinical presentation if GI-PAN is suspected.
2661 A Rare Case of Poorly Differentiated Lung Carcinoma With Duodenal Metastasis
Authors: Ahmed Ahmed , Delle Donna Paul , Nasir Umair M. , Swantic Vanessa , Ahmed Shahida , Lenza Christopher 
Published: October 2019

INTRODUCTION:
Lung cancer metastasis to the gastrointestinal (GI) tract is uncommon, with the duodenum being particularly rare. We present a unique case of a 61-year-old male with a history of lung cancer, who was found to have a metastatic mass on esophagogastroduodenoscopy (EGD) that was histologically similar to his lung cancer, ultimately being a diagnosis of poorly differentiated carcinoma (PDC) with focal neuroendocrine differentiation (FND).

CASE DESCRIPTION/METHODS:
61-year-old male presented with 1 month of worsening dizziness, fatigue, and early satiety. On physical exam, he was tachycardic with a blood pressure of 92/60. Labs were notable for a Hgb of 7.2 (baseline of 12). Of note, 6 months prior, he was having hemoptysis and was found to have a left apical lesion on computerized tomography (CT) scan of the chest. Results from a fine needle aspiration (FNA) of the mass showed PDC that was weakly positive for CK-7, and synaptophysin on immunohistochemical staining (IHCS); thus, he was started on chemoradiation therapy. His EGD showed an oozing ulcer in the third portion of the duodenum with heaped up borders. Bipolar cautery was performed, and biopsies were obtained which showed PDC, histologically and immunohistochemically similar to his previous lung biopsy. The patient’s Hgb continued to drop during the hospital course requiring multiple transfusions, and ultimately, a gastroduodenal artery embolization. He was eventually discharged after monitoring his hemodynamics, with close outpatient follow up, as he wanted to pursue continued medical management.

DISCUSSION:
The results of the lung FNA showed sheets of atypical cells with focal necrosis, and prominent nucleoli being dispersed without a specific pattern, consistent with a diagnosis of PDC with FND. IHCS was weakly positive (very few scattered cells) for CK-7, and synaptophysin but negative for CK-20, P63, TTF-1, chromogranin, and CDX2. The duodenal mass biopsy showed PDC with IHCS negative for CK-7, synaptophysin, CK-20, P63, P40, Napsin-A, P40, CDX-2, TTF-1, chromogranin, calretinin, CD20, and CD3; making it histologically similar to his previous lung biopsy. The IHCS of both biopsies could not identify a specific type of carcinoma and histological analysis only showed areas of FND; highlighting the unique aspect of this case. Treatment of duodenal metastasis is challenging and depends on many variables. He was deemed a poor surgical candidate due to his comorbidities/metastatic disease and eventually had a palliative embolization.
2668 Pleural Effusion From an Unexpected Source!
Authors: Alsheikh Mira , Kamar Khalil , Fady Haddad , Deeb Liliane 
Published: October 2019

INTRODUCTION:
Gastric adenocarcinoma (GAC) is a global health burden. It is the third-leading cause of cancer-related mortality. Diagnosis is often delayed given the non-specific symptoms attributed to this disease. Gastric cancer is well known to cause distant metastases to other organs. However, it is unusual for patients to develop malignant pleural effusion as a presenting manifestation. Our case illustrates a unique diagnosis of an occult GAC after initial presentation with shortness of breath that deemed to be due to a malignant pleural invasion by signet ring cell cancer of the stomach.

CASE DESCRIPTION/METHODS:
A 70-year-old woman presented with worsening dyspnea and orthopnea of 1-month duration. Her past medical history included asthma and hypertension. Initial evaluation revealed a saturation of 98% on room air with decreased breath sounds halfway up upon auscultation of the right lung. Chest x-ray demonstrated a moderate right pleural effusion. Thoracentesis was performed with removal of 1 L of amber-colored fluid. The cytological analysis revealed adenocarcinoma with signet ring cell features. Upper endoscopy showed an 8 cm irregular necrotic ulcer at the lesser curvature of the stomach. Pathology confirmed the presence of a moderately differentiated infiltrative signet ring cell adenocarcinoma. Giemsa stain revealed helicobacter pylori (HP). Immuno-histochemical stains were positive for CK 7, hMLH1, 2 and 6. A positron emission tomography showed evidence of metastasis in right pleural space and lumbar spine. The patient received triple therapy for HP and confirmed eradication as well as modified FOLFOX 6 therapy every two weeks.

DISCUSSION:
Gastric adenocarcinoma is the fifth most common cancer in the world. Helicobacter pylori is a well recognized underlying risk factor for GAC. Around 1-3% of patients infected with HP progress to develop GAC. Chronic infection in this setting results in hypochlorhydria that leads to atrophic gastritis and intestinal metaplasia followed by dysplasia and subsequent neoplasia. Malignant pleural effusion is a rare presenting manifestation of GAC accounting for only two percent of cases. In advanced stage GAC, common metastatic sites include distant lymph nodes, liver, peritoneum with rare metastasis to lungs, bone, brain, and leptomeningeal space. Our case was distinctive as the pleural effusion was the initial presentation of an occult GAC diagnosed after that. Prognosis of metastatic GAC remains poor because of limited effective therapies.
2669 Mucosa-Associated Lymphoid Tissue Lymphoma: Crossing the Borders!
Authors: Dhruv Samyak , Fady Haddad , Oana Rosca , Andrawes Sherif 
Published: October 2019

INTRODUCTION:
Mucosa-associated lymphoid tissue (MALT) lymphoma or MALTomas are responsible for half of the primary gastric lymphomas and up to 8% of B-cell lymphomas. It mostly affects patients in their 5th or 6th decade of life. MALT lymphoma is well known to remain localized in the stomach and to follow a benign course. Despite that gastric MALToma is well defined in the literature, it is rather uncommon to present as a peri-pancreatic mass. Herein, we present the case of a patient with an incidental peri-pancreatic mass diagnosed as an aggressive form of MALT lymphoma.

CASE DESCRIPTION/METHODS:
A 76-year-old male with hypertension presented to the gastroenterology clinic for the evaluation of peri-pancreatic mass incidentally found during computed tomography (CT) scan performed for renal colic. Physical examination was remarkable for an epigastric fullness with no tenderness. Laboratory tests were remarkable for iron deficiency anemia. CT showed a 7 cm ill-defined soft tissue mass within the pancreaticoduodenal groove abutting the pancreatic head and encasing the gastroduodenal artery suspicious for a pancreatic neoplasm (Figure 1). Endoscopic ultrasound (EUS) showed a hypoechoic heterogeneous mass arising from the gastric wall in close proximity to the pancreas (Figure 2). EUS-guided biopsies were consistent with extra-nodal marginal zone lymphoma of MALT (Figure 3). Gastric biopsies confirmed the presence of MALToma and revealed positive Helicobacter Pylori (HP) infection. Staging workup confirmed extensive bone marrow as well as para-aortic, mediastinal and paratracheal lymph node involvement. The patient received curative HP treatment and was started on bendamustine and rituximab.

DISCUSSION:
The stomach is the most commonly affected organ by MALT lymphoma. Helicobacter Pylori is a major precursor for the development of gastric MALT lymphoma as up to 90% of affected patients show H.Pylori on stomach biopsies. Chronic HP infection leads to lymphoid tissue proliferation within the stomach and progression towards lymphoma. In this setting, the course is usually indolent with the disease usually confined to the stomach but aggressive tumor behavior has been reported. HP antibiotic eradication remains the first line therapy for early-stage HP positive gastric MALT lymphoma. In other instances, a patient-tailored approach is recommended based on the stage, involved site, HP status and clinical characteristics. Therapeutic options include radiation therapy, chemotherapy and surgery accordingly.
2677 A Rare Case of Primary Signet Ring Cell Bladder Adenocarcinoma With Metastases to the Stomach
Authors: Yohannan Bryce , Hayat Maham , Hanafi Muhammad Z. , Moten Aqsa , Hayat Muhammad Hashim , Fazili Javid 
Published: October 2019

INTRODUCTION:
Primary signet ring cell adenocarcinoma (SRCA) of the urinary bladder is a rare malignancy, accounting for about 0.24% of all bladder malignancies. Additionally, metastases to the stomach regardless of primary malignancy is also rare, with rates estimated to be between 0.2-0.7%. Here we are reporting a case of primary SRCA of the bladder with eventual metastases to the stomach.

CASE DESCRIPTION/METHODS:
A 65-year-old male with rheumatoid arthritis on chronic immunosuppression and history of T4N0M0 primary SRCA of the bladder status-post radical cystectomy was admitted with persistent nausea, vomiting and reduced oral intake leading to acute kidney injury. Symptoms were refractory to conservative measures so CT Abdomen was obtained which revealed distal esophageal wall thickening. Due to concern for infectious esophagitis given his chronic immune suppression, esophagogastroduodenoscopy (EGD) was performed. EGD revealed multiple nodules (5-10 mm) with central umbilication scattered within the gastric fundus and body. The lesions were biopsied and stains were consistent with signet ring cell adenocarcinoma positive for CX7, CX20, CDX-2; Beta-catenin was not performed. Bladder specimen from prior cystectomy was also positive for CX7, CX20, CDX-2, and predominately membranous staining for Beta-catenin. PET scan obtained after EGD was significant only for retroperitoneal lymphadenopathy thought to represent metastases. Previous workup at the time of initial bladder adenocarcinoma diagnosis including colonoscopy and imaging were all negative for additional foci of malignancy confirming primary bladder adenocarcinoma. Hence, it was concluded that the gastric lesions represented metastasis to the stomach from primary SRCA of urinary bladder. Due to underlying comorbidities and poor baseline functionality, patient elected to proceed with hospice care.

DISCUSSION:
Primary urinary bladder SRCA is a rare type of malignancy that typically presents at an advanced stage. Standard therapy of local urinary bladder SRCA is radical cystectomy. Despite advances in identifying immunohistochemical markers which aid in determination of primary bladder vs. colorectal origin, rates of metastases after surgical intervention are uncertain which limits the discussion regarding the role of adjuvant therapy. Our case highlights the need for further investigation to evaluate the risk-benefit ratio of adjuvant chemotherapy after radical cystectomy in primary bladder SRCA in minimizing development of future distant metastases.