bluuebunny/crossref_metadata_2025_split huggingface dataset:
2765 A Rare Case of Diffuse Gastric Metastases Secondary to Breast Cancer
Authors: Sonti Sravanthi , Nagireddy Sumana , Parsa Laxmi , Birsan Christina 
Published: October 2019

INTRODUCTION:
Breast cancer usually metastasizes to bone, lung, liver, or brain, and it is extremely rare to metastasize to gastrointestinal tract. We report a unique case of breast cancer metastasizing to stomach. We have noted only a few similar cases in current literature.

CASE DESCRIPTION/METHODS:
A 71-Yr-Old Caucasian female was referred for evaluation of upper abdominal pain, nausea, and occasional vomiting for 3months. Denies excess NSAID use, melena, or hematochezia. She has history of Hodgkin's lymphoma in remission after chemoradiation 40 years ago, and bilateral metastatic breast cancer diagnosed five years ago. She initially was found to have bilateral breast masses on mammogram. Biopsies showed invasive mammary carcinoma with extensive lobular pattern in right breast and invasive ductal carcinoma in left breast. PET-CT scan showed innumerable mixed sclerotic and lytic lesions throughout axial and appendicular skeleton. She was started on endocrine therapy as she declined chemotherapy. Laboratory values include normal liver function tests, and complete blood counts. Upper endoscopy showed moderately severe erythematous mucosa, and multiple small nodules throughout the stomach. Biopsies showed infiltrative tumor cells in nests and cords, some with signet ring cell features and mucin production. Immunohistochemical staining showed positive GATA-3 and ER which confirmed poorly differentiated adenocarcinoma of primary breast origin. She had another endoscopy a year ago which showed similar biopsy findings at an outside facility. Currently, she has been receiving capecitabine and following with oncology.

DISCUSSION:
Metastasis to gastrointestinal tract from other solid organ cancers is very rare. Breast cancer, mainly invasive lobular carcinoma, metastasizing to gastrointestinal tract, noted in <1% cases. It usually involves rectum, stomach, small bowel, and esophagus. Metastases to stomach mimic primary gastric cancer on imaging and endoscopically. Symptoms are nonspecific including abdominal pain, nausea, early satiety, bloating, and weight loss. Endoscopically, the stomach may have diffuse infiltration as linitis plastica, isolated, or multiple nodules, or a superficial mucosal lesion. Histological features especially immunohistochemical markers like GCDFP-15 and GATA 3 expression help to differentiate from primary gastric adenocarcinoma. Our patient had non-specific upper gastrointestinal symptoms. Endoscopy and biopsies confirmed the diagnosis.
2770 A Unique Case of Bezoar and Incidental Situs Ambiguus
Authors: Pisipati Sailaja , Jones Blake , Freeman Alison 
Published: October 2019

INTRODUCTION:
Situs ambiguous refers to abnormal arrangement of thoracoabdominal organs along left-right body axis, and is associated with multiple complex congenital cardiac as well as non-cardiac anomalies. This abnormal arrangement is different from orderly arrangement seen in situs solitus or situs inversus. We report a unique case of incidental situs ambiguous discovered during management of aspiration pneumonia caused by gastric outlet obstruction.

CASE DESCRIPTION/METHODS:
62-year-old gentleman presented with one month history of multiple episodes of non-bilious vomiting and watery diarrhea, two weeks of abdominal distension and discomfort. Semi-urgent esophagogastroduodenoscopy (EGD) revealed partially digested food particles with inadequate views (bezoar). Placement of a nasogastric tube (NGT) triggered gag reflux resulting in vomiting and aspiration of gastric contents, causing hypoxia needing emergent intubation. Chest x-ray revealed bilateral infiltrates with loss of lung volume on the right. Urgent bronchoscopy revealed food particles predominantly in right bronchus intermedius. Patient developed acute respiratory distress and septic shock from aspiration pneumonia. CT abdomen showed a grossly enlarged stomach (gastric outlet obstruction) on the right side of the abdomen (situs ambiguous) with bezoar. EGD revealed voluminous amount of residue in markedly distended stomach; three liters were suctioned using a large bore Edlich gastric lavage tube. Benign appearing tight stenosis was noted in the duodenal bulb. Biopsies were negative for Helicobacter pylori or lymphoma. Although endoscopic dilation of stricture was initially considered, gastrojejunostomy was performed to bypass the stricture given severity of illness and prolonged recovery.

DISCUSSION:
Situs ambiguus is classified into two groups. Group I has isomerism of right atrial appendage and is usually associated with absence of spleen (Asplenia syndrome). Group II has isomerism of left atrial appendage and is usually associated with multiple spleens (Polysplenia syndrome). Liver is usually centrally placed or may remain in right or left hypochondrium. Mortality up to 40% at a very young age up was reported. Our patient remained asymptomatic due to absence of cardiac anomalies. Edlich tube is a large bore 36Fr NGT, 36” long, with a closed tip and multiple eyes, a 140cc syringe with a quick connect adapter on the tube. It is used to irrigate or lavage the stomach and plays an essential role in breakdown and evacuation of bezoars.
2771 Acute Gastric Dilatation: A Cause for Concern
Authors: Shaikh Danial , Mehershahi Shehriyar , Jyala Abhilasha , Sinha Chandni , Chilimuri Sridhar 
Published: October 2019

INTRODUCTION:
Gastroparesis in diabetics can be worsened by hyperglycemia. Acute elevations in blood glucose suppress the frequency and contraction amplitude of antral pressure waves while stimulating phasic pyloric pressure waves, which can result in Acute Gastric Dilatation (AGD). Though an unusual occurrence, it requires a high degree of suspicion to avoid its rare but life-threatening complications. We present our experience of two patients with AGD.

CASE DESCRIPTION/METHODS:
Case 1: A 30-year-old male presented to the ER with nausea, vomiting and abdominal pain. His comorbidities included type 1 diabetes and end-stage renal disease. On examination, his abdomen was notably distended and bowel sounds were sluggish. No guarding or rigidity was appreciated. He was hypotensive (76/49 mmHg) and hypoxic. Lab values were significant for blood glucose of 1155 mg/dL and a pH of 6.97. He was emergently intubated and started on IV insulin and Epinephrine. An abdominal plain film x-ray showed acute gaseous distention of the stomach. An NG tube was passed which drained 500cc of brownish gastric content. A repeat x-ray 4 hrs later revealed resolution of gastric dilatation which was confirmed by CT-abdomen. Patient's abdominal symptoms improved thereafter and he made a full recovery in time. Case 2: 59-year-old male was brought to the ER with an altered mental status. As per EMS, he had “very high” blood sugar levels. His comorbidities included diabetes mellitus and chronic hepatitis C. His abdomen was distended with decreased bowels sounds. His vital signs were stable. Lab values were significant for hyperglycemia (649 mg/dL), and a blood pH of 7.29. He underwent an abdominal x-ray which showed marked distention of the stomach. A follow-up CT abdomen confirmed the finding, with no mechanical cause of obstruction identified. He was started on IV Insulin, IV antibiotics and was planned for endoscopic workup, however, his conditioned rapidly deteriorated and he required pressors with mechanical ventilation. The patient eventually suffered a cardiac arrest and was unable to be revived.

DISCUSSION:
AGD presents with nausea, vomiting, succussion splash, and abdominal distension. Acute hyperglycemia in uncontrolled diabetics is the precipitating factor. If intragastric pressures exceed 20 cmH20 (lower limit of gastric venous pressure), it can cause mucosal ischemia and necrosis. This may be followed by perforation, which has a high mortality rate. Emergency decompression with NG tube seems to be the treatment of choice.
2774 Gastritis After Combination Ipilimumab and Nivolumab: A Rare Adverse Event After Immunotherapy
Authors: Mahpour Noah , Bhagat Vicky , Sarkar Avik 
Published: October 2019

INTRODUCTION:
Immunotherapies are commonplace in the treatment of many neoplasms, and have an array of commonly reported toxicities. Among the reported gastrointestinal side effects, diarrhea and colitis are most frequently cited. However, there have only been a rare handful of reported cases of Immune-checkpoint modulator toxicity affecting only the upper GI tract. In this paper we report a case of Ipilimumab-Nivolumab associated Gastritis in a patient treated with these medications at our facility.

CASE DESCRIPTION/METHODS:
The patient is a 78-year-old male with Stage IV Melanoma who presented to the hospital with nausea, vomiting, weight loss, and reduced oral intake for two weeks. The patient had most recently received 2 rounds of Ipilimumab and Nivolumab for his Melanoma 2 weeks prior to his presentation to our hospital, concurrent with the start of his symptoms. There had been no history of NSAID usage during this time, and physical exam was notable for mild epigastric tenderness. A Computed Tomography scan of the Chest/Abdomen/Pelvis showed diffuse thickening of the stomach, compatible with gastritis. Upper Endoscopy revealed diffuse severely erythematous mucosa with bleeding on contact in the entire examined stomach, and patchy, mildly erythematous mucosa without bleeding was found in the duodenal bulb, with the second portion of the duodenum being normal. The pathology report revealed subacute gastritis with acute inflammatory exudate consistent with an area of mucosal ulceration, with other etiologies of gastritis ruled out. The patient was begun on glucocorticoid therapy, with rapid resolution of his symptoms. Repeat endoscopy 2 weeks later revealed resolution of the previously noted gastritis and inflammation. Pathologic examination of biopsies confirmed resolution of the inflammatory process.

DISCUSSION:
On review of the literature, gastritis resulting from immune-checkpoint modulators has rarely been reported on. Some common side effects associated with these immune modulating medications, colloquially called immune-related adverse events (irAEs), include diarrhea, colitis, and hepatitis. However, there are a few case reports concerning the development gastritis without enterocolitis after Nivolumab treatment alone. Approximately 3 case reports and 1 case series of 20 patients describe such a side effect, To date, there are no reported cases of a patient treated with both Nivolumab and Ipilimumab who developed gastritis as the only adverse event.
2776 Not for Human Consumption: Caustic Ingestion Causing Delayed Gastric Outlet Obstruction
Authors: Wang Joy I. , Chen Patrick , Agrawal Sangeeta 
Published: October 2019

INTRODUCTION:
Corrosive injuries from acid ingestion can cause scarring and fibrosis of the pyloric antrum. Scar formation of the gastric outlet may be evident as early as three weeks, occurring within eight weeks in 80% of cases. We present a rare case of caustic ingestion causing a delayed onset of gastric outlet obstruction.

CASE DESCRIPTION/METHODS:
A 55-year-old male with a past medical history of hypertension and caustic ingestion of toilet cleaner as a suicide attempt in 1986 presented with intermittent dysphagia. Endoscopy in 2012 showed antral narrowing with a normal pyloric channel. Vitals were significant for blood pressure of 158/94 mmHg otherwise within normal limits. Complete blood count and complete metabolic panel were within reference ranges. Repeat endoscopy found a pyloric stricture and biopsies were negative for neoplastic changes. Patient was managed conservatively with lifestyle modifications.

DISCUSSION:
Gastric outlet obstruction is a late sequelae of caustic injury and is more common with acid ingestion. Concentrated acids, such as hydrochloric acid, are generally the active ingredient of toilet cleaners. Acids clear rapidly from the esophagus into the stomach and pool in the pre-pyloric area due to corrosive-induced pyloric spasms, leading to damage of the pyloric antrum through scarring and surrounding adhesions. Endoscopic evaluation of the upper gastrointestinal tract establishes the diagnosis and determines the extent and severity of injury. Intralesional triamcinolone injections have been proposed for preventing stricture formation, but its efficacy remains unknown. The treatment of choice for gastric outlet obstruction is endoscopic dilatation. Surgery is an option for endoscopic failure or for patients with complications from endoscopic dilatation.
2777 Nutritional Deficiencies in a Patient With Roux-en-Y Gastric Bypass Surgery
Authors: Al-Douri Abdul , Chambers Jessica , John Jaison 
Published: October 2019

INTRODUCTION:
Bariatric surgery is one of the most commonly performed surgeries in the US. Several types exist including vertical sleeve gastrectomy (VSG), adjustable gastric banding (AGB), and Roux-en-Y gastric bypass (RYGB). VSG and RYGB work through caloric restriction and neurohormonal changes. While there are many benefits of bariatric surgeries, there are also many complications including malabsorption of nutrients.

CASE DESCRIPTION/METHODS:
A 41-year-old African-American female with prior RYGB in 2014 presented to the hospital with general malaise, crampy abdominal pain, back and joint pain, nausea, dyspnea, and intermittent headaches with photophobia and phonophobia for the past 1 month. Labs revealed moderate microcytic anemia with hemoglobin of 9. Reticulocytes were depressed at 13.8. Metabolic panel was within normal limits. Rheumatologic panel including ANA, C3/C4 was negative. On exam, pertinent findings included tachycardia and epigastric tenderness with deep palpation. She had multiple 1 cm hyperpigmented circular lesions on the forehead, upper back, and bilateral upper arms. This prompted testing for copper and zinc, which were decreased at 26 and 54, respectively. CT abdomen/pelvis with contrast showed a small pericardial effusion but was otherwise normal. MRI brain showed no changes to prior images. The patient was discharged on a multivitamin with zinc and copper to follow up with her PCP.

DISCUSSION:
Copper and zinc are essential nutrients for humans and act as cofactors for a variety of metalloenzymes that participate in critical body functions. Deficiency in these nutrients is rare in the US as it’s found in commonly consumed foods. Copper deficiency results in brittle hair, skin depigmentation, neurologic dysfunction, and osteoporosis. Zinc deficiency can result in pustular skin rash, impaired taste, and immune dysfunction 4Zinc and copper are usually not added to multivitamins and not routinely measured by physicians, however patients with modified GI physiology due to bariatric surgery can be at risk. RYGB reduces the stomach’s capacity and re-routes ingested food to bypass the duodenum, where copper and zinc are absorbed. Patients with a history of gastric bypass surgery and ill-defined symptoms should be tested for trace mineral deficiencies. Patients who recently underwent a gastric bypass, particularly a RYGB, should be placed on a multivitamin that includes zinc and copper.
2778 A Cytomegalovirus Masquerade
Authors: Diallo Souleymane Y. , Haris Muhammad , Garapati Karthik , Parker Allan L. , Brady Charles 
Published: October 2019

INTRODUCTION:
Plasmablastic lymphoma (PBL) is a very rare but highly aggressive lymphoma seen in HIV patients. It is typically seen in the oral cavity and extraoral involvement is even rarer. We present a unique case of gastric plasmablastic lymphoma initially thought to be cytomegalovirus (CMV) gastritis.

CASE DESCRIPTION/METHODS:
A 30-year-old HIV positive female presented with epigastric pain. She had an esophagogastroduodenoscopy (EGD) that showed non-bleeding erosive gastropathy 6 weeks before presentation. Biopsy showed CMV gastritis. She was given valganciclovir. Repeat EGD 4 weeks later showed a cardia ulcer with an adherent clot and oozing that was treated with epinephrine. She was given a proton pump inhibitor and valganciclovir. Her pain worsened after discharge despite treatment leading her to present to our facility. She was tachycardic and tender to palpation of the abdomen. Labs revealed CD4 246, viral load of 2760 and platelets of 1.1 million. A CT scan showed diffuse gastric thickening up to 2 cm (Figure 1.) EGD revealed an edematous, friable and oozing mucosa with scattered Forrest III ulcerations (Figure 2). Gastric biopsies were consistent with plasmablastic lymphoma without H pylori. She had six cycles of chemotherapy with complete response at 6 months. Repeat EGD at 6 months showed erythematous gastropathy (Figure 3.) Biopsies revealed chronic active gastritis with H. pylori and no lymphoma. She completed quadruple therapy for the H. pylori infection.

DISCUSSION:
PBL is a rare disorder seen in the HIV population, usually involving the oral cavity. EBV is seen in 74% of AIDS-related PBL. There has been no association with CMV or Helicobacter pylori reported in the literature. PBL is associated with an aggressive course and poor survival. Despite good initial response to chemotherapy, relapse rates are as high as 54% within the first year. The endoscopic appearance of gastric lymphoma is nonspecific presenting as tumor lesions, thickened folds, ulcerative, infiltrating, bulky, or as gastritis-like changes. CMV gastritis is typically seen with CD4 count < 50. A high index of suspicion was required to make an alternative diagnosis of PBL in this patient with a CD4 count > 200.
2780 A Case of a 20-Year-Old Female With Hereditary Diffuse Gastric Cancer Syndrome With Synchronous Diffuse Gastric Cancer and a Giant Uterine Tumor
Authors: Rosenkranz Laura , Kitano Mio , Hopp Grace 
Published: October 2019

INTRODUCTION:
Hereditary Diffuse Gastric Cancer (HDGC) is defined by germline autosomal dominant mutation in the CDH1 gene causing an inherited form of diffuse gastric cancer. There are no reported cases of HDCG presenting with a synchronous giant uterine tumor.

CASE DESCRIPTION/METHODS:
A 20-year-old female with known pathogenic CDH1 mutation presented with 3 days of pelvic pain and a palpable lower abdominal mass. She underwent a CT abdomen/pelvis which revealed a large uterine tumor measuring 16 cm. The patient’s family history is notable for maternal grandmother and maternal uncle who were diagnosed with and died of gastric cancer at 46 and 55, respectively. Her mother, the proband, was diagnosed with stage IV diffuse gastric cancer at age 46, underwent genetic testing and was found to have a pathogenic mutation in the CDH1 gene. The patient’s 42-year-old maternal aunt, who also tested positive, underwent prophylactic gastrectomy. There was no evidence of gastric adenocarcinoma on pathology. The patient also tested positive for CDH1 mutation and was counselled about prophylactic gastrectomy. Given she had just turned 20, the patient was not offered immediate surgery. She underwent a baseline upper endoscopy prior to planned hysterectomy. Random endoscopic biopsies revealed diffuse poorly differentiated carcinoma with signet ring features. Given poor histology and diffuse nature, the patient received 3 cycles of neoadjuvant chemotherapy before undergoing total gastrectomy with Roux-en-Y reconstruction and uterine myomectomy. She opted for myomectomy to preserve fertility. Pathology revealed diffuse pT1aN0M0 poorly differentiated G3, stage IA gastric adenocarcinomaand a benign leiomyoma.

DISCUSSION:
HDGC is exceedingly rare, accounting for only 1% of all gastric cancers. The median age to develop gastric cancer in pathogenic CDH1 carrier is 33 to 40. The risk of developing gastric cancer is less than 1% in patients under the age of 20. HDGC has penetrance of up to 80%. Our patient’s 42 year old aunt had a pathogenic CDH1 gene; however, her final pathology following prophylactic gastrectomy did not show any evidence of cancer, highlighting the small possibility of having no disease manifestation. Lastly, our patient had a synchronous, yet separate, primary uterine tumor at the time of presentation. In reviewing the literature, there are no other reported HDGC cases with a concurrent separate primary uterine tumor.
2783 The Extreme of Morning Sickness: A Case of Gastric Adenocarcinoma in Pregnancy
Authors: Munoz Anisleidys , Pendela Venkata Satish , Soliman Youssef , Soliman Megan 
Published: October 2019

INTRODUCTION:
Gastric adenocarcinoma usually presents in advanced stages and after 40 years of age. Presentation in pregnancy is rare, occurring in less than 0.1% of all pregnancies, and it presses additional challenges as the symptoms are usually overlooked. Reports of gastric adenocarcinoma in pregnancy undergoing different mainstays of therapy have been described. Here, we present a case of poorly differentiated gastric adenocarcinoma diagnosed at 26 weeks gestation, who had to undergo an individualized and multi-disciplinary approach, with a favorable outcome thus far.

CASE DESCRIPTION/METHODS:
A 24-year-old woman with no significant history, gravida 2, para 1 at 26 weeks gestation presented with hyperemesis, dehydration and anorexia requiring inpatient management. She had lost 19 Kgs during the second trimester. Lab work revealed hypokalemia of 2.8 mEq/L, and transaminitis: AST 206 U/L, ALT 354 U/L. MRI abdomen without contrast showed mild distention of the proximal stomach of unclear significance. Ultrasound of the liver, kidneys and appendix were non-revealing. Symptoms progressed; therefore, she underwent upper endoscopy, which revealed inflamed antral mucosa with nodularity. Biopsy did not show H. pylori, but rather poorly differentiated adenocarcinoma with signet ring features. This was further classified as IHC positive for CDX-2 and E-cadherin, HER-2+ (IHC 2+, FISH amplified). The patient was initially treated with neoadjuvant FOLFOX for 4 cycles given concurrent pregnancy, followed by induction of pregnancy at 36 weeks gestation. She then underwent surgical resection with total gastrectomy, omentectomy and lymphadenectomy. Surgical biopsy showed metastatic disease stage ypT3N1. Currently, 7 months after diagnosis, the patient is tolerating adjuvant chemotherapy with FLOT (5-FU, oxaliplain, docetaxel). Radiation therapy is planned following chemotherapy. The patient’s baby is alive and thriving.

DISCUSSION:
Gastric adenocarcinoma rarely presents in pregnancy and is often overshadowed by pregnancy-related symptoms as these may overlap. Thus, red flags such as extreme weight loss in pregnancy should raise suspicion for underlying pathology. Diagnosis and treatment pose challenges as these can encompass risks for the fetus, especially early on gestation. Nevertheless, gastric adenocarcinoma often presents as poorly differentiated disease in pregnancy warranting prompt diagnosis, staging and expeditious intervention with chemotherapy and surgical resection.