bluuebunny/crossref_metadata_2025_split huggingface dataset:
2701 Not Your Usual Gastritis: A Case Report of Pembrolizumab-Induced Lymphocytic Gastritis
Authors: Alkayali Talal , Salem Ahmed I. , Ricardo Juan , Amer Bahaa , Harris Cynthia L. 
Published: October 2019

INTRODUCTION:
Pembrolizumab induces immune checkpoint inhibition of programmed cell death protein-1 (PD-1 inhibitors) in various malignancies. Toxicities have been described, including but not limited to, inflammatory reaction in any system, and infusion related side effects. We report a rare case of symptomatic lymphocytic gastritis after pembrolizumab treatment of vocal cord squamous cell carcinoma.

CASE DESCRIPTION/METHODS:
70 year old female with history of right true vocal cord squamous cell carcinoma status post excision and chemoradiation with cisplatin. Recurrence in 1 year to the anterior vocal cord prompted treatment with pembrolizumab. Patient suffered complete esophageal occlusion requiring multiple EGDs with dilatation, gastric tube placement, morphine and transcutaneous fentanyl analgesia. During pembrolizumab treatment she developed new onset nausea and vomiting, intolerance to feeding regimen for 3 weeks, and a 10 pound weight loss in 1 week but no change in bowel movements, melena, abdominal pain, or fever. Physical exam was significant for cachectic female, LUQ G-tube in situ with no erythema/discharge, no abdominal tenderness, rigidity, or organomegaly, normal bowel sounds, and normal rectal exam. Lab work up was not significant. EGD was performed showing diffuse erythematous mucosa in the entire examined stomach. Biopsy showed lymphocytic gastritis negative for metaplasia, dysplasia, or neoplasia with no H-Pylori or other infectious organisms. Patient was started on prednisone 60mg daily with slow taper, metoclopramide, ondansetron PRN, and pembrolizumab was stopped. GI symptoms improved significantly with resolution of emesis.

DISCUSSION:
Lymphocytic gastritis (LG) is a rare subtype linked with H-pylori infection, celiac, lymphoma, and medication side effect. Patient might be asymptomatic or exhibit dyspepsia, nausea, vomiting or weight loss. Work up includes EGD; however, endoscopic appearance can be nonspecific as patients might have erythema, erosions, nodules or normal appearing mucosa. Diagnosis is made when biopsies show intraepithelial lymphocytes with more than 25 in 100 epithelial cells. Recommended treatment is based on etiology and included removing the offending agent, H-pylori eradication and/or gluten free diet. Steroids are not usually considered in the treatment of LG, but they are proposed as first line therapy in treatment of PD-1 inhibitor related side effects (enteritis, colitis, etc). Our patient had good response to steroids as her LG was induced by PD-1 inhibitor.
2732 Signet Ring Cell Carcinoma: A Rare Case Report Masquerading as Digital Infarction
Authors: Gudipally Sindusha , Gowda Vinodhini , Minupuri Arun , Modi Simple , Salas Noain Jesus M. , Thirumaran Rajesh , Nair Jayamohan 
Published: October 2019

INTRODUCTION:
Signet Ring Cell Carcinoma (SRCC) is a mucin producing adenocarcinoma, commonly seen in the gastrointestinal tract, also rarely in the urinary bladder, pancreas, breast and gallbladder. Tumor embolism due to slowly evolving disseminated intravascular coagulation (DIC) can manifest as digital infarction and this report highlights its presentation in a case of SRCC.

CASE DESCRIPTION/METHODS:
An 82-year-old African American lady presented with 2 weeks of low back pain, hematuria and purplish discoloration of toes. Physical exam was significant for multiple gangrenous digits but palpable pulses. CT Abdomen and Pelvis revealed diffuse bony metastases and moderate bilateral hydronephrosis. Labs were significant for Hemoglobin of 6.6 gm/dl and Creatinine 1.8. Bone marrow biopsy was consistent with metastatic carcinoma of SRCC. Pathologic staining was positive for AE1/AE3, CK7, CK20, and CDX2, suggestive of gastric tract origin than urinary bladder. Further investigation for the location of the primary tumor was negative. Evaluation for peripheral arterial disease, vasculitis, thrombophilia, and endocarditis for digital infarction was negative. With elevated D-Dimer, prolonged PTT and normal fibrinogen suggestive of slowly evolving DIC, digital infarction from tumor embolism was diagnosed. Ureteral stent placement for hydronephrosis was attempted but was unsuccessful due to multiple clots in the bladder, likely owing to DIC and she further deteriorated to end stage renal disease. Goals of care were discussed with the patient and she was transitioned to hospice care.

DISCUSSION:
Slowly evolving DIC is seen in cancer (mostly adenocarcinoma), liver disease, aneurysm, hemangioma and rarely sepsis. It’s believed that the destruction and production of coagulation factors/platelets are balanced. Diagnostic labs indicate thrombocytopenia, normal to prolonged PT/PTT, normal to low fibrinogen level and elevated D-Dimer. Heparin is the treatment of choice when bleeding is not suspected. Unfortunately, heparin was contra-indicated in our patient who had hematuria.
In conclusion, this case illustrates the aggressive presentation of SRCC, which can present as digital infarction. Identifying tumor embolism and slowly evolving DIC is important as it may indicate poor prognosis. This case is unique in its presentation and cancer should be ruled out in digital infarction when other common causes are not identified.
2757 Gastric Amyloid: The Patient Who Could Not Eat at AL
Authors: Janssens Laurens , Kane Sunanda 
Published: October 2019

INTRODUCTION:
Gastroparesis is defined as delayed gastric emptying in the absence of mechanical obstruction. Diabetes and medication side effects are common causes. AL amyloidosis is a systemic disease due to extracellular fibril deposition that can affect multiple organs. Gastro-intestinal (GI) involvement is less common than in other organ systems but can present in many different ways, including gastroparesis.

CASE DESCRIPTION/METHODS:
A 77 year old non-diabetic man from Mississippi presented with a one year history of intermittent abdominal distention, nausea and bloating. In addition, he had increasing dyspnea on exertion and lower extremity edema. Outside work-up consisted of multiple imaging studies demonstrating marked gastric distention as well as delayed gastric emptying (Figures 1 and 2). Outside colonoscopy was unrevealing and EGD was negative except for a distal esophageal ulcer and focal active duodenitis. He was started on a PPI and trialed on an alternating regimen of metoclopramide and erythromycin, without symptomatic relief. He was referred to our hospital for further diagnostic work-up. Repeat colonoscopy showed congested distal ileal mucosa and friable ascending colonic mucosa. Biopsies from both sites revealed amyloid deposits by Congo red stain (Figure 3). Serum protein electrophoresis noted a monoclonal IgG lambda peak with M-spike of 1.5 g/dL and bone marrow biopsy revealed approximately 70% of marrow cellularity consisting of plasma cells. Echocardiogram confirmed severely increased concentric left ventricular wall thickening consistent with cardiac amyloidosis. Interestingly, neither fat pad biopsy nor bone marrow biopsy showed presence of amyloid. The patient was diagnosed with myeloma and AL amyloidosis with gastro-intestinal and cardiac involvement.

DISCUSSION:
This case highlights the broad differential for gastric distention and dysmotility. When the ‘usual suspects’ such as diabetes, medication, post-surgery and neurological disease have been ruled out, rarer causes like an infiltrative process should be considered. Common manifestations of GI tract amyloidosis include GI bleeding, malabsorption, protein-losing enteropathy and chronic dysmotility. The diagnosis of amyloidosis is based on positive tissue diagnosis. While the combination of a fat pad and a bone marrow biopsy has a high sensitivity (89%) for diagnosing AL amyloidosis, negative results do not rule out amyloid elsewhere and tissue sampling from the affected organ site is essential, as demonstrated in this case.
2775 Intragastric Balloon Hyperinflation: A Rare Cause of a Palpable Abdominal Mass
Authors: Bazarbashi Ahmad Najdat , Smith Benjamin N. , Thompson Christopher C. 
Published: October 2019

INTRODUCTION:
Intragastric balloons (IGB) are commonly being used for the treatment of obesity, with increasing data confirming their effectiveness. While usually well tolerated with rare adverse events, IGBs have been associated with complications including visceral perforation, pancreatitis and bowel obstruction. IGB hyperinflation, which occurs due to an abnormal accumulation of gas within IGB is rare. We present a case of a patient with abdominal pain and vomiting after recent IGB placement, found to have a palpable abdominal mass.

CASE DESCRIPTION/METHODS:
A 35-year-old female with class II obesity (BMI: 33 kg/m2) and recently placed adjustable IGB in the Dominican Republic presented to our emergency department with abdominal fullness, vomiting and inability to keep food down. The IGB had been placed for two months with reported 30 lbs weight loss. She denied fevers, dysphagia, hematemesis, melena or altered bowel movements. She was afebrile with normal vital signs. Physical examination revealed a palpable round-like mass in her epigastric region with tenderness to palpation. Laboratory workup, including complete blood count, basic metabolic panel, liver function tests and lipase were normal. CT scan of the abdomen and pelvis revealed a gas-filled hyperinflated IGB within the distal portion of the stomach with dilation proximally representing possible gastric outlet obstruction. There was no evidence of perforation or pneumatosis intestinalis [Figure 1a–c]. Due to her symptoms, and the patient’s wishes to have the balloon removed, endoscopy was performed. Endoscopy revealed a hyperinflated, adjustable IGB occupying two thirds of the gastric body and obstructing the gastric antrum. The balloon appeared mottled suggesting fungal colonization from the outside with food debris. Attention was then placed on balloon removal. Successful removal of 500cc of blue-colored fluid mixed with air was performed resulting in IGB deflation and subsequent retrieval. The patient did well with resolved symptoms and was discharged the next day.

DISCUSSION:
Intragastric balloon hyperinflation should be recognized as a possible complication of IGB placement and may be due to balloon permeability or gas-producing anaerobic bacteria. Patients usually present with nausea, vomiting and inability to tolerate oral intake and if left untreated can result in dire consequences. Imaging may assist with diagnosis. Treatment involves endoscopic IGB removal. In cases of adjustable IGB, deflation and fluid exchange can be considered.
2779 A Case Report of Co-Existing Helicobacter pylori and Clostridium difficile Infections: The Need for Treatment Guidelines
Authors: Bello Fatimah O. , Rivera Arturo Suplee , Herrera Henry R. 
Published: October 2019

INTRODUCTION:
Literature is replete with numerous papers reporting Clostridium difficile (C. diff) infection arising as a complication from the management of Helicobacter pylori (H. pylori) infection. However, not much is known about the guidelines for the management of these 2 infections when they occur in the same patient simultaneously. We present a rare case of independent H. pylori and C. diff infections and our treatment modality.

CASE DESCRIPTION/METHODS:
A 56-year-old woman with a history of recent C. diff infection and end stage renal disease presented to the clinic on account of recurrent abdominal pain of about 3 months duration with associated diarrhea, early satiety and subjective unintentional weight loss. Gastrointestinal panel was ordered as part of her diarrhea workup and she was scheduled for an EGD for evaluation of her abdominal pain. Her C.diff returned positive, the third time within the year. She was prescribed oral vancomycin. Her EGD did not reveal any gross abnormalities. However, pathology results returned positive for H.pylori infection. Patient was followed up in clinic after she had completed the vancomycin. She continued to complain of diarrhea and abdominal pain. Her stool sample was re-sent to the laboratory after a few days and it returned positive, for the fourth time. An extensive discussion was held with the patient and she agreed to go ahead with fecal microbiota transplant (FMT) then wait for a month and commence H.pylori eradication regimen using quadruple therapy. Florastor was also added to her regimen and she continues to be under close follow up. Successful treatment of both C diff and H pylori were achieved using this method, without C diff recurrence to date.

DISCUSSION:
About 4.6% of individuals treated for H.pylori infection will develop C. diff infection. This is typically treated using the existing guidelines. However, not much is known about the management of the 2 infections when they co-exist. In the case of our patient, a FMT was performed prior to H.pylori therapy, as the diarrhea appeared to be the chief complaint. Florastor was added to the H. pylori regimen in an effort to reduce the risk of recurrent C. diff infection. There are no guidelines to support our modality of treatment which was decided upon using our best clinical judgement. To the best of our knowledge, there has been no reported case of C.diff and H.pylori co-infection in the context of recurrent C. diff infection. There is a need for treatment guidelines for such clinical scenarios.
2813 Endoscopy and Radiation Oncology Collaboration - The Evolution of Techniques and Applications of EUS-Guided Fiducials for Pancreatic Neoplasm and Beyond: A Tertiary Cancer Institute Experience
Authors: Sharma Neil , Krishnakurup Jay , Rumancik Brad , Kota Sharwani , Gopakumar Harishankar , Zelt Christina , Gupta Saurabh 
Published: October 2019

INTRODUCTION:
Stereotactic ablative radiotherapy (SABR) offers improved tumor control, lees number of treatments, and reduced toxicity compared with conventional therapies. The role of SABR continues to expand. Fiducial markers are required to guide SABR.Traditionally CT guided or surgical placement had been used to facilitate the delivery of stereotactic radiotherapy. EUS-guided fiducial marker placement has been introduced as a safe and feasible alternate method. We share our experience with the two types of the fiducial delivery system & evolution of applications & technique. The back loaded fiducial needles (BLFS), which need to be inserted to the needle by hand, is cumbersome, more prone for needle stick injury to the operator, and time consuming. A novel preloaded system (PLFS) delivers 2 fiducials per needle and can be interchanged with the FNB needle enabling biopsies in the same setting. The preloaded system has an automatic safety shield enabling safety during needle exchange. With advance of Endoscopic oncology, a trained advanced endoscopist can implant fiducials in a variety of solid organ tumors accessible by EUS and needing SABR.

METHODS:
We conducted a retrospective review of our experience from 2015-2017. We started using fiducials in late half of 2015 and changed to PLFS in early 2016. We reviewed our experience on the total procedure time (TPT) with the BLFS with PLFS. The PLFS allows for ease of application. After the switch to PLFS, through conversations with radiation oncology, we reviewed the extension of the technology to additional applications outside the pancreas.

RESULTS:
The mean total procedure time TPT with the back loaded system was 31.68 min, while the mean TPT with the preloaded system was 22.68min, a 30% reduction in the total procedural time for pancreatic cases. (Table 1) We then evolved use of the PLFS to place fiducials in other solid tumors such as mediastinal lesions with lung CA, esophagus, cholangiocarcinoma. (Table 2). No migration of fiducials were noted during the mapping for radiotherapy in either cohort, and all patients successfully received SABR. No bleeding or other adverse events were noted.

CONCLUSION:
We believe that the endoscopic interventional community should adopt the use of PLS systems and work with radiation oncology to expand the use of EUS guided fiducial placement to solid malignancies that are accessible through EUS. This will reduce the number of interventions, the lag time to treatment and overall cost.
2830 Bowel Preparation Quality in a Multiethnic Population in a Safety Net Hospital
Authors: Zaki Timothy A. , Williams Renee L. , Lawrence Zoe , Goodman Adam J. 
Published: October 2019

INTRODUCTION:
Colonoscopy is the only colorectal cancer screening modality that permits direct visualization of the entire colon and removal of polyps. Low-quality bowel preparation has been associated with lower adenoma detection rates, increased procedure time, and increased hospital cost. An inadequate preparation limits the diagnostic accuracy and overall efficacy of colonoscopy. Factors that contribute to inadequate bowel preparations include age, male sex, inpatient status, low socioeconomic status, low English proficiency, obesity, diabetes, and cirrhosis. We investigated the complex relationship between socioeconomic factors and medical comorbidities on the quality of inpatient colonoscopy preparation.

METHODS:
We conducted a retrospective chart review of inpatient colonoscopies between October 2017 and April 2019. All patients received a single-dose preparation of polyethylene glycol. We collected data including demographics, medical history, indication, and bowel preparation. A Boston Bowel Preparation Score of 6 or above or an Aronchick score of “good” or “excellent” was used to define an adequate preparation.

RESULTS:
A total of 230 patients were included in the final analysis (Table 1). An inadequate bowel preparation was reported in 16.1% of our inpatient colonoscopies. Within the inadequate preparation group, a greater percentage of patients were male (17.3% vs. 12.3%), had low English proficiency (18.3% vs.15.3%), were not diabetic (17.7% vs.12.3%), and did not have prior bowel surgery (16.4% vs. 0.0%). Within the age, race/ethnicity, and insurance subgroups, patients who were age 80+ (21.4%), Asian-American (25%), unreported race/ethnicity (29.4%), uninsured (25%), and prisoners (22.8%) had a greater percentage of inadequate preparation (Table 2). A logistic regression was performed to assess the effects of age, sex, race/ethnicity, insurance, English fluency, diabetes, restricted mobility, and prior surgery on bowel preparation. The logistic regression model was not statistically significant.

CONCLUSION:
No significant socioeconomic or medical predictors of bowel preparation were found in this inpatient population which is in contrast to prior literature. While less than 20% of our patient population had inadequate bowel preparation, this is still significant in the broader context of quality, safety, and healthcare costs. Identifying strategies to increase the quality of bowel preparation still remains at the forefront of our field.
2832 Real Life Impact of Physician Awareness of a Positive Stool DNA Test on Subsequent Colonoscopy Outcome in Colorectal Cancer Screening
Authors: Huq Nadia , Fahed Gracia , Affi Aboud , Fahed Julien 
Published: October 2019

INTRODUCTION:
A recent study that included 244 subjects has looked into clinical outcome of colonoscopy based on the physician’s awareness of the positive result. That study showed significant differences in colonoscopy findings. We present a larger real-life study on the impact of physician awareness of a positive stool DNA test on colonoscopy results.

METHODS:
Chart review of 1413 patients who had a positive stool DNA followed by documented subsequent colonoscopy was done. Attention was made to the indication of the procedure in the colonoscopy report. A total of 5 patients were excluded, 3 of them had unknown indication and 2 of them had a finding of “other carcinoma” aside from adenocarcinoma. Index lesions were recorded and patients were divided in 2 groups. Group 1 included patient who had indication of “stool DNA testing” or its equivalent, while group 2 included all the other indications assuming that the provider was not aware of the positive stool DNA testing. Advanced adenoma was defined as an adenoma that is larger than 10 mm or had high risk features such as villous transformation or high grade dysplasia. Nonadvanced adenoma was defined as an adenoma that is smaller than 10 mm and had no high risk features. Statistical analysis with Chi-square was done to compare the proportions. A P-value < 0.05 was considered to be statistically significant.

RESULTS:
Out of the 1408 patients included in the analysis, 979 (70%) patients had an indication of “stool DNA testing” or its equivalent while 429 (30%) had another indication. Results of group 1 and group 2 were as follows. “Adenocarcinoma” was found in 1.84% vs. 1.4% respectively (P = 0.56). “Advanced adenoma” was found in 24.82% vs. 21.21% respectively (P = 0.14). “10 mm adenoma” was found in 7.25% vs. 6.99% respectively (P = 0.86). Non advanced adenoma was found in 28.7% vs. 31.24% respectively (P = 0.57). Finally, no adenomas were found in 37.39% vs. 39.16% respectively (P = 0.33).

CONCLUSION:
Following a positive stool DNA test, 1 out of 3 colonoscopies are done without the physician’s awareness of the positive result. Fortunately, there was no difference in the outcome of colonoscopy whether the physician was aware of the positive result or not.
2868 A Single Academic Institution Experience With Caustic Ingestion to the Gastrointestinal Tract
Authors: Argueta Erick A. , Ferreira Kaio , Sukrit Jain , Rupawala Abbas , Bakhit Mena 
Published: October 2019

INTRODUCTION:
Patients with caustic ingestion present with a range of gastrointestinal (GI) manifestations. The severity of injury depends on the type of substance ingested, its concentration, and duration of contact with the GI mucosa. Apart from usual supportive care, esophagogastroduodenoscopy (EGD) performed within 24 hours of ingestion is generally recommended. This study reports clinical, endoscopic features and hospital outcomes in patients presenting following ingestion of a caustic agent at a single large academic center.

METHODS:
A retrospective chart review was performed at two academic hospitals between January 2000 and October 2018 in adult patients presenting with caustic ingestion. Demographic data, type of ingestion, endoscopy and computed tomography (CT) findings, in-hospital mortality and length of stay (LOS) was collected. (Table 1).

RESULTS:
A total of 89 patients were included in the study. Suicidal ingestion occurred in 49.4% cases compared to accidental. The mean age was 43 ± 20 years with 50.6% males. Ingestion of alkalis (81.0%) was higher than acids (15.7%). The most common presenting symptom was vomiting (31.5%). Endoscopy was performed in 54 patients (60.7%) with 45 (83.3%) performed within 24 hours. Endoscopic findings are summarized in Table 2. Patients undergoing endoscopy had a longer duration of hospitalization (5.58 vs 1.67 days, P < 0.001). Patients with Zargar grade 0 had shorter hospitalization compared to those with grade IIA-IIB esophagitis (2.87 vs. 7.53 days, P < 0.001). However, there was no difference in LOS when comparing grade II to III esophagitis (8.4 vs. 11.2 days, P = 0.238). All patients with grade IIA-IIIB were started on a PPI during hospitalization. Only 19.1% of patients had a CT with the majority (70.6%) being normal. Death occurred in 3 patients.

CONCLUSION:
In this single center cohort, patients mainly presented with alkali ingestion with varying symptoms. An endoscopy was performed in about 60% patients, most within 24 hours and the majority of patients demonstrated Zagar scores of 0 or 1. Despite recent data suggesting cross-sectional imaging as a triage tool, its utilization in this academic center was limited. Implementing a CT-first strategy prospectively may provide additional data and may minimize the utilization of inpatients endoscopy. To our knowledge, this is one of the largest samples to date on caustic ingestion in the United States.