bluuebunny/crossref_metadata_2025_split huggingface dataset:
1710 Symptomatic Concomitant Sarcina Associated Erosive Esophagitis and Refractory Helicobacter pylori Gastritis
Authors: Chan Matthew , Jain Deepanshu , Minimo Corrado , Platt Alison 
Published: October 2019

INTRODUCTION:

Sarcina is a gram-positive, non-motile, anaerobic cocci that was first identified in the gastric contents of humans by John Goodsir in 1842. Since then, its precise pathogenetic role in humans still remains unclear, as clinical observations have ranged from asymptomatic to life-threatening complications such as gastric perforation and emphysematous gastritis. Our review of literature yielded a total of 7 case reports which reported 8 patients with Sarcina on esophageal biopsies. Two of these had concomitant H. pylori gastritis. We report the third case of Sarcina of the esophagus associated with H. pylori gastritis.

CASE DESCRIPTION/METHODS:
A 70-year-old woman presented to the Gastroenterology clinic with an increase in abdominal discomfort, nausea, and vomiting over the past several months. She had previously been taking Omeprazole for reflux symptoms without relief and Naproxen for joint pain. She underwent an EGD, which showed erythematous mucosa in the distal esophagus, gastropathy, and a hiatal hernia. Targeted esophageal and gastric mucosal biopsies showed erosive esophagitis with many colonies of Sarcina species and chronic gastritis with H. pylori infection, respectively. Patient was prescribed tetracycline, metronidazole, and bismuth subsalicylate for two weeks and her omeprazole increased to twice daily for treatment of both infections. After completing the treatment regimen, the patient reported having little improvement in symptoms. Repeat EGD showed normal appearing mucosa of the esophagus, stomach, and duodenum. Esophageal biopsies showed normal squamous mucosa. Gastric biopsies showed persistent H. pylori gastritis. She was started on a salvage treatment regimen of levofloxacin, amoxicillin, and omeprazole for two weeks. Repeat testing was noted for persistent H. pylori infection.

DISCUSSION:
In our case, we treated our patient with antibiotics and a proton pump inhibitor, which covered for both Sarcina and H. pylori infections. However, minimal improvement in our patient's symptoms despite successful Sarcina eradication and persistent H. pylori infection suggests that although there was endoscopic and histologic evidence of esophagitis, the majority of patient symptoms were likely due to H. pylori or non-infective etiology. This finding supports those who favor Sarcina to being a benign pathogen in the GI tract. It is unclear if H. pylori gastritis in any way can be associated with Sarcina esophagitis, but this case definitely raises a question.
1712 Detection of Sub-Surface High-Grade Dysplasia Following Radiofrequency Ablation (RFA) of Barrett’s Esophagus
Authors: Bsrat Makda , Kassim Gassan , Hershman Melissa , Tan Amy , Rubinov Jason , Alialy Roshanak , Smith Michael S. 
Published: October 2019

INTRODUCTION:
Barrett's esophagus (BE) occurs when intestinal epithelium replaces squamous epithelium normally lining the distal esophagus. BE is associated with an increased risk of esophageal adenocarcinoma (EAC). While traditionally associated with Caucasian males, prevalence of BE and EAC in Asian populations is projected to rise, associated with increasing prevalence of gastroesophageal reflux disease (GERD), which is associated with obesity and hiatal hernia. Radiofrequency ablation (RFA) is an endoscopic treatment modality shown to be safe and effective in inducing reversion to squamous epithelium, with a treatment depth of 500-1000 microns. We present a case of BE with high-grade dysplasia identified on random forceps biopsy after RFA for BE with low grade dysplasia, after which significant sub-surface disease was detected by volumetric laser endomicroscopy (VLE).

CASE DESCRIPTION/METHODS:
A 72 yo Chinese male was diagnosed with short-segment BE containing low grade dysplasia, and was treated with 2 sessions of focal RFA 5 months apart. He was lost to follow up and re-established care two years later. At presentation, the patient denied any heartburn, dysphagia or weight loss. Surveillance endoscopy with white light and narrow band imaging (Figure 1) revealed short tongues of salmon-colored mucosa suspicious for residual BE. Forceps biopsy confirmed BE with high grade dysplasia at the 12:00 position. Repeat endoscopy using VLE demonstrated suspicious-appearing glands, primarily sub-surface, which were laser marked and resected with band ligation and snare instead of forceps biopsy (Figure 2). Pathology results confirmed high-grade dysplasia within BE (Figure 3). Due to the presence of dysplasia deeper into the epithelium, in the setting of prior RFA, the patient was referred for liquid nitrogen spray cryotherapy.

DISCUSSION:
Residual or recurrent BE following RFA is a relatively common finding, but it is uncommon to see disease with a higher dysplasia grade than what was found pre-treatment. In this case, the use of VLE to evaluate these findings identified deeper disease that may not have been amenable to initial RFA treatment, with the lesion becoming “buried” after incomplete ablation. VLE, which visualizes the esophageal wall to a depth of 3 mm, should be considered as part of the evaluation of residual BE, especially when dysplasia is present. Its use may improve patient outcomes by leading to an alternate approach to both tissue sampling and further treatment selection.
1713 Dark Side of the Esophagus
Authors: Makedon Alan , Botros Youssef , Volfson Ariy 
Published: October 2019

INTRODUCTION:
Esophageal melanosis a rare disease of the digestive system which is characterized by melanocytic proliferation in the squamous epithelium of the esophagus and melanin accumulation of esophageal mucosa (EM). It was first described by De la Pava in 1963. The disease is extremely rare in Western countries and most of the previously reported cases were diagnosed in Japan and India. Despite an unclear pathogenesis, esophageal melanosis hypothesized to arise from chronic irritation of the esophageal mucosa that stimulate keratinocyte differentiation and subsequent hyperplasia in the basal epithelial layer of EM. Differential diagnoses of esophageal melanocytosis from its histologic mimics include benign melanocytic nevi and malignant melanoma. Esophageal melanosis has been reported to be the precursor lesion for esophageal melanoma. We report a case of esophageal melanosis in a 61-year-old woman who had esophagogastroduodenoscopy (EGD) done for dyspepsia.

CASE DESCRIPTION/METHODS:
A 61-year- old female with past medical history of hypertension presented to the gastroenterology service for persistent dyspepsia. She had a 10 pack-year smoking history. She had no history of acid reflux. Physical examination and blood work were unremarkable. EGD was performed and showed a pigmented (black) flat mucosal lesion in the middle third of the esophagus. Multiple biopsies were obtained. Histopathology showed squamous mucosa, with an organized cellular architecture, surface maturation, and lack of cellular atypia but with an increased lymphocytic infiltrate of the epithelium, with an increase in melanocytosis consistent with the features of esophageal melanosis. The patient was started on a proton-pump inhibitor with recommendations to repeat EGD in 1 year.

DISCUSSION:
Currently, one theory of esophageal melanosis pathogenesis implicates aberrant melanocyte migration during fetal development. Another theory suggests that esophageal melanosis arises from keratinocytic differentiation and subsequent hyperplasia in the basal epithelial layer of EM as a result of chronic acid reflux, Addison’s Disease, or chronic inappropriate eating. It is possible that combination of both conditions is likely to be stronger. Chronic alcohol use, cigarette smoking, diet and hereditary factors might also be associated with development of esophageal melanosis. Recognition of this lesion on endoscopy is important given the potential differential diagnosis including esophageal melanoma.
1714 A Case of a Primary Large Cell Neuroendocrine Carcinoma of the Esophagus Disguised as a Food Impaction
Authors: Patel Harsh D. , Beck Jared , Kataria Archish , Echavarria Juan 
Published: October 2019

INTRODUCTION:
Neuroendocrine carcinomas (NECs) are defined epithelial neoplasms with predominant neuroendocrine differentiation. They primarily arise from the gut and bronchopulmonary systems with the possibility of distant metastasis. We present a case of an esophageal neuroendocrine neoplasm with unique endoscopic/radiographic features on presentation disguised as a food impaction.

CASE DESCRIPTION/METHODS:
A 50-year-old Caucasian male with past medical history of tobacco dependence; presented to the ED with complaints of solid food dysphagia for 1.5 months with unintentional weight loss of 15 lbs and intractable hiccups. On arrival, he was hemodynamically stable. Physical exam was unremarkable. Laboratory testing revealed mild normocytic anemia of 12.3, otherwise unremarkable. An upper endoscopy was performed revealing a large amount of meat in the mid-esophagus; however, after further manipulation there appeared to be bleeding from the mucosa (Figure 1). Upon closer inspection, a mass originating from the lateral esophageal wall was caked with food debris giving it the appearance of meat. CT Chest was performed showing a large heterogenous esophageal mass (8.1 cm v 5.7 cm) extending from the mid-esophagus to the GE junction with no evidence of direct invasion (Figure 2). Biopsies returned positive for large cell neuro-endocrine carcinoma with diffuse synaptophysin and Ki67 positivity. PET-CT performed as outpatient showed prominent peri-gastric lymphadenopathy. EUS was attempted but failed due to inability to pass the ultrasound scope. CT surgery subsequently performed a McKeown transthoracic esophagectomy for definitive therapy as outpatient. He recovered well from the procedure with positive radial margins and lymph nodes on pathology and is now undergoing adjuvant radiation and chemotherapy.

DISCUSSION:
Esophageal NEC is a rare entity with a generally dismal prognosis when high-grade. A study out of a large volume, tertiary center reported approximately 40 cases over a 20-year period. Given the sparsity of esophageal NECs, most studies are retrospective case series and are from outside the USA. It is reported that esophageal NECs represent only 0.4-1.4% of the gastrointestinal NECs a majority of which arise from the mid-esophagus. To our knowledge, there is no reports of a single case with similar endoscopic and radiographic findings which makes it unique. There is also limited data reported on the endoscopic/phenotypic appearance of large cell neuroendocrine carcinomas of the esophagus.
1716 Esophageal Squamous Cell Carcinoma-Associated Dancing Eye Syndrome in an Adult: Negative Paraneoplastic Antibodies Screen and Rapid Response to Intravenous Immunoglobulin and Methylprednisolone
Authors: Hammami Muhammad B. , Aboushaar Reem , Azhar Mishah , Musmar Ahmad , Miller Stephen M. , Salomon Peter 
Published: October 2019

INTRODUCTION:
Dancing eye or opsoclonus-myoclonus syndrome is a rare paraneoplastic syndrome that has been mostly associated with small cell lung cancer. It was reported in association with esophageal cancer in one case. Here we report a second case.

CASE DESCRIPTION/METHODS:
A 59-year-old man presented with 5 weeks of rapidly worsening vertigo and gait difficulty that lead to frequent falls and inability to perform daily activities. About 5 weeks prior to presentation, he completed three rounds of cisplatin and 5-FU for recently diagnosed squamous cell carcinoma of the esophagus. He had long standing hypertension treated with hydrochlorothiazide, lisinopril, and carvedilol, and diabetes mellitus treated with glipizide, glyxambi, and sitagliptin. He denied alcohol, tobacco, or illicit drug use and recent viral infection. He was fully alert and oriented and afebrile. He had spontaneous, involuntary, arrhythmic, conjugate, multidirectional saccades occurring in all directions of gaze without a saccadic interval and pronounced ataxia on standing associated with unsteadiness. Complete blood count and routine chemistry were unremarkable. Brain MRI with and without contrast revealed no evidence of intracranial hemorrhage, mass lesion, acute infarct or pathologic enhancement. HIV screen was negative. Hepatits C virus antibody was non-reactive. Paraneoplastic autoantibodies screening was negative. He received 5 day course of 0.4g/kg/day intravenous immunoglobulin (IVIG) and 250 mg BID methylprednisolone with marked improvement of rhythmic eye beating at rest, coordination of multidirectional eye movements, ataxia, and vertigo by day 3. He was discharged to acute rehabilitation facility on day 8.

DISCUSSION:
Our patient has dancing eye or opsoclonus-myoclonus syndrome that followed the diagnosis of esophageal cancer and rapidly responded to IVIG and methylprednisolone, strongly suggesting a paraneoplastic association. Interestingly and consistent with the single case previously reported of this association, paraneoplastic autoantibodies screen was negative.
1717 “Dissec-ting” the Etiology
Authors: Rojas Patricia Guzman , Riestra Irene , Gonzaga Ernesto Robalino , Katukuri Vinay , Parikh Jignesh , Blonski Wojtek 
Published: October 2019

INTRODUCTION:
Esophagitis dissecans superficialis (EDS) was first described in 1892. It is a rare and benign desquamative disorder characterized by sloughing of the esophageal mucosa. EDS has been linked to coronary artery disease, chronic kidney disease, autoimmune conditions (celiac disease and pemphigus vulgaris) and medications known to damage the gastrointestinal tract. However, most cases are idiopathic.

CASE DESCRIPTION/METHODS:
A 48-year-old male with a PMH of GERD presented to the Gastroenterology clinic with a 6-month history of esophageal dysphagia to solid foods. He denies any nausea, vomit, abdominal pain, hematemesis or episodes of melena. Esophagogram revealed delay of the barium tablet (Figure 1). The patient underwent an EGD showing sloughing of the mucosa in the entire esophagus along with LA grade C esophagitis (Figure 2). Biopsies were taken from the proximal and distal esophagus with findings compatible with esophagitis dissecans superficialis (Figure 3). Ranitidine and PPI were continued and he was scheduled for a follow appointment in 6 weeks.

DISCUSSION:
EDS is typically seen in middle aged women, and is commonly misdiagnosed due to the lack of diagnostic or histologic criteria. Endoscopic features consist of esophageal mucosa with multiple columns of strips that have whitish/pearly appearance andsloughs which are > 2 cm in length, and lack of ulcers in the surrounding mucosa. These findings can be mistaken with esophageal candidiasis, eosinophilic esophagitis, lichen planus and even squamous cell carcinoma. For this reason, the diagnosis is made through histopathologic findings such as parakeratosis and intraepithelial splitting above the basal layer. As in our patient, dysphagia is frequently reported, but nonspecific symptoms like nausea, vomiting or heartburn are also found. There are no specific treatment guidelines. Nevertheless, acid suppressants can be started to aid mucosa healing. Some patients can present with esophageal strictures, but this entity mainly follows a benign course as it shows self-resolution from 8 weeks to 4 months of diagnosis. This case shows the importance of recognizing EDS not only as an underreported cause for dysphagia, but also as an important differential diagnosis for esophageal diseases. It is important to obtain mucosal biopsies in order to get a proper diagnosis and avoid unnecessary treatments.
1719 Esophageal Adenocarcinoma Arising From <1 cm of Intestinal Metaplasia at the Gastroesophageal Junction: Is <1 cm Actually Low Risk?
Authors: Ahuja Amisha , Elden Andrew C. , Tofani Christina , Infantolino Anthony 
Published: October 2019

INTRODUCTION:
Barrett’s esophagus (BE) is defined by length, which has been shown to correlate with the risk for esophageal adenocarcinoma (EAC). Although long-segment (>3 cm) and short-segment (between 1 and 3 cm) BE are well-established definitions, current ACG practice guidelines recommend against defining columnar goblet-cell metaplasia in the distal esophagus <1 cm as BE. This specific variation of metaplasia disease has been officially defined as “specialized IM of the esophagogastric junction” (SIM-EGJ) over alternatives such as ultra-short segment BE. Given the relatively low incidence of EAC in this group and the high degree of inter-observer variability in defining metaplasia of this length, current guidelines recommend against biopsy in this setting. Individual cases in practice however have demonstrated reasons to question this paradigm.

CASE DESCRIPTION/METHODS:
A 42 year old white man with obesity and 10 years of reflux symptoms was diagnosed with a GE junction nodule on index endoscopy. Cold forceps biopsy of the nodule revealed high grade dysplasia, prompting referral to the BE Treatment Center at Thomas Jefferson University Hospital (TJUH). His repeat EGD revealed salmon-colored mucosa suggestive of intestinal metaplasia in an area less than 1 cm in length (Z-line at 39 cm). An 8 mm nodule was identified in the area of abnormal mucosa and removed by endoscopic mucosal resection. Pathology of the nodule revealed a T1a moderately differentiated intramucosal adenocarcinoma arising in BE. All margins were negative for invasive carcinoma, dysplasia, and intestinal metaplasia. The patient patients underwent endoscopic eradication therapy (EET) with radiofrequency ablation at the GE junction and in subsequent endoscopy achieved complete eradication of intestinal metaplasia (CE-IM) and dysplasia (CE-D).

DISCUSSION:
Although current guidelines advise against biopsying <1 cm of variability in Z line given its status as a relatively low risk lesion, data used to generate many of these risk predictions for EAC exclude visible lesions in their studies. Therefore in practice there may be under-evaluation of SIM-EGJ, potentially missing advanced dysplastic or cancerous disease. This case illustrates that the consideration BE risk factors and all endoscopic findings, such as nodules, need to be taken together when assessing abnormal mucosa at the GE junction, even with <1 cm variability of the Z line.
1723 Esophageal Granular Cell Tumour: An Unusual Polypoid Lesion
Authors: Bandaru Praneeth , John Febin , Tsipotis Evangelos , Etienne Denzil 
Published: October 2019

INTRODUCTION:
Esophageal granular cell tumours (GCTs) account for 1% of all Esophageal tumors and up to two-third occur in the distal third of Esophagus. Since first reported in 1931 approximately 400 cases have been reported so far. We report a case of Esophageal GCT incidentally found on endoscopic evaluation for resistant GERD.

CASE DESCRIPTION/METHODS:
A 42-year-old Hispanic male was seen for evaluation of refractory GERD and occasional dysphagia to solids of 3-month duration. There were no alarm symptoms or use of NSAIDs. Physical examination and labs were unremarkable. EGD was performed that showed a 4mm yellowish, sessile, subepithelial nodule with intact mucosa in the distal Esophagus (Figure 1). Biopsy showed clusters of polygonal cells with abundant granular cytoplasm that was Periodic acid–Schiff (PAS) positive suggestive of GCT. Immunohistochemical staining was positive for S100, CD 68, CD56 and Vimentin, thus conforming the diagnosis of GCT (Figure 2). EUS performed subsequently showed a 4mm, submucosal, hypoechoic, homogenous mass with no extension into muscularis propria (Figure 3); completely removed by hot snare technique with pathological conformation. Patient was discharged home with close endoscopic surveillance.

DISCUSSION:
Granular Cell Tumors (GCTs) arise from Schwann cells of the nerve sheath with incidence of about 0.03% and has a predilection towards skin, oral cavity and breasts. Of all GCTs, 6-8% occur in the GI tract with esophagus (65%) being the most common site. It has predilection towards females and African Americans between 40-60 years of age. Generally asymptomatic and found incidentally during endoscopy. However, GERD and dysphagia are associated with GCTs of more than 2 cm in size. EUS is invaluable in differentiating GCTs from other subepithelial tumors, determining size, depth and invasion. Biopsy/FNA can be performed during the initial endoscopy or during EUS. Definitive diagnosis is by histopathology and immunohistochemical staining. The treatment of esophageal GCTs is controversial. Conservative management is recommended for tumors <1 cm, asymptomatic, no deep tissue invasion or malignancy. However, resection is warranted for symptomatic tumors, >1 cm size, with deep tissue invasion or malignancy. Endoscopic removal is preferred over surgery for tumors without deep tissue infiltration or malignant. Endoscopic and histologic surveillance every 1-2 years is recommended.
1726 A Tough Pill to Swallow: A Rare and Unusual Case of Recurrent Esophageal Candidiasis
Authors: McDonald Emmanuel , Trejoss Marisol , Choi David , Panicker Linoj , Frontela Odayls , Sobrado Javier 
Published: October 2019

INTRODUCTION:
Esophageal candidiasis (EC) is one of the most common infections in immunocompromised individuals. Fungal infections, particularly in the esophagus, have been found in individuals with predisposing factors, such as uncontrolled diabetes mellitus, gastric acid suppression, malignant neoplasms, corticosteroids, antibiotics, or immunosuppressant use. Factors that suppress cellular immunity often cause opportunistic fungal infections; however, little is known regarding significant risk factors in individuals who are immunocompetent. For our study, we report a rare and unusual case of a 58 year old immunocompetent male who presented with recurrent esophageal candidiasis.

CASE DESCRIPTION/METHODS:
EC is not a rare complication for individuals who are immune compromised or who are uncontrolled diabetics; however, our case is unique and rare because our patient did not have the typical comorbidities associated with esophageal candidiasis. The patient had a PMHx of well-controlled DM type 2, HIV (-), diet controlled GERD who is not taking PPI therapy who presented with a 20 pound weight loss and dysphagia to solids. An EGD revealed a benign gastric mass and esophageal candida, then treated with Fluconazole. After completion of therapy, he returned with dysphagia, abdominal pain, weakness, and weight loss, requiring hospitalization. A repeat EGD revealed a second EC infection, this one an ulcerated EC infection, which was treated with IV Fluconazole. On outpatient follow up after discharge, the patient underwent CT scan of abdomen/pelvis. It showed moderately thickened and dilated esophageal walls, bullae, and migration of the stent into the stomach which had been placed previously. Additional findings on imaging include, bilateral renal masses, left para-aortic adenopathy, and loculated fluid collection in the abdomen. Consequently, the patient underwent another EGD to remove the stent and was sent to Oncology for further care.

DISCUSSION:
Our patient’s clinical manifestations, initial findings, and developmental course of the presenting illness in this patient makes this case particularly rare and unusual in terms of assessment and diagnosis. EC in an immunocompetent patient is rare; however, recurrent EC is even rarer. At this time there is limited data reported on attributable causes of EC, especially in individuals without predisposing factors. Thus, this case highlights the need for further investigation regarding the mechanisms of colonization and its development in such individuals are needed.