bluuebunny/crossref_metadata_2025_split huggingface dataset:
2036 A Rare Cause of Obscure Gastrointestinal Bleeding
Authors: Som Aniruddh , Nath Anand , Lee Zone-En 
Published: October 2019

INTRODUCTION:
Serrated adenomas are most commonly detected in the colon and characterized by the saw-tooth-shaped infoldings of the mucosa and crypt epithelium. It is a precursor precancerous lesion accounting for 10–30% of all colorectal carcinomas. Serrated adenoma in the small intestine have been reported much less frequently and are localized predominantly in the duodenum, with jejunal adenomas being rarer (< 10 cases). We hereby describe a case of recurrent melena in the setting of a jejunal serrated adenoma.

CASE DESCRIPTION/METHODS:
A 63-year-old male with a past medical history of CAD, ischemic cardiomyopathy with ejection fraction 10-15%, paroxysmal A Fib, PE on warfarin presented to the hospital in acute decompensated heart failure. After further workup and evaluation, the patient underwent LVAD placement. The hospital course was complicated by respiratory failure requiring intubation and cardiogenic shock requiring inotropes. He then had an episode of melena with a fall in hemoglobin from 9.4 to 7.0 gm/dl on anticoagulation. He underwent push enteroscopy that revealed a pedunculated jejunal polyp with active bleeding noted in the proximal jejunum. This was resected, clipped and the site was tattoed leading to stabilization of his hemoglobin.10 days later the patient had a repeat episode of melena after resumption of anticoagulation. Repeat push enteroscopy showed visible bleeding vessel adjacent to jejunal tattoo treated with epinephrine injection and bicap cautery. The pathology report was consistent with serrated adenomatous polyp of the jejunum. The patient recovered well after the repeat procedure and is doing well after resumption of anticoagulation.

DISCUSSION:
The small bowel accounts for 75% of the length of the alimentary tract yet small intestinal serrated adenomas are extremely rare. They are challenging to diagnose because of their nonspecific presenting symptoms. Barium GI series or CT scans are not sensitive in detecting lesions smaller than 4 cm. Enteroscopy is an ideal tool in evaluating these cases with obscure GI bleeds. Although the morphology of small bowel serrated adenoma resembles that of traditional adenomas of the colon, the biomolecular alterations and biological behaviors indicate a distinct subtype with more aggressiveness and higher malignant potential. Hence they need therapeutic resection either endoscopically or surgically based on an assessment of their size and location. Given the paucity of data, currently, there is no consensus on surveillance interval.
2037 Intestinal Spirochetosis: An Unexpected Cause of Massive Gastrointestinal Bleed
Authors: Bilal Muhammad , Umar Anam , Chang Eric Y. , Abe Temidayo , Simien Melvin 
Published: October 2019

INTRODUCTION:
Human intestinal spirochetosis (HIS) is a condition characterized by the presence of spirochetal microorganisms attached to the apical cell membrane of the colorectal epithelium leading to chronic diarrhea. The invasive form of this disease is more often seen in HIV patients or homosexual individuals. Here, we present a rare case of HIS presenting as lower gastrointestinal (GI) bleed and abdominal pain in the absence of diarrhea.

CASE DESCRIPTION/METHODS:
A thirty-year-old male with a history of peptic ulcer disease (PUD) and HIV (CD4 >250) presented to the emergency department with a two-days duration of severe, generalized abdominal pain and bleeding per rectum. On presentation, the patient was hypotensive (mean arterial pressure < 65) and tachycardic (heart rate 120). Physical examination revealed generalized abdominal tenderness with normal bowel sounds but no rebound tenderness or guarding. Labs were significant for anemia (Hemoglobin 6.5 g/dl; baseline >14 g/dl). The rest of his labs including serum chemistry, white blood cells, amylase, lipase levels, were within normal limits. Due to the patient’s significant history of PUD and concern for rapid GI bleed, aggressive fluid resuscitation and proton pump inhibitor infusion were initiated. He also received two units of packed red blood cells with good toleration. CT scan of the abdomen/pelvis did not reveal any acute intraabdominal pathology. Despite the achievement of hemodynamic stability, the patient continued to have bright red blood per rectum. Extensive infectious workup (including blood cultures and stool tests such as stool culture, ova, and parasites) were negative. Esophagogastroduodenoscopy was performed and revealed well healed PUD without any signs of bleeding. Colonoscopy, however, revealed pan-colonic ulcers, most pronounced in the descending colon. Histopathology revealed spirochetal microorganisms attached all the way from the ascending colon to the rectum consistent with invasive HIS. Metronidazole was initiated with significant clinical improvement and he was subsequently discharged home with appropriate outpatient follow up.

DISCUSSION:
Most cases of HIS are asymptomatic and often diagnosed during screening/surveillance colonoscopy. Thus, data regarding symptomatic patients is scant. The few cases describing affected patients generally associate infection with chronic watery diarrhea, acute appendicitis or intermittent hematochezia. Metronidazole is an effective treatment of choice in symptomatic patients.
2041 Successful Treatment of Ulcerative Colitis and Seronegative Inflammatory Spondyloarthritis Using Concomitant Vedolizumab and Tofacitinib: A Case Report
Authors: Lee Joy A. , Magavi Pooja R. , Konijeti Gauree G. 
Published: October 2019

INTRODUCTION:
Inflammatory bowel disease (IBD) encompasses ulcerative colitis (UC) and Crohn’s disease, two chronic digestive diseases that fall on a clinical spectrum. While they overlap in some ways, many of their defining characteristics are distinct. The management of IBD continues to evolve. Combination therapy has emerged as a strategy to achieve remission through various mechanisms. The use of multiple agents with distinct molecular targets may be the key to helping patients achieve steroid-free remission.

CASE DESCRIPTION/METHODS:
55-year-old female with pan-UC and seronegative HLA B27 inflammatory spondyloarthritis, both with partial response to adalimumab, presented with abdominal pain, diarrhea, and rectal bleeding. C-reactive protein and tissue transglutaminase IgA were normal. Stool testing was negative for pathogens. Colonoscopy revealed moderate, active pan-UC (Mayo 2) without dysplasia. The patient was switched to infliximab, with inadequate response. Given the limited efficacy of anti-TNF therapy, vedolizumab was initiated. Despite vedolizumab dose escalation to q5weeks, she continued to have intermittent abdominal pain, loose stools, and arthralgias. Fecal calprotectin was < 100 ug/g. Vedolizumab trough level was > 40 ug/mL without anti-drug antibodies. Subsequent add-on trials of mesalamine and methotrexate were unsuccessful. Repeat colonoscopy showed mild, diffuse colonic erythema without erosions (Mayo 1), with active colitis in the proximal and distal colon and inactive colitis in the rectum. Despite steroid-free response, the patient’s abdominal and arthritic symptoms persisted. Thus, tofacitinib (5 mg twice daily) was added, with resolution of all symptoms. Colonoscopy after 6 months on combination therapy showed normal colonic mucosa (Mayo 0) and inactive colitis.

DISCUSSION:
Although the response to treatments for moderate-to-severe UC remains low, combining newer therapies with differing mechanisms of action may improve remission rates, particularly in refractory patients. However, cost and the risk of adverse reactions must be determined before initiation. Vedolizumab, a gut-specific anti-integrin with a favorable safety profile, led to improvement in our patient’s UC, but not her arthritis. The addition of tofacitinib, a janus kinase inhibitor, led to resolution of arthralgias and remission of UC. Randomized trials evaluating combination therapy in IBD may help guide future management of patients with refractory UC.
2052 Crohn's Disease and Rare Renal Extra-Intestinal Manifestations: Two Case Reports
Authors: Simmelink Andrew , Spence Linsey , Hanson John 
Published: October 2019

INTRODUCTION:
Crohn's Disease (CD) diagnosis is usually based on the presence of gastrointestinal symptoms and findings. Extra-intestinal manifestations (EIMs) occur in up to 50% of patients with CD. We present two cases of rare renal EIM associated with CD activity.

CASE DESCRIPTION/METHODS:
Case 1: 31 yo white male w/ ileal-colonic CD diagnosed in 2014 presents with 6 weeks of diarrhea, abdominal pain, fatigue, and frothy urine. 3 years prior he developed biopsy proven acute interstitial nephritis from mesalamine which resolved with cessation and steroid taper. He is not on any medications. Laboratory analysis reveals: BUN 40 mg/dL, Cr 6.06 mg/dL, GFR of 13 mL/min, CRP 4 mg/dL, urinalysis with 25 RBCs and no leukocytes, urine protein/creatinine ratio (Pr/Cr) of 1.6, and negative serologies for HIV, HCV, HBV, ANA, ANCA. Complement levels were normal. Renal biopsy shows tubular interstitial nephritis (TIN) with lymphocytic T-cell infiltrate with interstitial fibrosis and tubular atrophy. Random colon biopsies show mild active pan-colitis with non-necrotizing granulomas and normal terminal ileum. He is treated with a slow prednisone taper and adalimumab, but does not have renal recovery resulting in a kidney transplant. Immunosuppression includes tacrolimus, mycophenolate mofetil, and prednisone. Follow-up CD monitoring reveals no symptoms and negative fecal calprotectin. Case 2: 21 yo healthy white female presents with 3 months of watery diarrhea, abdominal pain, and fevers up to 103 F. She is on no medications. Laboratory analysis reveals: Hgb 8.4 g/dL, normal BUN, and a Cr of 1.8 rising to 2.6 mg/dL. Urinalysis with 4 RBCs, 39 leukocytes with negative culture, positive urine eosinophils, Pr/Cr 0.36, CRP of 17 mg/dL, and negative serologies as in case 1. Colonoscopy reveals moderate pan-colitis with non-necrotizing granulomas. Renal biopsy reveals granulomatous interstitial nephritis. She improves with a prolonged steroid taper but has persistent but mild colitis on evaluation. She has no renal recovery but does not require dialysis.

DISCUSSION:
Renal EIMs of CD are rare. Most commonly they include nephrolithiasis in 28% CD, medication adverse effects, amyloidosis, as well as CD activity correlated TIN and glomerulonephritis. There is no standard treatment for TIN, but a prolonged steroid taper, MMF, cyclosporine, and anti-TNF therapy may be attempted for CD and renal recovery. Both cases reveal renal recovery may not occur with significant immunosuppression and transplant may be required.
2056 CMV Colitis Superimposed on Ischemic Colitis in an Immunocompetent Individual
Authors: Surapaneni Balarama K. , Choksi Vivek , Sorathia Sufian , Patel Nehal , Yella Prashanth R. , Priyadarshni Shivani , Kasmin Franklin 
Published: October 2019

INTRODUCTION:
Cytomegalovirus (CMV) infections are more commonly seen in individuals with immunosuppressive diseases. We present a unique case of CMV colitis superimposed as ischemic colitis in an immunocompetent individual.

CASE DESCRIPTION/METHODS:
A 68-year-old man with history of PE (on Xarelto), pneumothorax & COPD presented with 10 weeks of diarrhea, associated with chills, lower abdominal discomfort, poor appetite, and weight loss of 15 pounds. Rectal exam showed dark stool and FOBT was positive Lab data showed elevated ESR and CRP. All stool studies were negative. CT Abdomen reported colonic findings suggestive of colitis with areas of active inflammation. Colonoscopy showed inflammation characterized by congestion (edema), erosions, granularity & ulcerations in a continuous and circumferential pattern from the sigmoid colon to the terminal ileum with sparing of mid & distal sigmoid colon and the rectum (Figures 1 and 2). Preliminary biopsies were suspicious for Crohns Disease. Patient was started on PO Prednisone 60 mgs daily & Pentasa TID and discharged for close follow up with GI. He kept on failing outpatient treatment, and was re-admitted twice with worsening of symptoms. Repeat CT scans showed worsening diffuse colitis. C Diff was checked, which was –ve. He was re-started on IV Abx, IV Steroids and supportive care. His symptoms continued to worsen, so Colorectal Surgery was consulted and, he underwent open subtotal colectomy. Pathology Slides from the Surgical Specimen were diagnostic for Ischemic looking bowel, and showed no features of IBD. So, decision was made to send the slides for second opinion. Meanwhile, he continued to deteriorate, so he was taken for emergent exploratory laparotomy and was found to have diffusely ischemic and distended bowel. Confirmation of pathology was not consistent with IBD. It showed Ischemic ileocolitis with possible superimposed CMV colitis with CMV inclusion bodies (Figure 3). IV Ganciclovir was initiated, steroids were discontinued. He began to improve, diet was advanced and was discharged with GI follow up.

DISCUSSION:
Suspicion of CMV colitis should be investigated by endoscopic evidence. The typical findings such as owl’s eye inclusion bodies on histology is specific for CMV. This is an unusual case of CMV associated ischemic colitis in an immunocompetent individual. This case report also should sound an alarm to GI physicians on thinking about CMV colitis infections even in immunocompetent individuals.
2071 Rare Case of Ulcerative Colitis With Autoimmune Hemolytic Anemia
Authors: Manoharan Suganya , Aloreidi Khalil , Gujjula Srilaxmi , Vachhani Akshaykumar , Reddy Madhavi , Etienne Denzil 
Published: October 2019

INTRODUCTION:
Inflammatory Bowel disease (IBD) encompasses Ulcerative colitis (UC) and Crohn’s disease. UC is a chronic inflammatory process causing inflammation limited to the mucosal layer of the intestine. Anemia can occur due to multiple reasons in UC - iron deficiency anemia, anemia of chronic disease and rarely autoimmune hemolytic anemia. Here, we present an UC patient with rare manifestation of autoimmune hemolytic anemia (AIHA).

CASE DESCRIPTION/METHODS:
Report: 42-year-old male with significant past medical history of UC was admitted because of diarrheal episodes, jaundice for one week. He discontinued mesalamine two months prior to presentation. His vital signs were unremarkable and physical exam were was significant for pallor. Pertinent labs include hemoglobin: 5.7 g/dl, WBC count: 11.8 k/mm3, MCV: 113 fl, RDW 20.8%., Total Bilirubin: 4.1 mg/dl with direct of 2.7 mg/dl, LDH 592 U/L, and Haptoglobin was 8 mg/dl and reticulocyte count: 14.3%. On further studies cold agglutinin were found to be positive. Peripheral smear showed significant polychromasia, anisopoikilocytosis, macrocytes, mild agglutinated RBC. Stool studies were negative as well. Patient was transfused two units of blood. Colonoscopy with biopsy confirmed active colitis throughout cecum, ascending colon, transverse colon, sigmoid colon and rectum. Colonoscopy didn’t reveal any bleeding. Subsequently, patient was started on mesalamine, which lead to improvement of his symptoms. Hemoglobin level remained stable. Patient was discharged on maintenance dose and to follow up with hematology and gastroenterology as outpatient.

DISCUSSION:
AIHA is a rare complication of UC. It occurs in less than 1 % of UC cases. It is associated with acute flare up of UC. AIHA is caused by presence of warm agglutinins present in the blood that’s mostly IgG which reacts with the proteins on RBC membrane at particular temperature and causing hemolysis. There are several mechanisms causing AIHA in UC, IgG autoantibodies targeted against the RBC, modification of RBC when they pass through the colon and absorption of the antibodies from the colitis lesions. The treatment includes steroids and mesalamine. For resistant cases, immunotherapy and splenectomy can be considered and the last resort being colectomy. It is important to keep AIHA as a differential for secondary causes of anemia in patient with UC. Further studies are needed for the pathogenesis and treatment of the same.
2078 Can Dosing Intervals of Adalimumab Be Increased in Crohn’s Disease?
Authors: Euers Lindsay , Glassner Kerri , Wilhite Amanda , Abraham Bincy 
Published: October 2019

INTRODUCTION:
Adalimumab is a recombinant monoclonal antibody that binds to human tumor necrosis factor alpha (TNF-a), thereby interfering with TNF-α receptor sites and cytokine-driven inflammation. There is limited data on de-escalation of adalimumab dosing to intervals greater than every other week (EOW) in Crohn’s disease. We present a case of a young man with Crohn’s who remained in clinical remission on adalimumab de-escalation dosing.

CASE DESCRIPTION/METHODS:
A 23-year-old man with Crohn’s disease presented to clinic in September 2018 in remission on adalimumab 40 mg every 7 weeks. He initially presented in January 2011 with bloody diarrhea, fever, anemia, leukocytosis and elevated ESR. Colonoscopy revealed a normal small bowel with pancolitis. He started oral budesonide and mesalamine, however due to lack of improvement he required escalation to biologic therapy with infliximab. Several months after initiation, he developed an infusion reaction and was switched to adalimumab. After induction, he went into clinical remission. At each yearly follow up his dosing interval was increased, until 2018 when he was on every 7 week dosing. In October 2018, inflammatory markers were normal and adalimumab level was low but detectable at 1.1 without drug antibodies, so dosing was increased to every 5 weeks. Colonoscopy in February 2019 revealed moderate inflammation in the descending, transverse and ascending colon with a total SES-CD score of 12. He is scheduled to have a repeat adalimumab level drawn before his next infusion.

DISCUSSION:
Recommended maintenance dosing for adalimumab is 40 mg EOW. Drug levels can vary from one patient to the next. In a retrospective cohort study Van Steenbergen et al. identified 40 patients with Crohn’s who de-escalated adalimumab to every 3 week dosing. At a median follow-up of 24 months, 65% of patients maintained clinical response, and 35% needed dose escalation back to EOW because of relapse, low drug levels, or both1. Our case is the first of a patient maintained in clinical remission, with detectable drug level and no antibody formation on adalimumab at intervals greater than 3 weeks. Given the economic burden of biologic therapy, prolonging the dosing interval of therapy is of interest. More studies are needed to investigate the effects of de-escalation in Crohn’s disease.
2080 The Curious Case of the Belly Button: Penetrating Crohn’s Disease Presenting as Umbilical Drainage
Authors: Steinhauser Christina M. , Singla Manish 
Published: October 2019

INTRODUCTION:
Crohn’s disease is an inflammatory condition that can present with fistulous communications with extraluminal structures. The presence of urachal remnants that do not communicate with the skin account for 50% of urachal malformations and are generally asymptomatic and benign.

CASE DESCRIPTION/METHODS:
We present a case of an active duty soldier, with no previous medical history, found to have Crohn’s disease presenting as an enterourachocutaneous fistula. The patient presented to primary care with persistent umbilical drainage that did not resolve with antibiotics given. Computed tomography showed a mass on the dome of the bladder with surrounding inflammation but no extravasation of contrast outside of the bladder during cystography. Ileocolonoscopy revealed a narrowed ileocecal valve with biopsies consistent with active Crohn’s disease. Magnetic resonance enterography showed a fistulous communication from the terminal ileum to a urachal cyst which drained to the skin via the umbilicus. After multi-disciplinary discussion with urology and colorectal surgery, patient will undergo planned cyst, fistula, and terminal ileal resection.

DISCUSSION:
This case represents a rare presentation of Crohn’s disease. The true prevalence of urachal malformations is unclear; a large number remain undiagnosed until noted on imaging when asymptomatic. Enterourachal fistulas are rare, with only 13 cases reported; cutaneous communication has occurred in only 4 of the 13 reported cases. Cutaneous fistulas are more commonly seen in penetrating Crohn’s Disease given proximity of the bowel to the abdominal wall. In our case, the involved segment of bowel created a cutaneous fistula by way of a patent urachal remnant. This case highlights the ability of Crohn’s disease to mimic more benign conditions. A diagnosis of Crohn’s disease should be considered in patients with umbilical drainage that fails to resolve with antibiotics.
2098 Management of Severe Ulcerative Colitis in a Patient With Familial Dysautonomia
Authors: Hine Ashley M. , Ramprasad Chethan , Barnes Erin , Kaufmann Horacio , Chang Shannon , Malter Lisa 
Published: October 2019

INTRODUCTION:
Familial dysautonomia (FD) is a progressive neurogenetic disease with carrier rate as high as 1 in 18 persons in European Jews of Polish origin. Clinical hallmarks include cardiovascular instability, spinal deformities, renal dysfunction, alacrima, ataxia, and impaired nociception. Physical or emotional stress may elicit autonomic crises characterized by hypertension and vomiting. Despite profound sensory deficits, GI perturbations are frequently reported by FD patients. While the incidence of inflammatory bowel disease (IBD) and FD is unknown, concurrence is underreported given increased frequency of both diseases in Ashkenazi Jews.

CASE DESCRIPTION/METHODS:
We report a 33-year-old female with FD and ulcerative colitis who presented with one week of abdominal pain and bloody diarrhea. She had been maintained on balsalazide. Colonoscopy one year prior revealed endoscopic and histologic remission. On physical examination, her abdomen was tender in the lower quadrants. A CT scan revealed pancolitis. Stool studies resulted negative. Her CRP was 58.4 mg/L and albumin was 2.4 g/dL. A flexible sigmoidoscopy noted Mayo endoscopic score 3 in the rectum and CMV staining was negative. The patient was started on IV steroids. Her hospital course was complicated by ileus, parainfluenza infection, and MSSA bacteremia with a pacemaker lead vegetation, requiring extraction. Lack of optimal clinical response to treatment on hospital day five led to consideration of alternative treatments with careful attention to her underlying FD. A subtotal colectomy with end ileostomy was unfavorable due to concern for volume loss. Infliximab and cyclosporine were opposed due to infection risk and later exhibiting possible nephrotoxicity. During this discussion the patient improved enough to be transitioned to oral steroids with a plan to initiate vedolizumab as an outpatient. On recent colonoscopy she had achieved mucosal healing.

DISCUSSION:
This is the first case of UC in a FD patient reported. Given myriad GI symptoms in the later diagnosis it can be hard to distinguish disease-related from treatment-related events. Due to the gut-specificity of vedolizumab, infection risk is considerably reduced compared to that of other biologics and is the most favorable option in the setting of underlying FD. This case highlights the difficulty encountered when treating IBD in the setting of systemic illness and underscores the need to carefully consider management options to enhance patient outcomes.