bluuebunny/crossref_metadata_2025_split huggingface dataset:
1863 The Mouth Is More Than Just an Entry Path to the Esophagus: A Rare Site of Breast Cancer Metastasis
Authors: Malik Neena , Brandt Lawrence , Timsar Ali Kazerouni 
Published: October 2019

INTRODUCTION:
The following case highlights a rare site for breast cancer metastasis, as well as demonstrates the importance of careful attention to all structures including the oral cavity, during endoscopy.

CASE DESCRIPTION/METHODS:
A 53-year-old woman with a history of a recent dental abscess presented with weakness. She reported that 2 weeks before presentation she developed a dental abscess that required drainage. Upon further questioning, she also recalled a 2-month history of right breast pain and swelling. CT abdomen and pelvis obtained raised concern for infiltrative breast cancer with metastases to the liver, lung, bone, and brain. Prior to dedicated breast imaging and biopsy, the patient developed large-volume hematemesis and urgent endoscopy was performed. As the endoscope was advanced into the mouth, a 15 mm soft, friable polypoid mass was seen on the hard palate off the midline, as well as a cratered lesion with rounded walls in the gastric body. These lesions were biopsied with pathology showing poorly differentiated carcinoma composed of nests of malignant cells with marked atypia and pleomorphism, positive for pancytokeratin, GATA3 and CK7. The morphology and immunoprofile supported the diagnosis of metastatic carcinoma of breast origin.

DISCUSSION:
Breast cancer most often metastasizes to the liver, lung, bone, and brain. Gastric metastases are infrequent, with an estimated incidence rate of approximately 0.3%. Metastasis of malignant tumors to the oral cavity is exceedingly rare and accounts for approximately 1% of all malignant oral tumors. There are insufficient data to account for the true incidence for breast cancer metastasis to the oral cavity. Management of metastatic breast carcinomas of the oral cavity is primarily palliative, as prognosis for patients with these metastatic lesions is generally poor. As gastroenterologists, we are often focused solely on the proximal gastrointestinal tract during upper endoscopy, but we have the ability to fully evaluate and detect abnormalities of a number of other structures, including the oral cavity, oropharynx, and larynx. We should take full advantage of this opportunity to view these structures in an attempt to aid in early detection of what would otherwise be neglected disease. This case not only demonstrates the need for awareness of the oral cavity as a potential site for metastasis of breast cancer and its associated poor prognosis, but it also highlights the key principle of conducting a thorough endoscopic evaluation.
1866 “I am Choking:” An Unusual Late Complication of a Gunshot Injury
Authors: Kulkarni Deepika , Kulkarni Prasad 
Published: October 2019

INTRODUCTION:
Benign tracheo-esophageal fistulas (TEF) in adults are an uncommon entity. We present the case of a patient who presented with dysphagia, was diagnosed with a benign TEF, and was successfully managed with endoscopic clipping with complete resolution.

CASE DESCRIPTION/METHODS:
A 64-year-old male veteran was referred to gastroenterology clinic for evaluation of dysphagia, specifically coughing and choking when eating. Previous history included stable pulmonary nodules, PET-avid mediastinal lymphadenopathy of unclear etiology, and GERD. Patient reported a gunshot wound to the throat over 30 years prior to presentation, which had required a left posterior thoracotomy. Barium esophagram showed a 6 mm diverticulum of the proximal esophagus, with extravasation of contrast into the trachea. EGD was performed, which identified a diverticulum with a small fistula at 20 cm from the incisors. The remainder of the esophagus appeared to be unremarkable, with no evidence of masses. Three hemoclips were deployed, with successful closure of the defect. Repeat barium esophagram 6 weeks post-procedure noted no contrast in the trachea, with the patient reporting improvement of symptoms. Repeat EGD 6 months post-procedure showed no evidence of diverticulum, fistula, nor clips.

DISCUSSION:
Nonmalignant TEF in adults are uncommon entities. Most acquired benign TEF are secondary to endotracheal cuff injury from prolonged mechanical intubation, but may be due to trauma, prior surgeries, foreign bodies, and mediastinal infections. Classical treatments for acquired TEF include surgical approaches with single or multistage procedures. Endoscopic therapies are increasingly studied with high technical and clinical success rates. While management of TEF is often performed with esophageal stents, tracheal stents, or a combination of both, literature review shows that patients may be successfully managed with endoscopic clips, or stents with a combination of sutures and cautery. For patients with persistent dysphagia and unexplained pulmonary findings, a high index of suspicion must be maintained for a benign TEF, and endoscopic interventions may be critical for clinical resolution. References Silon, Bryan, et al. “Endoscopic management of esophago-respiratory fistulas: a multicenter retrospective study of techniques and outcomes.” Digestive diseases and sciences 62.2 (2017): 424-431. Santosham, Rajan. “Management of acquired benign tracheoesophageal fistulae.” Thoracic surgery clinics 28.3 (2018): 385-392.
1868 Novel Use of Overtube for Rectal Foreign Body to “Clean” Out the Colon: Extraction of Large Tide-To-Go Pen
Authors: Shao Paul , Grewal Jasleen , Perumpail Ryan , Leung Felix 
Published: October 2019

INTRODUCTION:
The rate of colorectal foreign bodies is rising. This poses an interesting challenge to endoscopists as there is great variability in object size, shape, and surface characteristics. This heterogeneity requires endoscopists to have a diverse range of techniques at their disposal to safely remove colorectal foreign bodies in a minimally invasive manner. We present a case of the novel use of an esophageal overtube to aid in the removal of a difficult-to-remove Tide To Go cap.

CASE DESCRIPTION/METHODS:
The patient was a 55-year-old male who presented to the ED about 24 hours after inserting a smooth plastic Tide To go pen into his rectum. When he attempted to remove the pen, the cap was left behind. He denied any pain, hematochezia, fevers or chills. In the ED he underwent a CT scan which showed a well circumscribed air-containing elongated and conelike region occupying the rectum and rectosigmoid with mild thickening of the rectal wall without extraluminal air. We initially gave him 4L of Golytely to flush the object, but he did not pass the object on his own. During flexible sigmoidoscopy we could appreciate a very strictured and erythematous rectum and a smooth, white, plastic object lodged in the rectosigmoid colon. Multiple attempts at pulling the object out with rat-tooth forceps, snare, and Roth net were all futile as we could not pull the object through the narrowed rectum. We then inserted a heavily lubricated esophageal overtube through the rectum and pulled the object into the overtube and removed the cap and overtube together. The overtube helped dilate and straighten the rectum while allowinging the object to be secured into the overtube.

DISCUSSION:
The incidence of patients presenting to emergency departments with rectal foreign bodies is increasing, particularly in males. Recurrent episodes of rectal foreign body insertion requiring repeat endoscopic and surgical interventions for extraction can lead to anorectal stricturing. The alteration of anatomy may, as in this case, result in difficulty with foreign body extraction despite endoscopic access to the object. Stenting of the overlying mucosa and straightening of the rectum with overtube placement may facilitate successful retrieval of the rectal foreign body.
1871 Rare Case of Endoscopic Erosive Ulcerations in Celiac Disease
Authors: Rezaie Aida , Ahmed Shifat , Goldberg Aaron 
Published: October 2019

INTRODUCTION:
Celiac disease is a common disorder of the small intestine caused by an autoimmune reaction to dietary gluten in the setting of genetic predisposition. Patients can present with a variety of symptoms ranging from diarrhea and unintentional weight loss to extraintestinal signs such as iron deficiency anemia and dermatitis. The diagnosis is confirmed with serologies and duodenal biopsies while a patient is on a gluten-containing diet. Histopathology of the small bowel demonstrates characteristic villous atrophy, mucosal inflammation, or crypt hyperplasia with increased intraepithelial lymphocytes. Gross endoscopic findings are typically normal with occasional endoscopies can show gastritis or atrophy. This is the first case of celiac disease with gross endoscopic findings consistent with non-bleeding erosive gastropathy.

CASE DESCRIPTION/METHODS:
A 68-year-old Veteran male presents for evaluation of weight loss, left lower quadrant discomfort and chronic loose stools. He denied any dietary changes, changes in appetite, nausea, vomiting, skin lesions, joint pain or recent travel. Endoscopy was performed demonstrating petechial gastropathy in the proximal stomach, mild duodenal bulb erosions with marked transverse-oriented erosions from the second part of the duodenum to proximal jejunum. Jejunal and duodenal biopsies were consistent with Celiac disease without H pylori, intestinal dysplasia or metaplasia. Serum TSH was 0.876, IgA was 276 (normal 58-484 mg/dL), Tissue transglutaminase IgA >100 U/mL and gastrin <15 pg/mL.

DISCUSSION:
The chronic lymphocytic infiltration triggered by the ingestion of gluten causes the classic histopathological findings. However, endoscopically, celiac disease has not been shown to have significant features outside of scalloped duodenal folds, fissures and grooves. This is the first documented case that presents an endoscopic pattern of erosive ulcerations consistent both histologically and serologically with celiac disease. While biopsy remains the standard of care, further exploration into diagnosing this disease through gross pathology is warranted.
1872 Mycobacterium Avium Complex Colitis in a Patient With AIDS
Authors: Rezaie Aida , Pradhan Faruq , Wadas Darrell 
Published: October 2019

INTRODUCTION:
Disseminated mycobacterium avium complex (MAC) is an uncommon diagnosis with the advent of highly active anti-retroviral therapy (HAART). The International Antiviral Society-USA Panel and the US Department of Health and Human services recently changed their guidelines recommending against routine MAC prophylaxis in patients on HAART. Gastrointestinal manifestations of MAC typically result in diarrhea, fever, weight loss, and abdominal pain. The diagnosis is clinically challenging as radiographic findings are non-specific and cultures can be negative for up to 2 weeks. Upper endoscopy with biopsy is required to make the diagnosis. We present a rare case of MAC colitis in a patient with AIDS with only focal subtle endoscopic changes.

CASE DESCRIPTION/METHODS:
A 31-year-old male was admitted for fevers, chills, diarrhea and rectal pain for 1 week. The patient was diagnosed with HIV 1 year prior and declined HAART. On admission, the patient had a benign abdominal exam with tender inguinal lymphadenopathy. Computed tomography (CT) of the abdomen/pelvis without contrast demonstrated subtle wall thickening in the rectosigmoid consistent with proctocolitis. His absolute CD4 count was 38 cells/uL, unfortunately an HIV viral load was not checked. Stool culture with shiga toxin, clostridioides difficile, coccidioides, stool giardia/ova and parasites/cryptosporidium were negative. Cytomegalovirus (CMV) serum PCR was positive at 15,400 IU/mL. Colonoscopy showed normal mucosa throughout the colon and terminal ileum, except for a single, subtle, erosion of the rectum 2 mm in length. Biopsies taken of the solitary erosion were notable for acid fast bacilli concerning for intestinal MAC, CMV was negative. An interferon gamma release study was indeterminate. The patient was discharged on therapy for CMV viremia.

DISCUSSION:
The incidence of disseminated mycobacterium avium infection has decreased to 2 cases per 1000 person-years with the use of HAART. However, the risk of infection increases with high HIV viral loads >1000 copies/mL, previous or concurrent opportunistic infections, and CD4 count <50 cells/uL. Gastrointestinal MAC is rare, and when identified is most commonly found in the small bowel. Endoscopically, this is associated with granular, erythematous mucosa with ulcerations. Identification of the pathogen can be difficult unless direct biopsies of suspicious lesions are obtained on endoscopy.
1876 A Rare Case of Giardia Duodenalis on Duodenal Biopsy in a Patient With Chronic Abdominal Pain
Authors: Moore Andrew , Lee Salina , Jakate Shriram 
Published: October 2019

INTRODUCTION:
Giardia duodenalis is an intestinal flagellated protozoan parasite and is the most common parasitic infection in the GI tract, having been estimated to effect as much as 2-5% of the population in developed countries. Symptoms of giardiasis in children include diarrhea, flatulence, abdominal cramping, nausea, and dehydration; however, in adults the symptoms are often absent or short-lived. Giardiasis is typically diagnosed by identification of cysts or trophozoites with a test for ova and parasites in the stool of infected patients. Here we present a rare care of a patient with chronic abdominal pain who was diagnosed with giardiasis via duodenal biopsy.

CASE DESCRIPTION/METHODS:
A 65-year-old male with a past medical history of COPD, HTN, and depression was evaluated for abdominal pain that had been ongoing for the last two years. The pain was primarily epigastric with occasional radiation to the upper quadrants, worse after eating, and often occurred at night, awakening him from sleep. He denied any constipation, diarrhea, hematochezia, melana, or weight loss. He did not take any PPIs or H2 blockers. His last colonoscopy was in 2015 and was notable only for a few polyps. Physical exam was notable for mild tenderness in the upper quadrants and epigastric area. Esophagogastroduodenoscopy (EGD) showed mild dilation in the distal esophagus, nodularity in the gastric corpus, patchy erythema and erosions in the antrum of the stomach. Duodenum was notable for diffuse erythema and friability in the bulb. The second portion of the duodenum appeared normal. Pathology was notable for multiple pieces of the duodenal mucosa showing numerous Giardia parasites and focal acute erosive duodenitis (Figure 1). Multiple pieces of gastric mucosa showed chronic gastritis and numerous H. pylori organisms. Moderate esophagitis compatible with reflux was also observed. Presidential Poster AwardThe patient was prescribed triple therapy with omeprazole 20mg BID, amoxicillin 1g TID, and metronidazole 500mg TID for 10 days to cover both H. pylori and Giardia duodenalis and then was instructed to continue on omeprazole 20mg daily.

DISCUSSION:
For patients in whom Giardia or other infectious etiology is suspected, stool O&P are routinely ordered. However, the sensitivity of examining one stool specimen is only 50-70%. This case demonstrates the utility of EGD as a more sensitive diagnostic tool when there is strong clinical suspicion but stool studies fail to reveal a definitive diagnosis.
1886 Endoscopic Management of Tubulovillous Adenoma Within a Diverticulum: Report of a Case and Review of Literature
Authors: Hawa Fadi , Tworek Joseph A. , Catanzaro Andrew T. , Gunaratnam Naresh T. 
Published: October 2019

INTRODUCTION:
Colonic polyps within a diverticulum are technically challenging to resect as the polyp might be difficult to access if it is buried within the diverticulum. There is also an increased risk of perforation upon endoscopic resection owing to the lack of muscularis propria in the wall of the diverticulum. We describe an endoscopic technique for management of a rare case of tubulovillous adenoma within a diverticulum with review of literature.

CASE DESCRIPTION/METHODS:
A 74-year-old male underwent screening colonoscopy which identified a 15 mm polyp within a sigmoid colon diverticulum. Attempted resection was unsuccessful despite sub-mucosal injection with saline and the use of multiple snares. Therefore, the endoscopist elected to use a variceal band ligator. The polyp was then suctioned into the band ligator cap and 2 bands were deployed which exposed a clearly defined 15 mm polyp. This was followed by endoscopic resection using hot snare polypectomy. Histopathology revealed a tubulovillous adenoma. Inspection of the resection site demonstrated a 3 mm perforation which was closed using 4 endoscopic clips. The patient was admitted overnight for observation and was discharged the following day without complications.

DISCUSSION:
Colonic polyps within a diverticulum are technically challenging to resect given that the majority of the polyp might be buried within the diverticulum. Suction over the polyp using a variceal banding device and deploying bands across the base was an effective method for exposing and resecting the entire polyp in this case. However, it was complicated by a small iatrogenic perforation likely due to the lack of a muscularis propria within the wall of the diverticulum. Review of literature revealed three other cases which reported endoscopic management of colonic polyps within a diverticulum. Two of the cases utilized an over the scope clip at the base of the suctioned polyp prior to resection with a hot snare to reduce the risk of iatrogenic perforation. The third case allowed for natural sloughing of the polyp to occur without tissue retrieval as a result of tissue ischemia from the band. In conclusion, colonic polyps within a diverticulum can be successfully removed by using a band ligator and/or over the scope clip to isolate the polyp. The polyp can then be resected using hot snare polypectomy to ensure tissue retrieval. However, an over the scope clip should be used prophylactically to prevent a perforation or a perforation can be closed with endoscopic clips.
1892 Stomach Where the Sun Don’t Shine: A Rare Case of Gastric Adenocarcinoma Metastasizing to the Colon
Authors: Houston Trevor , Lim Diego , Andraws Nevene , Vennalaganti Prashanth 
Published: October 2019

INTRODUCTION:
Gastric cancer has been known to have a poor prognosis worldwide. It frequently leads to a metastatic disease, but rarely to the colon.

CASE DESCRIPTION/METHODS:
A 73-year-old male presented for a routine surveillance colonoscopy. He reported new onset constipation over the last 6-8 months that was not relieved by over-the-counter laxatives. He was found to have a stricture approximately 30 cm from the anal verge (Figure 1). This stricture was not seen on previous colonoscopy in 2014. He had a history of gastric adenocarcinoma 4 years ago, underwent a subtotal gastrectomy followed by chemotherapy and radiation and was closely followed in the oncology clinic. In addition, he also had a gastrointestinal stromal tumor (GIST) in the stomach. Histopathology was consistent with gastric adenocarcinoma (Figure 2). Widespread metastatic disease was found on PET scan (Figure 3).

DISCUSSION:
Although gastric cancer metastasizes to the liver, peritoneum and distant lymph nodes commonly, colon metastasis is rare and even rarer is sigmoid metastasis. We report a case of a patient with a change on bowel habits and was found to have gastric adenocarcinoma that has metastasized to the sigmoid colon causing a structuring lesion. In addition, both gastric adenocarcinoma and a concurrent GIST have been reported in literature. It has been suggested that C-KIT or PDGFR-a mutations can lead to both cancer types but more information on this subject is lacking in current literature. It appears though that having both types of cancers do not significantly influences symptoms or disease outcome.
1895 “The First Burn Is the Deepest:” A Cautionary Tale in Superficial APC Therapy for Radiation Proctopathy
Authors: Pineles David , Vareedayah Ashley , Poppers David 
Published: October 2019

INTRODUCTION:
Globally, prostate cancer is the most commonly diagnosed cancer in men. Radiation therapy remains a mainstay in the armamentarium in the treatment of this disease. Radiation proctopathy is a common side effect of this treatment modality with an incidence in patients treated with brachytherapy alone estimated to range from 8 to 13%, and up to 21% in combination with other modalities [2]. Radiation proctopathy typically presents with diarrhea, mucoid discharge, urgency, tenesmus, and bleeding. Argon plasma coagulation (APC) has become the primary therapeutic modality in the management of radiation injury. It is essential that physicians of all specialties (as well as others who care for these patients) be aware of the multiple complications of this therapy. More severe adverse events, notably rectal ulcers following APC therapy are not uncommon, with an incidence ranging from 3 to 16%.

CASE DESCRIPTION/METHODS:
A 67-year-old man with a history of prostate cancer treated with radiation therapy one year prior presented with intermittent rectal bleeding for one and a half months. A colonoscopy was performed, which revealed a small area near the dentate line characterized by slightly oozing neovascularized tissue consistent with radiation proctopathy. This area was treated with APC with good effect. Biopsies of this area revealed hyperplastic crypts, lamina propria fibrosis, and vascular ectasias compatible with radiation injury. Three months following treatment, the patient developed recurrent rectal bleeding. A flexible sigmoidoscopy revealed a deep non-bleeding ulcer in the rectum. Subsequent CT enterography and MRI of the pelvis demonstrated a deep rectal ulcer with abutment of a 1.5cm peri-prostatic abscess. The patient was followed closely over the next several months in concert with colorectal surgical colleagues, with serial imaging and subsequent resolution of the peri-prostatic abscess as well as cessation of rectal bleeding.

DISCUSSION:
As more patients with prostate cancer are treated with radiation therapy the incidence of radiation proctopathy is increasing. Although argon plasma coagulation has been shown to be an effective therapy for this issue, providers must consider and discuss with patients the potential complications of this otherwise effective and generally well-tolerated mode of treatment.