bluuebunny/crossref_metadata_2025_split huggingface dataset:
2011 Jejunal Varices: A Diagnostic and Therapeutic Nightmare!
Authors: Adoor Dayyan M. , Buffie Charlie 
Published: October 2019

INTRODUCTION:
Gastrointestinal hemorrhage is a common complication among cirrhotic patients with portal hypertension, due to the development of bleeding varices. While esophagus and stomach are the most common location for development of varices, it can also rarely occur in ectopic locations, such as the jejunum, ileum, rectum and duodenum. Here, we report a case of a patient with severe gastrointestinal hemorrhage due to a bleeding jejunal varix.

CASE DESCRIPTION/METHODS:
A 55-year-old male with a history of hypertension, splenectomy, and alcoholic cirrhosis had presented initially to an outside ED with complaints of bright red blood per rectum. At admission, he required multiple infusions of pRBCs, and several upper endoscopies due to refractory bleeding with unclear source. Initial endoscopies showed non-bleeding esophageal varices, for which he underwent ligation banding. However, he continued to deteriorate, developing recurrent melena, hypotension, and syncope. On admission to our hospital, he had a repeat upper endoscopy, lower endoscopy, CT angiography and tagged red blood cell study; but we were unable to localize the source of the bleeding. He continued to deteriorate, and also developed a PEA arrest in the setting of a profuse bright red blood per rectum, requiring massive transfusion protocol. After successful resuscitation, he underwent a small bowel enteroscopy, which finally revealed a bleeding jejunal varix. However, the varix was not amenable to any endoscopic intervention. Subsequently, he underwent a successful balloon-occluded retrograde transvenous obliteration (BRTO) of varix. Patient’s condition stabilized and after adequate recovery, he was extubated.

DISCUSSION:
Early diagnosis of ectopic varices is difficult to achieve due to low likelihood of presentation and low sensitivity to various diagnostic tests. Due to its low prevalence, there are no protocols for its management. As in our patient, endoscopic intervention such as sclerotherapy and band ligation can be difficult due to the narrow lumen of the small bowel. Alternatively, BRTO and TIPS are also considered effective therapeutic options. However, due to his poor liver function, BRTO was a better alternative. In conclusion, through this case report, we want to emphasize the importance of early recognition and appropriate management of ectopic varices due to its potential for massive, even fatal hemorrhage.
2015 Dieulafoy Lesion on the Other Side of the Tract
Authors: Khan Sarosh , Pinto Jonathan , Genao Alvaro , Culpepper-Morgan Joan 
Published: October 2019

INTRODUCTION:
Dieulafoy lesions involve a large-caliber, tortuous artery in the muscularis mucosa that protrudes due to a submucosal defect with fibrinoid necrosis at the base. The submucosal artery is found to have atypical branching and as a result has a diameter of 1-3 mm, which is 10 times that of a normal mucosal capillary. These lesions can be found throughout the gastrointestinal tract, though they are most frequently found in the stomach, ranging between 61 to 82%. However 10% of all gastrointestinal tract Dieulafoy lesions are found in the colon with 42% of these lesions found in the rectum.

CASE DESCRIPTION/METHODS:
A 79-year-old male with past medical history significant for prostate cancer, hypertension, gout, degenerative joint disease and alcohol abuse disorder presented with bilateral leg weakness and was admitted to the medical service for alcohol dependency and acute kidney injury. On day 12 of hospitalization, he developed melena with a drop in hemoglobin from 12.0 g/dL at the time of admission to 7.7 g/dL. He was then transferred to the critical care unit and underwent esophagogastroduodenoscopy that revealed angioectatic lesions that bled and were treated with argon photocoagulation. On day 15, he developed hematochezia, which further decreased his hemoglobin to 6.9 g/dL. He became hemodynamically unstable, requiring rapid fluid and blood resuscitation. Emergent CT angiography was concerning for vascular malformation in the rectal wall. Colonoscopy was performed and a stream of pulsatile bleeding without an ulcer or varix, consistent with a Dieulafoy lesion, was seen in the rectum. Epinephrine was applied, the lesion was clipped, and hemostasis was achieved. No repeat episodes of gastrointestinal bleeding were reported afterwards.

DISCUSSION:
Bleeding from Dieulafoy lesions can cause hemodynamic compromise as noted in this patient. Therefore prompt identification and treatment is warranted. Endoscopy serves as a gold standard for identification. Hemostasis has been achieved with many techniques in case reports including: BICAP cauterization; combined sclerotherapy and electrocoagulation; heater-probe coagulation; and epinephrine injection combined with electrocoagulation. Rebleeding rate ranges from 6 to 28%. Systemic reviews and retrospective analysis suggest that mechanical ligation to achieve hemostasis, especially the use of hemoclips, may be superior to other techniques employed.
2016 Hemorrhagic Shock Secondary to Ruptured Splenic Artery Pseudoaneurysm: A Rare Fatal Condition
Authors: Kobeszko Matthew , Sullivan Halley , Elkhatib Imad 
Published: October 2019

INTRODUCTION:
Splenic artery pseudoaneurysm (SAPA) is a potentially fatal but rare complication of acute or chronic pancreatitis. We present a case of 37-year-old male with history of pancreatitis and a 7.9 cm pseudocyst complicated by hematemesis requiring coiling embolization and massive reperfusion.

CASE DESCRIPTION/METHODS:
A 37-year-old male with history of chronic pancreatitis complicated by pancreatic pseudocyst measuring 7.9 cm presented with acute left upper quadrant abdominal pain and new hematemesis. He appeared diaphoretic, pulse 125 bpm, blood pressure 141/72 mmHg; with no palpable abdominal mass or bruits. Initial labs revealed hemoglobin of 12.8 gm/dL, lipase 74,238 units/L and lactic acid 4.9 mmol/L. Patient underwent CT abdomen/pelvis that revealed acute hemorrhage into the stomach with multiple wedge-shaped splenic hypodensities suggestive of infarcts. Patient continued to rapidly decompensate progressing into hemorrhagic shock requiring massive blood transfusion and vasopressors. Emergent EGD showed plethora of blood with clots in the gastric body with no visible source of bleeding. Due to limitations of endoscopy, patient was taken emergently for mesenteric angiography. A large SAPA with active extravasation into the stomach was visualized and successfully embolized using coiling technique. Total of 30 units of RBCs, 9 units platelets, 15 units plasma and 8 units cryoprecipitate were transfused. Patient recovered well post-op requiring no further transfusions and discharged home in stable condition.

DISCUSSION:
Due to diagnostic challenges and varied initial presentations, splenic artery pseudoaneurysm (SAPA) is a rare disorder predominantly associated with acute/chronic pancreatitis, pancreatic pseudocyst, or trauma. Mostly commonly, the splenic artery is affected in true visceral aneurysms versus the hepatic artery in visceral pseudoaneurysms. SAPAs have a high risk of rupture with a three-fold higher incidence in men, and a mortality rate of up to 90% if untreated. While computed tomography is often the first diagnostic test, mesenteric angiography is the gold standard. Treatment options vary from endoscopic ultrasound guided coiling, percutaneous coiling/stent, or surgical repair. This case emphasizes the need of early recognition, massive reperfusion, and definitive treatment before rapid decline from hemorrhagic shock. Sudden epigastric pain with hematemesis in patients with chronic pancreatitis or pancreatic pseudocysts, may be clues in the development of this rare complication.
2020 Well Differentiated Neuroendocrine Tumor Arising From the Gastric Cardia Presenting With Hematemesis
Authors: Aponte-Pieras Jose 
Published: October 2019

INTRODUCTION:
Neuroendocrine tumors (NETs) of the Gastrointestinal (GI) tract are rare and arise from neuroendocrine cells of the pancreas and tubular GI tract. The annual incidence of NETs has increased from 1.09 per 100,000 in 1973 to 6.9 per 100,000 in 2012, reflecting the increased use of endoscopy. Gastric NETs (G-NETs) are divided into three subgroups, type I account for 80%. They are often incidental in workup of non-specific upper GI symptoms, GERD and epigastric pain. Endoscopically they appear as multiple polypoid lesions or ulcers arising in the fundus/body on a background of atrophic gastritis. We report an unusual case of a solitary pedunculated type I G-NET found in the gastric cardia, presenting with hematemesis.

CASE DESCRIPTION/METHODS:
An 82-year-old male with atrial fibrillation on Warfarin presented with melena and hematemesis causing hemorrhagic shock. He denied NSAID or alcohol use, but was on a steroid taper for a COPD exacerbation. Initial blood work was notable for hemoglobin 11.7, platelet count 191, INR 3.4, BUN 79 and creatinine 0.95. A CT Angiogram showed active extravasation in the distal esophagus. He was treated with K-centra, phytonadione, pantoprazole, and intubated prior to Esophagogastroduodenoscopy (EGD). A 20 mm pedunculated polyp with central ulceration and adherent clot was noted in the cardia, adjacent to the GE junction, prolapsing into the esophagus; no active bleeding. Endoloop ligation of the polyp was performed prior to ICU admission. On repeat EGD, polyp was removed with hot snare and retrieved; endoloop was left for hemostasis.

DISCUSSION:
Pathology was consistent with a well-differentiated type 1 G-NET; stains positive for synaptophysin, chromogranin, CD56, and keratin, with lack of proliferative activity. Management and surveillance of type 1 G-NETs is based on consensus guidelines. Due to their indolent nature, lesions < 6 in number and < 2 cm in size can be resected or surveilled with EGD every 3 years. In our case, a large pedunculated polyp was fully resected. A CT or MRI is not recommended as this tumor rarely metastasizes. Our patient underwent CTA to evaluate bleeding, which could have been deferred in favour of EGD given witnessed hematemesis with hemodynamic instability. For type 1 G-NETs >2 cm an endoscopic ultrasound is recommended to assess depth of mucosal invasion. An analysis showed worse survival associated with tumors of the gastric cardia and esophagus, highlighting the importance of better understanding the natural history of these tumors.
2021 Ischemic Duodenal Ulceration After Thoracic Endovascular Aortic Repair (TEVAR)
Authors: Bierle Lindsey A. , Moon Sol , Sweet Jon M. 
Published: October 2019

INTRODUCTION:
Ischemia is a rare cause of duodenal ulcers due to the redundant blood supply in the duodenum. Aortic surgery is a known, but rare, risk factor for mesenteric ischemia. Endovascular aortic repair is an increasingly common alternative to open surgery for select patients with aortic aneurysms, however post-procedural complications including endoleaks and graft migration can occur. Less commonly reported complications include bowel ischemia, with only a handful of reports detailing duodenal ulceration in the current literature. Here we present a case of ischemic duodenal ulceration following thoracic endovascular aortic repair (TEVAR).

CASE DESCRIPTION/METHODS:
An 82-year-old male on dual-antiplatelet therapy presented with complaints of lightheadedness, dyspnea, and melena. He had been discharged to skilled nursing three days earlier following thoracic endovascular aortic repair (TEVAR) for DeBakey type III aortic dissection distal to the left subclavian artery. His recovery was complicated by endovascular leak at the left subclavian artery, left renal artery dissection, and thrombosis of the superior mesenteric artery (SMA), which were treated with coiling and stenting of the left renal artery and SMA. Hemoglobin upon hospital return was 6.7 g/dL compared to 8.3 g/dL on initial discharge. Esophagogastroduodenoscopy revealed a large, near-circumferential Forrest IIc ulcer in the duodenum with concern for underlying ischemic etiology. Computed tomography angiography (CTA) of the chest and abdomen revealed a duodenal ulcer with associated mural thickening and fat stranding. CTA reconfiguration identified stenosis at the bifurcation of the common hepatic artery and stenosis of the celiac artery compared to post-TEVAR CTA images. These findings were confirmed with celiac angiography and repaired using drug coated balloon catheter percutaneous transluminal angioplasty to the common hepatic artery and balloon expandable stenting to the celiac artery. The patient’s hemoglobin stabilized post-operatively and he had complete symptom resolution.

DISCUSSION:
Upper intestinal ischemia is a rare but important cause of duodenal ulceration and hemorrhage following TEVAR, as demonstrated in this case. Bowel ischemia from TEVAR is more commonly seen when the distal aspect of the graft has celiac artery involvement. Early recognition of ischemic duodenal ulceration after TEVAR is of significant clinical importance, as treatment differs from other etiologies of duodenitis and early intervention lowers morbidity.
2024 Novel Approach for Management of Stomal Variceal Bleed
Authors: Olson Kristin , Uhlenhopp Dustin , Sunkara Tagore , Gaduputi Vinaya , Chadrasekaran Bharanidhar 
Published: October 2019

INTRODUCTION:
Patients with cirrhosis are prone to developing bleeding from varices. Patients with cirrhosis and ileostomy can develop ileostomy varices. Only 5% of variceal bleeds are reported to be from an ileostomy varix.

CASE DESCRIPTION/METHODS:
A 51-year-old female with heart failure, hepatitis C cirrhosis, esophageal varices with recent banding, colectomy with ileostomy presented with ostomy bleeding. Examination of the ostomy revealed oozing from the ostomy site. The ostomy site was cauterized with silver nitrate which initially stopped the bleeding. Esophagoduodenoscopy demonstrated three columns of non bleeding varices, no red whale/nipple sign and two non bleeding esophageal ulcers. Later, ostomy bleeding recurred which led to an ileoscopy. A non-bleeding ulcer was noted in the ileum. As the scope was withdrawn, an osteal varix was noted and due to the manipulation of the scope, the varix started squirting blood. Manual pressure was applied and a foley was inflated in the ostomy tract for tamponade. After 15 minutes of tamponade, the scope was re-inserted which did not demonstrate active bleeding. Banding couldn't be performed as there was no room to manipulate the scope. A CTA demonstrated two varices originating from the superior mesenteric vein within the ostomy track (Figure 1). TIPS was contraindicated due to heart failure. 2cc of Sotradecol was injected into each varix for obliteration via ultrasound guidance. After the injection, ultrasound showed successful obliteration of the varices (Figure 2). There was no further bleeding during her hospital stay.

DISCUSSION:
Ileostomy variceal bleeding is uncommon. Bleeding from an ileostomy varix can occur as early as a year after ileostomy placement in patients with cirrhosis. Diagnosis is often missed. It is key to inspect the stoma for bleeding after removal of the appliance. Doppler ultrasound or CT/MRI can aid in the diagnosis. There are multiple strategies to treat a variceal ostomy bleed including local control (ligation, sclerotherapy, intravascular coil or glue emboliziation) and portal vein decompression (TIPS). In majority of cases, local therapy is used as first line treatment as demonstrated in our patient who was successfully treated with sclerotherapy. We'd like to highlight the possibility of ultrasound guided sclerotherapy of osteal varices if endoscopic sclerotherapy is not feasible. More research is needed to assess which treatment strategy provides the best outcome for patients coming in with ileostomy variceal bleeding.
2030 A Unique Case of Appendiceal Orifice Bleeding
Authors: Valadez David , Camero Alfredo , Hackman Sarah , Penninti Pranav , Echavarria Juan 
Published: October 2019

INTRODUCTION:
Appendiceal orifice bleeding is an uncommon etiology of lower gastrointestinal bleeding and is often attributed to various appendix pathologies. We report a case of appendiceal orifice bleeding in a woman with fibrous obliteration of the appendix.

CASE DESCRIPTION/METHODS:
A 51-year-old female with fibromyalgia and chronic abdominal pain underwent outpatient colonoscopy to evaluate several months of intermittent hematochezia. Hemoglobin four months prior to procedure was 12.3 g/dL. Colonoscopy revealed fresh blood in the cecum and right colon. After irrigation, active oozing from the appendiceal orifice was seen. There was no blood in the terminal ileum. She was also found to have a non-bleeding rectal AVM, which was cauterized. Hemoglobin the day of procedure was 11.8. She had normal vitals and physical exam. A CT scan obtained three days later revealed a normal appendix and GI tract. She was referred to general surgery and underwent laparoscopic appendectomy three months later. She reported intermittent hematochezia two months after her surgery but did not pursue further work up. Her next follow up encounter was 15 months after her surgery and no further hematochezia was reported. Pathology analysis of her appendix revealed fibrous obliteration with foci of neural hyperplasia and entrapped residual neuroendocrine nests. There was no evidence of cellular atypia, mitotic activity, or neoplasm.

DISCUSSION:
Available literature on appendiceal orifice bleeding is sparse and mainly compromised of isolated cases. Most case reports involve acute, inpatient situations and abnormal CT findings, so it is important to underscore the decision to pursue a CT scan despite our patient’s chronic and mild presentation. The recurrent hematochezia two months after surgery is difficult to explain, but it did resolve by the time she re-established care and could be unrelated. Pathology findings did not include previously noted etiologies of appendiceal orifice bleeding (erosions, diverticula, malignancy). However, fibrous obliteration of the appendix is a rare finding and occurs when spindle cell proliferation replaces the appendiceal lumen. Fibrous obliteration of the appendix is also termed neurogenic appendicitis or appendiceal neuroma. There does not appear to be any previous associations of documented appendiceal orifice bleeding and fibrous obliteration of the appendix. Our case highlights the need for further investigation into these two rare entities.
2031 Metastatic Neuroendocrine Tumor of Unknown Primary Presenting as Acute Gastrointestinal Bleed With Hemorrhagic Shock
Authors: Mankoo Ravinder , Malik Lybia , Habib Mustafa , Smith Zachary , Kuwajima Vanessa , Ibdah Jamal A. , Tahan Veysel 
Published: October 2019

INTRODUCTION:
Neuroendocrine tumors (NETs) are often localized, however up to 50% of cases can be metastatic, with 13% having an unknown primary . Most NETs are identified during work up of related symptoms or functional syndrome (i.e. carcinoid) or found incidentally. We present a case of metastatic NET of unknown primary origin presenting as acute hemorrhagic shock from gastrointestinal bleeding.

CASE DESCRIPTION/METHODS:
A 21-year-old male presented with hematochezia, abdominal pain and nausea and was admitted to the ICU for hemorrhagic shock with a drop in hemoglobin from 14.5 to 8.2. EGD showed 15 mm, necrotic, oozing duodenal ulcer without visible blood vessel, treated with Hemospray. Recurrent episode of bleeding necessitated IR-guided GDA embolization. CT imaging initially identified, and later MRI confirmed three complex hepatic lesions in both right and left lobes of the liver . IR-guided liver biopsy showed low-grade, well-differentiated metastatic NET, Ki-67 1%. Gastrin and chromogranin A levels were elevated at 166 pg/mL and 223 ng/mL respectively. Otreotide scan found enhancement in the liver consistent with metastatic NET, without identification of a primary site. He was started on octreotide infusions. Additional work-with CT chest and pelvis, repeat EGD/EUS and colonoscopy were negative for primary tumor. He underwent laparotomy with left lateral segment partial hepatectomy, microwave ablation of the remaining liver lesion and cholecystectomy.

DISCUSSION:
NETs are typically indolent cancers involving the small intestine, appendix, colon/rectum, pancreas or lung. Common sites of metastasis include the liver, peritoneum, lymph nodes and lungs. The majority of metastatic NETs have an identifiable primary site, but it is important to recognize that many can have an unknown origin. Understanding the primary site of NETs is an important prognostic factor in overall survival. In general, metastatic disease is associated with a poorer prognosis, particularly in the setting of unknown primary origin. This case illustrates that patients with NETs can have a variable initial presentation, including acute GI bleeding from peptic ulcer disease. In addition, this case shows that despite appropriate diagnostic testing including biochemical markers, anatomic and functional imaging studies, endoscopic procedures and tissue biopsies, the primary site of metastatic NETs can go unidentified, which can effect definitive treatment options.
2035 Small Cell Carcinoma of Rectum: A Rare Cause of Hematochezia
Authors: Wieckowska Joanna , Patel Kruti , Minaudo Mark 
Published: October 2019

INTRODUCTION:
Small cell carcinoma (SmCC) is a subtype of neuroendocrine tumor that has commonly been associated with lung malignancy. However, it has been seen in <1% of colorectal malignancies. Majority of neuroendocrine tumors are asymptomatic and non-functioning, but about 75% have metastatic disease by the time of diagnosis. We present a case of SmCC of the rectum in a patient who presented with intermittent hematochezia.

CASE DESCRIPTION/METHODS:
A 65-year-old female with a medical history of Diabetes Mellitus Type II, Hypertension, and Hyperlipidemia, was referred for endoscopic evaluation of intermittent hematochezia ongoing for several months with the following associated symptoms: change in bowel habits, constipation, perianal discomfort increased upon defecation, urinary frequency, and dysuria. She was not on anticoagulation or NSAIDs. She had no personal or family history of GI malignancy or IBD, and she denied tobacco, alcohol, or illicit drug use. Screening colonoscopy ten years ago had been negative for any abnormalities. Laboratory data was unremarkable for anemia or liver disease, but did reveal a mildly elevated CEA 4.8 ng/mL. Subsequent colonoscopy revealed large ulcerated rectal mass at 15 cm with luminal narrowing concerning for rectal malignancy. Follow up imaging with CT of the abdomen and pelvis with contrast showed a large rectal mass with multiple enlarged peri-rectal lymph nodes, 1.5 cm right adrenal nodule, 3 mm non-calcified nodule of left lower lobe and multiple sub-centimeter hypodense lesions in left liver lobe. Biopsy with histological staining suggested neoplastic cells consistent with rectal small cell carcinoma. Patient was treated with neoadjuvant chemotherapy and radiation therapy followed by abdominoperineal resection. Ultimately, she could not tolerate adjuvant therapy and enrolled in hospice.

DISCUSSION:
To date, fewer than 1000 cases of GI SmCC have been reported with prevalence of 0.1% to 1% of all GI tumors. Seventy- five percent of patients present with metastasis at the time of diagnosis. Six-month survival rate is 58%, and five-year survival is 6%. Clinical presentation generally mimics the usual presentation of colorectal malignancies. Workup is also similar. However, there is no standard treatment approach for SmCC as none has been developed due to low incidence. Given the paucity of literature, cases should be reported to influence future prospective studies to establish standard diagnostic and treatment regimens and to improve the overall prognosis.