bluuebunny/crossref_metadata_2025_split huggingface dataset:
1598 Late-Onset Post-Transplant Lymphoproliferative Disorder Presenting as Diffuse Large B-Cell Lymphoma in the Ascending and Transverse Colon
Authors: Levine Louis J. , Groff Andrew , Gordin Yuri , Manzo Carl , Munyon Ryan , Krok Karen 
Published: October 2019

INTRODUCTION:
A serious complication of solid organ transplantation is post-transplant lymphoproliferative disorder (PTLD). The vast majority of PTLD was previously found to present within the first year after transplant, when immunosuppression is highest. However, newer studies suggest a bimodal peak in incidence.
1
This case describes PTLD occurring in the colon as a late complication of multi-organ transplant.

CASE DESCRIPTION/METHODS:
A 54-year-old male with a complicated transplant history, on tacrolimus for immunosuppression, presented with worsening abdominal pain, nausea, diarrhea, and weight loss. His transplant history includes cardiac transplants in 1980 and 1993 for idiopathic cardiomyopathy, and renal transplant in 2003 due to tacrolimus toxicity. He denied fever, night sweats, or recent sick contacts, and was hemodynamically stable. On exam, he had diffuse abdominal pain with mild guarding but no rebound. Laboratory findings revealed a tacrolimus level of 11.1. Abdominal computed tomography scan was significant for fluid-filled loops of small bowel with focal thickening of the transverse colon, concerning for colonic malignancy (Figure 1). Gastroenterology was consulted for urgent colonoscopy, which showed mucosal ulceration and inflammation throughout the colon, with sparing of the sigmoid and rectum (Figure 2). Biopsy of the cecum, ascending colon, and transverse colon revealed diffuse infiltrate of pleomorphic large cells in the lamina propria and submucosa with focal ulcerations and necrosis, consistent with PTLD of monoclonal diffuse large-B cell morphology. The biopsy was negative for EBV and CMV. Immunohistochemistry was positive CD45RB, CD79a, CD30 and BCl2. He was referred to hematology-oncology and followed-up as an outpatient to begin chemotherapy.

DISCUSSION:
Though PTLD is classically described as an early complication of solid organ transplant, this case presents the development of colonic PTLD after over 15 years since last transplant. This finding supports the notion that there is a bimodal peak in incidence. This case also demonstrates the insidious, non-specific gastrointestinal findings of colonic PTLD. Because of this, and as survival after organ transplant continues to increase, providers must have a high index of suspicion for PTLD in the colon as a late complication of transplant.
1604 Multidisciplinary Approach for Prolonged Survival of Patients With MMIHS
Authors: Nallapeta Naren S. , Kohen Aniqa A. , Saleemi Maryam , Conway-Habes Erin 
Published: October 2019

INTRODUCTION:
Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS)/Berdon syndrome is a rare disorder characterized by a distended non-obstructed bladder, microcolon, and decreased intestinal peristalsis with average life expectancy less than 6 months. We present case of a patient with MMIHS.

CASE DESCRIPTION/METHODS:
A 23-year-old female with MMIHS presented to the emergency department for abdominal pain and inability to tolerate oral or feeds through gastrostomy tube for 3 weeks. She had extensive surgical history since birth with LADD’s procedure due to intestine malrotation, exploratory laparotomy and subtotal colectomy for volvulous, colectomy with end ileostomy, Bilroth I, gastrostomy tube, and multiple nephrostomy tube for recurrent urinary infection. Patient had similar recurrent symptoms thought to be due to small intestinal bacterial overgrown and recurrent urinary tract infection. It appeared with each hospitalization her ability to tolerate oral intake declined to a lower baseline. At home patient was on Cisapride 14ml four times daily. During hospitalization lab work and imaging was non-contributory other than urine culture positive for Klebsiella. A small bowel follow through showed delayed gastric empting. Due to inability to tolerate oral intake or feeds patient was started on total parenteral nutrition (TPN). Esophagogastroduodenoscopy showed esophagitis, moderate chronic active gastritis with widely patent gastrojejunostomy anastomosis and jejunal limb. Her symptoms were likely due to progression of hypomotility syndrome. Cisapride was increased by 14%, under direction of outpatient pediatric gastroenterologist, with good response. However, due to prolonged QTc on electrocardiogram, upon discharge she was changed to Lubipristone.

DISCUSSION:
Our case demonstrates a complex presentation of a rare but fatal intestinal myopathy with most patients not surviving past infancy with even fewer cases surviving long term. Complications such as perforation, sepsis, malnutrition, multi-organ failure and pseudo-obstruction is not well understood in these patients and needs to be ruled out at each hospitalization. A multidisciplinary approach is needed for long term survival of patients with MMIHS. Main goals of treatment include providing a bladder-emptying strategy and adequate nutrition. In our case study, we demonstrate off label use of Cisapride and Lubiprostone for dysmotility. Close long term follow-up is necessary with multidisciplinary approach for long term survival.
1606 A Very Unusual Case of Colonic Adenocarcinoma Originating From an Enterocutaneous Fistula
Authors: Moore Andrew , Lee Salina , Jakate Shriram 
Published: October 2019

INTRODUCTION:
Enterocutaneous fistulas are a well known sequelae of intrabdominal surgeries. Common complications of these fistulas include sepsis, electrolyte abnormalities, and nutritional deficiencies. We present an unusual case of a mucinous colonic adenocarcinoma originating from an enterocutaneous fistula. To our knowledge, there are no other known cases of colonic adenocarcinoma originating from an enterocutaneous fistula.

CASE DESCRIPTION/METHODS:
Patient was a 65-year-old male with a past medical history significant for Korsakoff dementia and OLT ten years ago who presented to GI clinic. He had complaints of weight loss, decreased appetite, and increased lethargy. The patient had an enterocutaneous fistula as a result of a bowel resection following perforation from ERCP nine years prior. The fistula was never repaired as the patient was thought to be a poor surgical candidate and it did not seem to interfere with his quality of life.
Physical exam was notable for a tender abdomen with several scattered erythematous and excoriated lesions. There was an ostomy bag covering a 10cm fungating, necrotic appearing, malodorous mass with greenish liquid in the ostomy bag (Figure 1). This was surrounding the fistula site. Based on CT abdomen results from six months prior, it was suspected that this was an enterocutaneous fistula that may connect to the transverse colon. Biopsies were taken at bedside which revealed mucinous moderately differentiated adenocarcinoma, morphologically suspicious for colonic-type adenocarcinoma (Figure 2). Repeat CT abdomen showed a large heterogeneous abdominal wall lesion and mild wall thickening of adjacent mid-transverse colon consistent with the known mass.

DISCUSSION:
The prevalence of enterocutaneous fistulas in the population is not known; most are iatrogenic or postoperative in etiology (75-85%), with the ileum being the most common location. This patient’s enterocutaneous fistula was never repaired and was likely the result of a bowel resection following perforation from ERCP several years prior. As with chronic inflammatory states, such as that seen in IBD which can predispose to colorectal cancer, we hypothesize that a similar mechanism of chronic inflammation from a fistula connection to the outside environment may have contributed to this patient developing a colonic malignancy, especially in the setting of his immunosuppression. Furthermore, in patients who are unable to undergo repair of enterocutaneous fistulas, their risk of colorectal cancer may be increased.
1609 Spontaneous Perforation of a Sigmoid Gastrointestinal Stromal Tumor
Authors: Ngu Sam , Haddad Fady , Kingsley Ebare , Kong Fanyi , Wu Hueizhi , Deeb Liliane 
Published: October 2019

INTRODUCTION:
Most gastrointestinal stromal tumors (GISTs) are asymptomatic and involve the stomach and small intestine. Spontaneous rupture of a large sigmoid GIST is an exceptionally rare complication. Only three other cases of sigmoid perforation due to a GIST were described in literature.

CASE DESCRIPTION/METHODS:
A 90-year-old male with acutely worsening lower abdominal pain underwent emergent bowel resection for presumptive colonic perforation secondary to sigmoid diverticulitis. Initial abdominal computed tomography (CT) showed wall thickening in the sigmoid colon as well as an air-containing interloop heterogeneous mass measuring 3.5 × 2.0 cm with free intraperitoneal air. Laparotomy thereafter revealed a mass at the perforation site which was resected. Histopathologic examination revealed an infiltrative high-grade spindle cell neoplasm with marked cellular atypia, involving the muscularis propria and submucosa with extension to the adjacent pericolonic fat. CD117 (C-kit), CD34 and DOG1 biomarkers were negative, as well as actin, desmin, keratin and S100 stains. Hence, the diagnosis of a dedifferentiated KIT-negative GIST was made based on the favorable histopathology of the tumor via a consensus from the pathology department.

DISCUSSION:
Spontaneous bowel perforation, particularly in the sigmoid colon, is an exceedingly rare complication of GIST. Immunohistochemical studies can confirm the diagnosis; however, the absence of positivity for biomarkers does not exclude it in which case consensus from the pathology department is required to confirm the diagnosis. Physicians need to be cognizant of the propensity for GISTs to lead to bowel perforation, including the sigmoid colon.
1615 Rare Case of Abdominal Wall Metastasis Secondary to Colon Cancer
Authors: Badrinath Madhuri , Tambe Ajay , Masood Umair , Manocha Divey 
Published: October 2019

INTRODUCTION:
Colorectal cancer(CRC) with direct abdominal wall and skin invasion is an extremely rare finding. We present a unique case of CRC with an oligometastatic lesion in the abdominal wall.

CASE DESCRIPTION/METHODS:
Patient is a 56-year-old male who presented to the gastroenterology clinic with 2 months of constipation and hematochezia, in the absence of melena,weight loss, anorexia and abdominal pain. A screening colonoscopy revealed severe stenosis in the descending colon(50 cm proximal to the anus) with inability to further advance the scope. This area was biopsied and tattooed; pathological diagnosis was confirmed to be moderately differentiated adenocarcinoma.Tumor markers were negative and CT of the abdomen/pelvis was done which showed lymphadenopathy around the descending colon with no evidence of metastasis. 2 weeks later he underwent a robotic-assisted left colon resection with intracorporeal anastomosis, with no immediate postoperative complications.The histopathology of the resected mass was consistent with the initial biopsy findings and lymph nodes were negative for malignancy. Patient underwent adjuvant chemotherapy with capecitabine and oxaliplatin for 4 cycles which was well tolerated.A year later he developed a slowly progressive asymptomatic mass in the right abdominal wall.CT of the abdomen revealed a focal soft tissue mass measuring 3 × 3cm, involving the right lower anterolateral abdominal wall and rectus abdominis muscle.CT guided biopsy revealed metastatic adenocarcinoma consistent with primary CRC. PET scan was devoid of any metastatic or recurrent disease in other locations. Hence proceeded with resection of the mass and mesh placement for the abdominal wall defect. Patient tolerated the procedure well. The follow up scans have shown no evidence of recurrence or metastatic disease, and patient is symptom free.

DISCUSSION:
CRC often metastasizes to regional lymph nodes,liver, lung or bone via lymphatic and hematogenous routes. Abdominal wall metastasis is very rare and can be caused by direct invasion, lymphatic or hematogenous routes, and direct cancer cell implantation during prior surgical intervention which is the probable source in our patient. Laparoscopic resection is a feasible treatment option for solitary abdominal wall metastasis along with the advantage of assessing the abdomen for other metastases; especially in patients with advanced CRC who are at higher risk of developing fatal complications like peritoneal dissemination that may affect management.
1616 Unusual Baby Bump: Hidden Pregnancy in the Setting of Chronic Opioid-Induced Pseudo-Obstruction
Authors: Brar Tony , Jacobs Chelsea , Riverso Michael , Perbtani Yaseen , Yang Dennis 
Published: October 2019

INTRODUCTION:
Opioid addiction and abuse have become a serious public health problem in the United States. The most common gastrointestinal adverse effect is dysmotility and decreased peristalsis, manifesting as constipation. We present an extreme case of a young woman with chronic constipation in the setting of opioid abuse. Imaging obtained during her diagnostic workup revealed unexpected findings and further highlight the consequences of the opioid crisis in the United States.

CASE DESCRIPTION/METHODS:
A 26-year-old woman with known opioid-induced chronic constipation (OIC) presents to an outside emergency department with abdominal pain, distention, and leakage of yellow-brown fluid from the anus and vagina. She had been admitted multiple times over the course of the past year for management of chronic pseudo-obstruction.
Outside abdominal computed tomography (CT) revealed a diffusely dilated colon with large amounts of stool. Incidentally, an advanced intrauterine pregnancy was identified on imaging. The patient was unaware of the pregnancy. Ultrasound exam was consistent with a gestational age of 32 weeks and 6 days complicated by oligohydramnios and cord prolapse. The patient underwent emergent cesarean delivery without immediate complications. Flexible sigmoidoscopy was performed following delivery. Extensive amounts of solid stool were removed with digital disimpaction and copious lavage. During hospitalization, the patient was counseled regarding opioid abuse, management of chronic constipation, and scheduled for outpatient follow-up.

DISCUSSION:
The opioid epidemic in the United States has reached epic proportions, with drastic consequences on public health. OIC is the most frequent and prevalent adverse effect among opioid users. While conventional and new laxatives have been shown to be effective for OIC, focus should be shifted towards awareness and prevention of opioid abuse.
Another important note to be made is the importance of history taking on a patient with multiple hospitalizations with similar presentations. While she did have an extraordinary stool burden that did require manual disimpaction, the patient was also found to be in her third trimester of pregnancy on CT imaging. Fortunately, no harm occurred to the patient or child, however obtaining the proper history and diagnostic work-up could have helped limit any potential injury that might have resulted.
1623 Extra Nerves in the Gut: A Case of an Incidental Ganglioneuroma in the Colon
Authors: Jencks Kara J. , Bilal Mohammad , Luthra Gurinder 
Published: October 2019

INTRODUCTION:
Ganglioneuromas are exceedingly rare in the gastrointestinal tract and are typically found in the head, neck, or adrenal glands. We present a unique case of a ganglioneuroma in the colon found incidentally on a screening colonoscopy.

CASE DESCRIPTION/METHODS:
A 55-year-old male with no prior medical history underwent a routine screening colonoscopy. He had no hematochezia, melena, changes in bowel habits, weight loss, or other alarm symptoms. He had not had a previous colonoscopy and did not have any family history of gastrointestinal malignancies. Physical examination was unremarkable. The patient was found to have two sub-centimeter polyps in the transverse and descending colon, which were removed via cold snare. In addition, a 2-cm pedunculated polyp was found in the sigmoid colon [Figure 1]. The polyp was removed using hot snare polypectomy, and two endo-clips were placed post-polypectomy. The two sub-centimeter polyps were reported to be tubular adenomas. Hisotological examination of the pedunculated polyp showed spindle and ganglion cells. Immunohistochemical staining was performed, and it was positive for S-100, consistent with a ganglioneuroma. The patient has been scheduled for surveillance colonoscopy in 1 year.

DISCUSSION:
Ganglioneuromas are rare, slow-growing tumors that are derived from sympathetic ganglion cells in the nervous system. When present in the colon, patients are usually asymptomatic. However, patients can present with constipation, ileus, hematochezia, abdominal pain, or other nonspecific symptoms. Our patient was asymptomatic, which is the case in most colonic ganglioneuromas. As colonic ganglioneuromas are rare, there is no clear consensus on how to approach surveillance in these cases. Our report and several other recent reports highlight the need for consensus guidelines regarding approaching surveillance strategies in these patients.
1626 Primary Adenoid Cystic Carcinoma Presenting as Distant Metastasis to Ascending Colon
Authors: Collins Kelsey , Dong Ray , Rozenshteyn Frederick , Naik Jahnavi 
Published: October 2019

INTRODUCTION:
Salivary gland tumors are rare, often benign, mostly originating from the parotid gland. Tumors can also arise from submandibular and sublingual glands, and while these tumors tend to be more rare, they are more often malignant. Salivary gland tumors usually metastasize to the lung, bone, and liver.

CASE DESCRIPTION/METHODS:
A 77-year-old Albanian male with history of a right-sided mandibular abscess s/p drainage in 2015 presented with confusion and abdominal pain. Labs were unremarkable. He underwent CT head, which was concerning for an occipital lesion, for which he proceeded with an MRI brain that revealed multiple intracranial lesions concerning for metastatic disease. He then had a CT Abdomen/Pelvis that revealed several hepatic lesions, innumerable pulmonary nodules, and an area of focal thickening and enhancement of the proximal ascending colon. Bone scan revealed likely metastasis to the L5 vertebral body. His CEA was 4.7 and CA 19-9 was 43.6. AFP was 1.7. He then had a colonoscopy, which was significant for 2 polyps in the descending colon, 2 umbilicated polyps in the transverse colon, a 4 mm sessile polyp in the transverse colon, and a submucosal and ulcerated non-obstructing mass in the proximal ascending colon distal to the ileocecal valve. Pathology showed small, round, blue cells with trabecular growth pattern and necrosis, consistent with invasive, poorly differentiated carcinoma with basaloid features. In addition, the immunohistochemistry was positive for CK7 and Sox10, focally positive for S100, and weakly positive for CD 117, all suggestive of an adenoid cystic carcinoma. Treatment first consisted of palliative radiation to his CNS lesions, a dexamethasone taper, and an Oncology consult for consideration of palliative chemotherapy. He was offered palliative paclitaxel and carboplatin, however he ultimately decided to return to Albania and forego treatment.

DISCUSSION:
This patient likely had undiagnosed, malignant, primary salivary gland cancer for many years; despite having his mandibular ‘abscess’ drained several years prior. In addition, the lesion metastasized to several uncommon locations, notably the brain and colon, which are the 2 sites that ultimately produced symptoms that prompted him to receive further medical care. Salivary gland tumors must be considered in patients presenting with head and neck swelling, and proper diagnostic workup must be obtained. In addition, uncommon sites of metastasis, such as colon, must be considered during staging of disease.
1627 Segmental Colitis Associated With Diverticulosis: An Emerging Entity Among the Non-Specific Colitis
Authors: Estremera-Marcial Rodolfo , Marzan-Loyola Adriana , Martin-Ortiz Jose , Martinez-Souss Jaime , Cerra-Franco Javier 
Published: October 2019

INTRODUCTION:
An 86 y/o male with diverticulosis and hypertension, arrived at the ER due to intermittent episodes of bright rectal bleeding associated with lower quadrant abdominal pain since 3 weeks ago. Laboratories without anemia, leukocytosis, eosinophilia or any other abnormality. CT abd/pelvic revealed a segmental area of concentric mural thickening and narrowing of the lumen of the sigmoid colon, concerning for a mass. No prior colonoscopies or GI alarming features. GI service consulted for diagnostic endoscopic procedure.

CASE DESCRIPTION/METHODS:
Sigmoidoscopy was remarkable for severe diverticular disease of the rectal mucosa with associated significant erythema, exudative material and loss of vascular pattern consistent with an inflammatory process. At 20 cm from the anal verge, a luminal narrowing covering > 90% of the lumen extended up to 27 cm. Pathology report from the area of obstruction showed acute over chronic inflammation without granulomas, microorganisms or dysplasia. He was started on rectal mesalamine and a 14-day course of oral antibiotics (metronidazole and ciprofloxacin). Surgery service consulted which agreed with medical management. Within two weeks after completion of antibiotics, colonoscopy was performed revealing marked improvement of the luminal narrowing evidenced in the previous colonoscopy at 20cm, including less degree of inflammation and fewer loss of vascular pattern among the segmental area within multiple diverticuli. Biopsies taken from the same narrowing were remarkable for chronic inflammation without dysplasia. All findings were consistent with segmental colitis associated with diverticulosis (SCAD).

DISCUSSION:
SCAD is an inflammatory process that affects colonic luminal mucosa in areas that are affected by diverticulosis. The prevalence is 1.5 – 11.4% among those with diverticular disease. The pathogenesis of SCAD is unclear. The clinical presentation is not specific and thus similar to other pathologies, including inflammatory bowel disease, for which makes this condition difficult to diagnose. There are currently no guidelines for its management. It is frequently based on the administration of salicylates, antibiotics and surgical intervention for refractory cases. Currently it is unclear if SCAD is in fact a spectrum of IBD or if it is itself a separate entity. The rarity of SCAD supports the claim that further research is needed to better understand the disease and thus improve its management and clinical outcomes.