bluuebunny/crossref_metadata_2025_split huggingface dataset:
2672 Gastric Amyloidosis: A Rare Cause of Gastropathy and GI Bleeding
Authors: Gregory Nicholas , Kachru Sumyra 
Published: October 2019

INTRODUCTION:
Amyloidosis is a disorder of protein deposition that often presents with systemic symptoms. Symptoms of GI amyloidosis include abdominal pain, upper and lower GI bleeding, weight loss, diarrhea, malabsorption, esophageal reflux, and spontaneous bowel perforation. GI amyloidosis involves, from most to least common, the duodenum, stomach, colorectum, and the esophagus. In this case report, we will present a rare case of symptomatic AL amyloidosis localized to the stomach in which diagnosis and management was delayed by 3 months.

CASE DESCRIPTION/METHODS:
The patient was a 64-year-old African American woman who presented with a one-day history of fatigue and shortness of breath and a one-week history of dark stools. She had a past medical history significant for untreated plasma cell myeloma and chronic anemia. The patient had an EGD for intermittent dark stools 3 months prior to this admission which demonstrated severe gastropathy on endoscopic exam, but unfortunately no biopsies were taken at that point. The etiology of gastropathy remained unclear and nonspecific. During this hospitalization, with the patient’s ongoing history of melena, she underwent a repeat EGD which again showed severe localized gastropathy in the proximal stomach. A gastric biopsy was obtained from the area. On pathology review, the biopsy showed deposition of amorphous, eosinophilic material, suspicious for amyloid. Congo Red stain highlighted apple green birefringent material, consistent with amyloid. Patient remained hemodynamically stable during the hospital admission and was discharged before the pathology results were back. A week later, she was called to notify her of the results and to follow up with hematology oncology, but unfortunately patient had passed away at home, and the reason of death remained unclear.

DISCUSSION:
In a patient with GI bleed or other GI symptoms such as abdominal pain, nausea/vomiting, or change in bowel habits a probable etiology of amyloidosis should be on the differential, especially with history of plasma cell dyscrasia. Evaluation should include endoscopy with biopsy and specific amyloid staining if any obvious lesion is noted. Localized gastric amyloidosis presenting with GI bleeding is rare. This rarity may lead clinicians to dismiss it as a possibility which can delay diagnosis and proper management. This case report demonstrates such a situation in which a patient with plasma cell myeloma and symptoms of GI bleeding was delayed diagnosis and management by 3 months.
2680 IgG4 Related Disease Presented as Diffuse Gastric Wall Thickening Resembling Gastric Cancer
Authors: Al Jobori Hussein , Castano Juan , Al Gburi Karrar , Garrison Keith , Chacon Ingrid , Herrera Henry R. 
Published: October 2019

INTRODUCTION:
IgG4 related disease (IgG4-RD) is an immune-mediated condition first described in 2001 as part of autoimmune pancreatitis with subsequent recognition as a systemic condition in 2003. IgG4-RD is characterized by lymphoplasmacytic infiltrates enriched with IgG4-plasma cells that involve different organ systems. The pathogenesis is still being studied. We present a case of gastric IgG4-RD initially suspected to be gastric cancer.

CASE DESCRIPTION/METHODS:
A 64-year-old woman with a history of Sjogren’s disease, presented with a one-month history of nausea, vomiting, abdominal pain, and poor appetite. Home medication included prednisone 10mg TID. Physical exam was non-contributory. Pertinent lab results showed elevated serum IgG, normal IgG4, elevated ANA and SS-A/Ro antibodies. CT abdomen/pelvis showed diffuse wall thickening in the stomach. EGD showed severe diffuse gastropathy with areas of ischemic tissue and fistula tracts. EUS showed marked submucosal gastric thickening. Endoscopic biopsies showed gastric epithelium with ulceration, inflammation, granulation tissue, and atypical cells, negative for H. Pylori. Endoscopic and EUS FNA biopsies were not diagnostic. The patient then underwent full thickness biopsy which showed IgG patchy dense plasma cells with an increase in IgG4 positive plasma cells. The patient had a complicated course with a gastric leak from the surgical biopsy site that eventually healed with observation and steroid therapy.

DISCUSSION:
Most cases of IgG4-RD involve 2 or more organs and commonly include pancreas, lymph nodes, bile ducts, salivary glands, lacrimal glands, kidneys, retroperitoneum, & lungs which account for 85% of IgG4-RD. Involvement of the GI tract is rare. Our case represents an example of isolated IgG4-RD of the stomach. Literature review showed 13 case reports of gastric IgG4-RD although most were presenting as a solitary mass treated with surgical therapy. Our case report is unique in that our patient presented with diffuse gastric involvement with the appearance of linitis plastica. It is also interesting because IgG4-RD was previously reported to have an association with Sjogren’s Syndrome (SS) or its subtypes; Mikulicz disease, and Küttner tumor. Our patient did not have a further investigation of her SS. Since IgG4-RD of the stomach could mimic gastric cancer clinically, it is essential to recognize it early with immunohistochemical, pathological testing, clinical correlation, and treatment to avoid the morbidity associated with gastrectomy.
2681 Emphysematous Gastritis: A Rare Consequence of Small Bowel Obstruction
Authors: Landesman Nathan , Patel Kruti , Kahl Ryan , Price Michelle D. 
Published: October 2019

INTRODUCTION:
Emphysematous gastritis is a rare form of gastritis that is characterized by presence of gas in the gastric wall and portal venous system. Prompt diagnosis along with early treatment is key in preventing fatal outcome. Etiology can be ingestion, infectious, mechanical, or ischemic with high mortality. We present a case of emphysematous gastritis in a patient with small bowel obstruction presenting with hematemesis.

CASE DESCRIPTION/METHODS:
A 70 year African American female with past medical history significant for HTN and Atrial Fibrillation (anticoagulated with Eliquis) presented with complaint of epigastric pain and hematemesis. CT abdomen/Pelvis without contrast showed acute high grade small bowel obstruction at the distal ileum, non-obstructing umbilical hernia and stomach distention with emphysematous gastritis with air in the portal venous system. Patient was hemodynamically stable. Laboratory findings with hemoglobin 13.0 g/dL (11.0-16.2 g/dL), mean corpuscular volume 76.7 fl (80.0—100.0 fl), platelet count 138 K/cmm(140-440L/cmm), white blood cell count 8.2 K/ccm (4.5-11.0 L/cmm) with 32% segmented neutrophils.Patient underwent exploratory laparotomy with release of small bowel obstruction and primary repair of umbilical hernia. Intraoperative Esophagogastrodudenoscopy (EGD) showed diffuse erythema and ulceration in the esophagus, areas of black/purple mucosal discoloration in the gastric cardia, fundus and body with clear demarcation of abnormal and normal tissue at body/antrum. Pylorus was patent with unremarkable first and second part of the duodenum. Findings were consistent with emphysematous gastritis. Patient tolerated the procedure well and was extubated without any hemodynamic decompensation. Broad spectrum antibiotics which were initiated were stopped as blood cultures x 2 had no growth. Patient was discharged from hospital on post op day four with Pantoprazole 40 mg twice daily and follow up endoscopy.

DISCUSSION:
Emphysematous gastritis is a condition with very high mortality rate of 50-80%. No standardized/definitive approach has been described in the literature though many cases do undergo prompt surgical exploration. Our case portrays a multidisciplinary approach to management of emphysematous gastritis with exploratory laparotomy for small bowel obstruction and intraoperative endoscopy without any need for resection or manipulation of effected area.
2686 Collagenous Gastritis: A Rare Entity
Authors: Yazdanpanah Fariba , Hindy Pierre , Rahmani Rabin , Tin Kevin 
Published: October 2019

INTRODUCTION:
Collagenous gastritis is a rare entity characterized by subepithelial deposition of collagen bands thicker than 10 μm and the infiltration of inflammatory mononuclear cells in the lamnia propia. While collagenous colitis has become more common in clinical practice, collagenous gastritis is rare. These two entities generally present differently. Collagenous colitis presents more commonly with diarrhea, while collagenous gastritis presents more commonly with abdominal pain. Since the disease was reported in 1989, only 60 cases have been documented in English literature. We present a case of collagenous gastritis in a pediatric patient.

CASE DESCRIPTION/METHODS:
A 17-year-old male patient presents to our office with a three month history of epigastric pain with no changes in bowel habits. He denies any previous past medical or surgical history. He immigrated to the United States from China. Physical examination was unremarkable aside from mild epigastric tenderness. A CMP, CBC and celiac serologies were unremarkable. Upper endoscopy was performed which revealed moderate erythematous mucosa in the gastric antrum (Figures 1 and 2). Biopsies of the antrum yielded mild chronic gastritis with sub-epithelial collagenous gastritis in the antrum (Figure 3). Helicobacter Pylori was negative. Patient symptoms gradually responded to a proton pump inhibitor.

DISCUSSION:
Collagenous gastritis is a rare condition with limited data in the literature. Most patients are young, abdominal pain and anemia occur secondary to stomach-specific infiltration. The etiology is mostly unknown and hypothesized. The endoscopic findings that are commonly reported include nodular changes in the mucosa, due to chronic inflammatory infiltration, mucosal atrophy and deposition of bands of collagen. Compared with the diffuse and continuous deposition seen in collagenous colitis, the changes in collagenous gastritis are heterogenous. Collagenous gastritis as a rare entity should be in the differential in younger patients who present with epigastric pain.
2696 Dysphagia: A Rare Presentation of Multiple Myeloma
Authors: Ghazaleh Sami , Nehme Christian , Khader Yasmin , Ghanim Marcel , Alhmoud Tarik 
Published: October 2019

INTRODUCTION:
Dysphagia is a common symptom with a broad differential diagnosis. Although the etiology of dysphagia is usually benign, it is critical to rule out serious causes. It is also important to think outside the box when the cause is not obvious. We describe a case of multiple myeloma that presented with dysphagia.

CASE DESCRIPTION/METHODS:
An 81-year-old male patient presented with progressive dysphagia to solid food associated with poor appetite and weight loss of 50 lb. over the last 6 months. Past medical history was significant for coronary artery disease, essential hypertension, hypothyroidism, chronic hepatitis B infection, and sarcoidosis. Past surgical history and family history were insignificant. Home medications included aspirin, atenolol, quinapril, levothyroxine, and entecavir. He denied the use of tobacco, alcohol, and illicit drugs. Review of systems was unremarkable On physical exam, the patient looked chronically ill and cachectic. Vital signs were within normal limits. Abdominal exam showed a soft, non-tender, and non-distended abdomen without organomegaly. Initial laboratory workup revealed microcytic anemia with a hemoglobin of 11.6 g/dL. He underwent upper endoscopy which revealed patchy erythema in the gastric antrum. Gastric biopsy was performed with findings of acellular, eosinophilic deposits and a Congo red stain showed apple-green birefringence on polarized light consistent with gastric amyloidosis. Further workup was done to look for the cause of amyloidosis. Serum and urine protein electrophoresis failed to show a monoclonal (M) band. Immunofixation revealed elevated free kappa light chains of 104.90 mg/dL and elevated free Kappa/Lambda ratio of 156.57. Bone marrow biopsy revealed that plasma cells constituted 28.5% of bone marrow cells. The patient was diagnosed with multiple myeloma (light chain myeloma) and was started on bortezomib, lenalidomide, and dexamethasone. During a follow-up visit 1 month later, he reported improvement in dysphagia and weight gain.

DISCUSSION:
Gastrointestinal involvement is common in patients who have amyloidosis. However, it is rare for amyloidosis to initially present with gastrointestinal symptoms. Depending on the site involved, patients can present with dysphagia, gastrointestinal bleeding, constipation, malabsorption, or protein-losing gastroenteropathy. Identification and treatment of the underlying disease, e.g. multiple myeloma, is important because it can lead to regression of gastrointestinal amyloidosis.
2700 A Rare Case of Hypersalivation as the Presenting Symptom of Zollinger-Ellison Syndrome
Authors: Kucharski Kimberly , Clayton Steven 
Published: October 2019

INTRODUCTION:
Zollinger-Ellison Syndrome (ZES) is characterized by hypersecretion of gastrin from duodenal or pancreatic gastrinomas. Ectopic secretion of gastrin results in high gastric acid output due to the trophic action of gastrin on parietal cells and histamine-secreting ECL cells. ZES typically presents with symptoms of severe acid-related peptic ulcer disease such as abdominal pain, diarrhea, heartburn, and weight loss as well as complications from acid hypersecretion such as GI bleeding, stricture, and perforation. We report a novel case of a 60-year-old female who presented with hypersalivation as her chief complaint.

CASE DESCRIPTION/METHODS:
A 60-year-old female with type 2 diabetes mellitus, gastroparesis, and GERD presented to her gastroenterologist with nausea, hypersalivation and a “sour taste” in her mouth over the past few months. She states that this sour taste is constantly in her mouth and throat but is worse in the evenings. Her symptoms are associated with belching but she denies any heartburn. Medications at that time included pantoprazole 40 mg daily and ranitidine 150 mg BID. She initially underwent EGD with findings of chronic gastritis. Gastric biopsies were consistent with mild chronic gastritis with foveolar hyperplasia and intestinal metaplasia and staining for H.pylori was negative. Serum fasting gastrin level was significantly elevated at 1,379 pg/mL (normal < 100 pg/mL). CT abdomen/pelvis revealed a 13 × 12 mm subtly enhancing soft tissue density between the pancreatic head and the lumen of the duodenum, with concern for neuroendocrine tumor. The patient is scheduled to undergo further evaluation of these CT scan findings with endoscopic ultrasound and fine needle aspiration.

DISCUSSION:
This case is an example of an atypical presentation of ZES leading to delayed diagnosis and treatment. Symptoms of hypersalivation have been described in GERD, however the literature does not describe any cases of hypersalivation as a presenting symptom in patients with ZES. It is thought that reflux of stomach acid into the pharynx may lead to an increase in saliva production in order to neutralize the excess acid. The rare nature of ZES can lower clinical suspicion for the disorder and ultimately result in a delay in diagnosis. This case provides a unique example of ZES that highlights the importance of increased awareness of this disorder in patients who present with chronic GI symptoms despite adequate therapy.
2710 Asymptomatic Bochdalek Hernia in an Adult Male: A Rare Entity
Authors: Then Eric O. , Castillo Adonis , Ofosu Andrew , Gayam Vijay , Culliford Andrea , Gaduputi Vinaya 
Published: October 2019

INTRODUCTION:
Bochdalek hernias (BH) are a type of congenital diaphragmatic hernia that mostly present in children. The diagnosis of a Bochdalek hernia in an adult patient is extremely rare accounting for an estimated 0.17% to 6% of all diaphragmatic hernias. Here we present a case of an asymptomatic Bochdalek hernia in adult patient.

CASE DESCRIPTION/METHODS:
Patient is a 51 year old female with a medical history of mental retardation, diabetes mellitus type 2, who was referred to our gastroenterology clinic for chronic constipation and abdominal mass. Per the patients nursing aid, on prior exam an abdominal mass was palpated on routine physical exam. On presentation to our clinic her physical exam was unremarkable. Recent complete blood count and comprehensive metabolic panel were within normal limits. Given these findings a computed tomography scan of the abdomen was done. This was done and showed no masses within the gastrointestinal tract, but was remarkable for a moderate sized left bochdalek type hernia with associated herniation of the third and fourth portions of the duodenum and the splenic flexure of the colon, without CT evidence of incarceration. On return visit, the patients nursing aid and family were notified of the findings, but refused surgical intervention for possible correction. She remained asymptomatic on follow up visits and the family continued to refuse treatment.

DISCUSSION:
Bochdalek hernias (BH) result are a rare congenital anomaly that results from a persistent pleuroperitoneal that occurs due to failure of the postero-lateral foramina to fuse. This allows contents of the abdomen to herniate into the thorax. Symptoms of BH depend on location. Right sided BHs may present with herniation of the liver and intestine. Left sided BHs may present with herniation of the stomach, small intestine and colon. Diagnosis of BH in adults can be challenging as symptoms are non-specific (mild abdominal pain) and up to 25% of patients are asymptomatic. Diagnosis of BHs in adults can be accomplished through imaging modalities such as computed tomography, magnetic resonance imaging, and fluoroscopy. The treatment of choice for BH is surgical repair. This should be considered in asymptomatic patients as well, given the potential for strangulation of the herniated contents.
2719 A Rare Cause of Chronic Diarrhea: Gastrocolic Fistula
Authors: Som Aniruddh , Mahmood Syed , Nath Anand , Patel Mitesh R. 
Published: October 2019

INTRODUCTION:
Gastro-colic fistula is a pathological fistulous tract usually between the stomach and the transverse colon. It is a rare presentation of both benign and malignant diseases of the GI tract. Most cases in the modern world are related to adenocarcinomas of the colon. Benign fistulas are a rarer occurrence due to advancements in the medical management of peptic ulcer disease. Here we present a case report of a benign gastro-colic fistula occurring in the setting of a prior Whipple’s surgery.

CASE DESCRIPTION/METHODS:
A 61-year-old male presented with chronic diarrhea associated with a 50-pound weight loss, fatigue, and weakness. His past surgical history was notable of a Whipple’s procedure done 10 years ago. A trial of lactose-free diet and a course of antibiotics did not improve his symptoms. Upon further investigations, it was revealed that patient had anemia, hypokalemia and a low albumin level. Workup was negative for celiac disease, carcinoid syndrome, gastrinomas, and therefore the patient had an endoscopy which revealed a benign gastro-colic fistula in the setting of an anastomotic pyloric ulcer eroding into the transverse colon. He was then referred for surgery following optimization of his nutritional status.

DISCUSSION:
A majority of cases are due to malignancy, specifically gastric cancer or transverse colon cancer, although fistulas due to benign causes have also been described. In addition, cases of gastrocolic fistula have been observed in the setting of prior gastric surgeries but the interval duration of development has been reported to be around 8 to 9 months. Patients generally present with undifferentiated symptoms like diarrhea, weight loss, abdominal pain, nausea and vomiting making the diagnosis difficult. Radiologic imaging studies such as barium enema (most sensitive test) and barium meals are the mainstay of diagnosis. Endoscopy is usually not recommended as a diagnostic tool. Endoscopy with biopsy is primarily done as part of the workup to rule out malignancy. Definitive treatment includes surgical resection. Conservative medical management such as proton pump inhibitors should be considered when surgery is contraindicated or in cases that occur in the setting of peptic ulcer disease.
2720 Iron Pill-Induced Gastropathy in Elderly Patients: A Case Series Report
Authors: Comba Isin Y. , Henriquez Richard , Kumar Sundeep , Wallis-Crespo Maria , Srinivasamurthy Ruthvik , Bhatia Lakhinder , Shultz Joshua 
Published: October 2019

INTRODUCTION:
Iron deficiency anemia is a global health problem with an estimated two billion cases worldwide. Oral iron supplementation is considered the first line treatment. However, recent studies favor the use of short-term IV iron especially in patients with drug tolerance and efficacy concerns. In this report, we present three cases of iron pill gastropathy in patient's whose clinical courses were complicated by gastric erosion, ulcer or gastrointestinal (GI) bleeding. All of our patients had a history of iron deficiency anemia and were being treated with oral ferrous sulfate.

CASE DESCRIPTION/METHODS:
The first case involved a 72-year-old male with multiple comorbidities was admitted to the hospital for an NSTEMI. Initial labs revealed severe microcytic anemia (Table 1). He denied any hematemesis, melena, or hematochezia. During his hospital stay, he underwent an EGD which showed several erosions in the antrum with no active hemorrhage or visible vessels. Biopsy taken from the erosions demonstrated reactive gastritis with chronic inflammation and focal pigmented deposits stained positive with iron dye. After establishing the diagnosis iron gastropathy, the patient was transitioned to IV iron. In a second case, an 81-year-old male presented with a three-day history of abdominal pain associated with nausea and vomiting. The patient was started on proton pump inhibitors, IV hydration, and antiemetics for suspected acute gastritis with complete resolution of the symptoms. Severe anemia on initial labs prompted an EGD, which showed a superficial ulcer in the gastric body with a caustic appearance. Microscopically, focal iron deposits were remarkable in the area of erosions and were consistent with iron gastritis. Lastly, an over-90-year-old female presented with acute shortness of breath. Initial labs revealed worsening iron deficiency anemia. An EGD showed erosions within the gastric body with mild superficial gastritis. Microscopically, biopsied erosions showed yellow deposits within the mucosa, which stained positive for iron.

DISCUSSION:
Iron pill gastropathy is an underrecognized condition particularly in the elderly. The liquid form of oral iron has been shown to be less toxic to the gastric mucosa compared to the tab formulation. Transition to liquid or IV iron should be considered in patients with iron gastropathy as use of iron pills can lead to gastric erosions, ulcers, and GI bleeding, which can worsen the underlying anemia and result in cardiovascular symptoms related to severe anemia.