bluuebunny/crossref_metadata_2025_split huggingface dataset:
2784 Steroid Responsive Gastric Dysmotility - Seronegative Autoimmune Autonomic Neuropathy
Authors: Harris Samar , Greenan Garrett , Naina Harris , Harris Adam , Philip Justin , Phillips Lauren 
Published: October 2019

INTRODUCTION:
Gastrointestinal motility disorders are complex conditions manifesting with a wide array of symptoms. In recent years, the increasing discovery of autoantibodies targeting the nervous system has led to the recognition of new neurologic autoimmune disorders (NAD) which present with the subacute development of profound neurological impairment and gastrointestinal motility disorders which when promptly treated with immunotherapy, may show dramatic improvement.

CASE DESCRIPTION/METHODS:
A 32 year old woman with a history of undifferentiated connective tissue disease presented to establish care for known gastroparesis Her symptoms started following an upper respiratory infection the age of 15 years, which was followed by development of arthralgia, rash, raynaud's, tonic pupils, and distal sensory symptoms. She also developed orthostatic intolerance and was diagnosed with severe gastroparesis with over 40 lb weight loss. Her medications included Plaquenil and methotrexate, as well as Zofran. She underwent extensive testing with autonomic function testing showing moderate sympathetic adrenergic dysfunction and distal sudomotor impairment which indicated a limited autonomic neuropathy and skin biopsy showed small fiber neuropathy. Paraneoplastic antibody testing, GAD antibody and ganglionic Acetylcholine receptor (gAChR ab) was negative. A trial of IVIg was started for suspected autoimmune GI dysmotility but this was complicated with pancytopenia. On exam she was malnourished with a BMI of 15, normal reflexes, and decreased distal sensations. She underwent repeat autonomic function testing which was normal. A 4 hour solid gastric emptying was performed which showed delayed emptying at 4 hr of 80%. She was underwent a 5 day infusion of IV Solumedrol at 1000 mg daily for suspected autoimmune dysmotility. A daily GCSI-DD ( gastroparesis cardinal symptom index- daily diary) score showed a >50% improvement in scores on Day 0 to Day 5 and normalization of 4 hour solid GES and was then started on IV Rituximab.

DISCUSSION:
This case highlights that importance of considering a diagnosis of neurologic autoimmune disorders which can present with as solitary GI dysmotility. Seronegative autoimmune autonomic neuropathy is a clinical entity which shows prominent sympathetic failure, sensory symptoms and is steroid responsive.
2787 Gastric Amyloidosis With Arteriovenous Malformation: A Rare Etiology of Upper GI Bleeding
Authors: Gujjula Srilaxmi , Barakat Mohamed , Aloreidi Khalil , Xiao Philip , Boire Nicholas , Reddy Madhavi , Gurram Krishna C. 
Published: October 2019

INTRODUCTION:
Amyloidosis refers to group of conditions caused by a build-up of amyloid fibrils in organs and tissues throughout the body. We present a very rare case of localized amyloidosis of the stomach presenting with an upper gastrointestinal bleeding (UGIB) due to arteriovenous malformation (AVM).

CASE DESCRIPTION/METHODS:
An 81-year-old female with past medical history significant for hypertension presented with hematemesis of one day duration. Vital signs were within normal limits. Physical exam was significant for epigastric tenderness. Initial lab work revealed hemoglobin 8.4 g/dL, mcv 83 fL, wbc 11.2 K/cm, platelets 513 K/cmm. Complete metabolic panel was within normal limits. Esophagogastroduodenoscopy (EGD) demonstrated oozing of blood on contact with air insufflation from the lesser curvature, body and fundus of the stomach with normal duodenum. Interventional radiology angiogram and computed tomography angiography were performed and were unable to localize source of bleeding. EGD was attempted four days later and recurrent oozing of blood on mucosal contact with air insufflation occurred. She was subsequently placed on total parenteral therapy (TPN) and sucralfate for ten days to help heal the cause of the inflammation. A third endoscopy showed similar findings. Thus, biopsies were taken. Hemoglobin remained stable with no recurrent hematemesis episodes and patient was discharged on PPI, sucralfate and liquid diet. CD34 staining on biopsy reveals dilated and congested blood vessels suggestive of AVM and special stain (Congo Red) portraying apple green birefringence confirming diagnosis of amyloidosis (Figures 1 and 2). Serum protein electrophoresis exhibited gamma globulin spike portraying AL amyloidosis.

DISCUSSION:
A single case of intraabdominal arteriovenous malformation and localized amyloidosis of an abdominal mass has been reported. This is the first reported case of localized gastric amyloidosis with AVM presenting with an UGIB. The association between AVM and amyloidosis is hypothesized to be due to amyloid proteins deposition predilection around leaky vasculatures, which was proven in mice. AVM causes amplified plasma flow and increased amyloid deposition leading to vessel friability and ischemia, ultimately resulting in mucosal ulcerations with delayed healing. This is our postulated mechanism as to why our patient had persistent gastric ulcer bleeding not amenable to multiple therapeutic/follow-up EGDs.
2790 Autoimmune Hemolytic Anemia and a Gastric Mass in a Patient With Acute Epstein-Barr Virus
Authors: Rosa Cesar J. , Foster Daniel , Fenderson Joshua , Thompson Misty , Gonzales Paul 
Published: October 2019

INTRODUCTION:
Angioimmunoblastic T-cell Lymphoma (AITL) is a rare peripheral T-cell lymphoma. This is the first reported case of AITL presenting with a gastric mass. There is an association with Epstein-Barr Virus (EBV), though its role in pathogenesis is unclear.

CASE DESCRIPTION/METHODS:
A 64-year-old female presented for abdominal pain with a suspicious gastric mass and lymphadenopathy. She developed autoimmune hemolytic anemia during the hospital course with Coombs testing revealing mixed warm and cold agglutinins. Anti-smooth muscle antibody was positive along with serology consistent with an acute EBV infection. Gastric mass biopsy returned inconclusive. Steroids were indicated but held given suspicion for lymphoma and need for accurate tissue samples. A blood transfusion was given and resulted in an appreciable increase in bilirubin level. Following lymph node resection, methylprednisolone was given and the patient’s hemoglobin stabilized. A tissue diagnosis of AITL was made and chemotherapy led to subsequent improvement in her anemia.

DISCUSSION:
Since AITL was first described in the 1970s, there has been a clear association with auto-immune phenomenon and correlation with EBV. This is the fourth reported case presenting with an acute EBV infection and the first presenting as a gastric mass.1,2 The presence of active EBV infection could potentially steer away from more insidious processes.1 Unfortunately, AITL is aggressive and has a bleak prognosis. Despite advancing treatments, median survival is only 3 years.3,4 The presence of active EBV infection can lead to misdiagnosis as there is some overlap in symptoms and presentation. High suspicion must be maintained for malignancy with this constellation of unusual hematological abnormalities.
2796 Possible Predictors of Gallbladder Stasis: Why Not Vitamin D?
Authors: Atem Ngum Kikah , Atem Folefac , Olanipekun Titilope , Weerakoon Sitara M. 
Published: October 2019

INTRODUCTION:
Gallbladder (GB) stasis is highly prevalent in the general population, especially amongst females. It is also one of the most common gastrointestinal causes of hospital admission. A limited number of studies have shown no association between vitamin D levels and gallstone disease in the general population, despite an established association between vitamin D deficiency among pregnant females and GB stasis among pregnant females.

METHODS:
We used the Framingham Heart Study database and performed descriptive and multivariate tests to identify possible confounders not limited to vitamin D levels that are associated with GB stasis. Unadjusted tests were based on t-test and chi-square test when appropriate. Logistic regression analyses were performed with possible confounders of GB stasis. In order to understand the high prevalence of GB among females, both univariate and multivariate tests were performed on the sub-sample of females.

RESULTS:
Gender was predictive of GB stasis, with females being more likely to have GB stasis (P < 0.0001). Age (P < 0.0001) and body mass index (P < 0.0001) were associated with GB stasis in the entire study population. In the sub-sample of females only, high density lipoprotein cholesterol (HDL) showed a significant association to GB stasis with a negative estimate of the coefficient of interest, signifying that higher levels of HDL were protective against GB stasis among females. However, there was no significant difference in GB stasis based on Vitamin D levels (P = 0.3213).

CONCLUSION:
Vitamin D levels are not significantly associated with GB stasis in the general population. However, a closed study of age of onset of GB stasis, sex differences in GB stasis, effect of BMI, and the effect of HDL to GB stasis require much more attention to the understanding of the disease.
2800 Safety of ERCP in People Older Than 90: Nationwide Analysis
Authors: Al-Aboodi Yasir , Al-Chalabi Ahmed , Kobeissy Abdallah , Sodeman Thomas , Nawras Ali 
Published: October 2019

INTRODUCTION:
The aim of this study is to examine the Endoscopic Retrograde Cholangiopancreaticograhy (ERCP) related complications and (all causes mortality in people above the age of 90 years who were hospitalized for Choledocholithiasis related admission.

METHODS:
National inpatient data sample(NIS) is used in this study. NIS is the largest publicly available all-payer inpatient care database in the United States, containing data on more than seven million hospital stays. Choledocolethiasis related admissions who had ERCPs during hospitalization are identified using the International classification of disease version 9(ICD9). We compared the ERCPs related complications and overall mortality between people above the age of 90 year old and people between the age of 70-89. A logistic regression is used to evaluate if there is any difference and SPSS Version 25 is used to execute the statistical analysis.

RESULTS:
924 patients with age above 90 are identified. (33.8%) are male, (66.2%) female, (82.4%) are white, 4%black, 7.6 Hispanic, 3.8% Asians, (0.2%) native, (1.6%) others. 8279 are in (70-89 years) group, 46.9% male, (53.1%) female. 71.1% white, 5.7% black, 9.8% Hispanic, 4.3% Asians, 0.6% natives Americans,2.5% other races. The percentage of post ERCP pancreatitis in the (70-89) vs (90 and above) group are 151(1.8%) vs. 17(1.8%). P > 0.05, OR = 0. 98. 95% CI (0.56-1.6). Post ERCP Cholangitis. are 169(2%) vs. 20 (2.1%), P = 0.86, OR = 1.01, 95% CI (0.6-1.65) respectively, Bleeding 5(0.1%) vs. 2(.0.2%). P > 0.13, OR = 3.51, CI 0.68-18.7 respectively. There were only 2 cases of perforation in the (70-89) group. All causes mortality is 206(2.5%) vs. 33(3.5%). P = 0.345, OR = 1.34, 95% CI (0.9-1.9).

CONCLUSION:
There are no morbidities or all-cause mortality differences in ERCPs related admissions in age group (90 and above) vs (70-90) group. Age by itself should not be an excuse to postpone, or cancel ERCP in this age group.
2802 Endoscopic Ultrasound (EUS)-Guided Needle Biopsy for Benign Pancreatic Diseases
Authors: Sánchez-Luna Sergio A. , Paleti Swathi , Gulati Rishabh , Wong Morgan , Sobani Zain A. , Rustagi Tarun 
Published: October 2019

INTRODUCTION:
Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is a well-established method for specimen acquisition in suspected pancreatic malignancies. However, the role of EUS-FNA for non-focal, non-neoplastic, benign pancreatic diseases such as chronic pancreatitis and autoimmune pancreatitis is diminished by the sample inadequacy and architectural distortion. This is evaded by histologic core biopsies obtained through newer generation EUS-fine needle biopsy (EUS-FNB). The aim of this study is to evaluate the feasibility, safety, and diagnostic yield of EUS-FNB for benign pancreatic diseases.

METHODS:
This is a retrospective review of a prospectively collected database of all patients who underwent EUS-FNB for suspected benign parenchymal pancreatic diseases from 02/2017 to 11/2018. The primary objective of this pilot study was to evaluate the feasibility, diagnostic adequacy, and safety of the newer 22-gauge EUS-FNB in the evaluation of benign pancreatic parenchymal diseases.

RESULTS:
Seven patients (mean age 36.5 ± 18.5 years; 57% males) were included in this study. The mean number of FNB passes was 1.7 (median 2, range 1-3) (Figure 1A and B). Adequate tissue for histopathogical diagnosis was obtained in all cases. Mean length of core biopsy specimen obtained was 12 ± 8.2 mm. Histopathologic diagnoses included: chronic pancreatitis in 2, autoimmune pancreatitis in 2 patients, and parenchyma with no diagnostic abnormality in remaining 3 patients. Two patients with autoimmune pancreatitis were treated with steroid therapy with excellent clinical response. No adverse events such as bleeding, perforation, or post-biopsy pancreatitis were observed on median follow-up of 8.3 (range, 1-21) months.

CONCLUSION:
EUS-FNB with the newer 22-gauge biopsy needle is a feasible and safe procedure, and provides adequate pancreatic tissue specimen (core biopsy) for histopathological diagnosis of benign pancreatic diseases such as chronic pancreatitis and autoimmune pancreatitis.
2809 The Role of Serum Total Bilirubin Level Pattern in Predicting Spontaneous Passage of Common Bile Duct Stones
Authors: Al-Ghanoudi Ashirf , Mardini Houssam , Frandah Wesam 
Published: October 2019

INTRODUCTION:
In patients with suspected choledocholithiasis, total bilirubin (T. bili) level is widely accepted as a marker of biliary obstruction. We sought to evaluate the role of bilirubin decline pattern and extent in predicting spontaneous passage of stone in patients with suspected choledocholithiasis.

METHODS:
Patients who were 18 or older and admitted to our institution between October 2015 and December 2017 with ICD 10 code(s) commonly used in patients with confirmed or suspected choledocholithiasis were identified through the University of Kentucky Medical Services Database. Only pts with documented elevated T. bili with at least three measurements 12 hours apart were included for further review. Only pts with high-probability of choledocholithiasis based on very strong and/or strong clinical predictors of choledocholithiasis per ASGE guidelines were included in the final analysis. All selected pts underwent one or more of the following studies: MRCP, ERCP, EUS or IOC during their hospitalizations. Categorical variables were compared using chi square tests and continuous variables using two-sample t-tests. Odds ratios and 95% confidence intervals (CI) were calculated for variables of interest.

RESULTS:
825 patients were identified according to the screening criteria. 723 patients were excluded due to having pathologies other than documented or suspected choledocholithiasis and 102 patients (48 males and 54 females) were included in this study. Mean age was 57.4 years +/- 22. Of the 102 patients, 74 (72.4%) were eventually documented to have retained stones requiring clearance. 75 (73%) patients had consistent decline in T. bili ( > 3 measurements) while 33 (27%) had fluctuating levels. In patients with a consistent decline in T. bili, 26 (34.7%) were found to have retained stones while 49 (65.3%) were confirmed to have spontaneous passage of stone based on subsequent study. In comparison, significantly lower number (3; 7.4%) of patients with fluctuating T.bili level had spontaneous passage (OR 6.6; 95% CI 1.5, 30.2; P = 0.06). The mean change of T. bili in patients with and without spontaneous stone passage on day 2 was not significant (1.16 mg/dl +/-2.23 vs. 1.04 mg/dl +/- 1.17, P = 0.78).

CONCLUSION:
Patients with consistent total bilirubin decline beyond day two after initial presentation were seven times more likely to have had spontaneous passage of bile duct stone regardless of the decline level and can be used to determine need for further diagnostic and/or therapeutic interventions.
2812 Impact of Rapid On-Site Evaluation (ROSE) on Endoscopic Ultrasound-Guided FNA of Pancreatic Cysts: A Five-Year Comparative Study Between Two Academic Institutions
Authors: Al-Chalabi Ahmed , Khatib Hasan , Al-Abboodi Yasir , Plavnicky John , Kovar Sierra , Galka Eva , Sun Hongliu , Shadid Rana , Nawras Ali , De Las Casas Luis 
Published: October 2019

INTRODUCTION:
Endoscopic Ultrasound Guided-Fine Needle Aspiration (EUS-FNA) is considered the modality of choice for diagnosing intermediate pancreatic lesions. Rapid-on site evaluation (ROSE), when performed by a cytopathologist, has been suggested to improve the diagnostic yield of EUS-FNA. Prior studies were inconsistent regarding the benefit of ROSE. In our study, we evaluated the diagnostic yield of EUS-FNA in the presence of an on-site cytopathologist providing real-time feedback to the endoscopist compared to EUS-FNA alone in two academic hospitals.

METHODS:
We conducted a 2010-2015 retrospective chart review of all EUS-FNA performed at two academic medical centers (UT and UR). The policy at UT is to perform all EUS-FNA with ROSE, whereas it is not routinely done at UR. Cases where included when surgical pathology was available. Patients’ demographics, pancreatic cyst characteristics and EUS techniques were analyzed. EUS-FNA were considered valuable when it provided a classifying cytopathologic diagnosis. Student T-test and Analysis of Variance (ANOVA) were performed when appropriate for descriptive purposes.

RESULTS:
Forty-five cases (13 at UT, 32 at UR) were identified. EUS FNAs coupled with ROSE (UT) rendered 100% (13/13) valuable diagnoses, while those done with no cytopathologist on site (UR) had valuable diagnosis in 37.5% of the cases (12/32, P < 0.0001). The sensitivity of EUS-FNA at UT was 85% compared to 33% at UR. There was no statistically significant difference in gender, age, site or size of the tumor. The mean number of needle passes at UT was 1.9 (range 1-6) vs. 1.1 (range 1-3) at UR. The majority of needles used were 19G (55%) at UT vs 22G (83%) at UR (P < 0.001). Only one patient at UR had a minor cyst bleeding to the main pancreatic duct that required no therapeutic action.

CONCLUSION:
The results highlight the advantage of bed-side cytopathologist interaction with the endoscopist during EUS-FNA of pancreatic cysts. Absence of malignant cells despite suspicious ultrasound findings may have prompted more needle passes. The use of 19G needle may have improved outcomes with no significant increase of complications. In addition to the small sample size and the retrospective nature, the study is limited by the variability in personnel experience (endoscopists and cytopathologists) and the techniques used, indicating that further studies are necessary to confirm these findings.
2814 Clinical Significance of an Impacted Bile Duct Stone at Duodenal Papilla
Authors: Guevara-Zavala Andrés E. , Monreal-Robles Roberto , Jáquez-Quintana Joel O. , González-González José A. , Maldonado-Garza Héctor , García-Compeán Diego , Garza-Galindo Aldo 
Published: October 2019

INTRODUCTION:
An impacted bile duct stone at duodenal papilla or Impacted Papillary Stone (IPS) can lead to acute cholangitis (AC) or acute pancreatitis (AP) due to an almost complete obstruction of the common bile duct. This study evaluates the prevalence of these two diseases and the clinical characteristics when a gallbladder stone is impacted at the duodenal papilla.

METHODS:
This is a retrospective case-control study. Between March 2014 and January 2019, 394 consecutive cases of choledocholithiasis treated with endoscopic retrograde cholangiopancreatography (ERCP) were studied. Cases were divided into two groups: Patients with IPS and patients without impacted papillary stone.

RESULTS:
IPS group included 31 cases and control group included 363 cases without IPS. Fifteen patients in IPS group (48.4%) and 67 patients in control group (18.5%) were diagnosed with AC based on the 2018 Tokyo Guidelines (Odds Ratio: 4.14 [95% CI 1.95-8.79]; P < 0.01). AP was found in 9 patients in IPS group (29%) and 62 patients in control group (17.1%) (Odds Ratio: 1.98 [95% CI 0.87-4.5]; P = 0.14). Four cases in IPS group (12.9%) and 9 cases in control group (2.5%) were diagnosed with both AC and AP (Odds Ratio: 5.82 [95% CI 1.68-20.15]; P = 0.01). A higher count of white blood cell levels (Odds Ratio: 2.84 [95% CI 1.35-5.99]; P < 0.01) and ALT levels 4 times upper limit of normal were found in the IPS group (Odds Ratio: 2.61 [95% CI 1.17-5.83]; P = 0.02).

CONCLUSION:
IPS was found in 7.86% cases of choledocholithiasis and AC is more frequent than AP; IPS was found to be a risk factor for AC and AP with concomitant AC. Thus prospective trials are needed to confirm these findings to dictate a different approach whether IPS is found.
2815 Outcomes of Interventional Endoscopy for Gallstone Complications in Early Pregnancy
Authors: Azab Mohamed , Kam Kelli , Hong Annie , Volk Michael 
Published: October 2019

INTRODUCTION:
Endoscopic retrospective cholangiopancreatography (ERCP) is a technically challenging procedure rarely associated with severe post-procedure complications. Pregnancy promotes cholelithiasis due to hormonal changes and ERCP may be indicated. Surgical intervention is preferred during the second trimester of pregnancy. However, limited data is available on the safety of ERCP in early pregnancy.

METHODS:
Over a 7 year period, all pregnant patients with complicated gallstone disease were studied retrospectively at Loma Linda University Medical Center in California (n = 41). Five patients underwent ERCP during either the first or second trimester for choledocholithiasis or gallstone pancreatitis. One patient underwent laparascopic cholecystectomy during the same hospitalization. All patients underwent sphincterotomy and stone removal with balloon sweeps. Fluoroscopy was utilized in all five cases.

RESULTS:
Three patients delivered full term, healthy babies. Two of the patients experienced spontaneous abortions within one week after ERCP. Both cases of spontaneous abortion were in their first trimester of pregnancy. There were no other clear etiologies reported for cause of both abortions.

CONCLUSION:
ERCP is reported to be a relatively safe procedure in pregnancy. More studies are required to investigate the safety of ERCP in early pregnancy.