bluuebunny/crossref_metadata_2025_split huggingface dataset:
3025 Losartan-Induced Pancreatitis: A Rare Cause
Authors: Tripathi Shalini , Khuttan Akhilesh K. , Anandam Anil , Charilaou Paris , Jose Merin 
Published: October 2019

INTRODUCTION:
Acute pancreatitis (AP) is an acute inflammatory state caused by multiple etiologies, the most common being gallstones, alcohol and hypertriglyceridemia. Less than <5% of pancreatitis is caused by medications and have excellent prognosis. Multiple medications have been associated with developing pancreatitis, and among these, one is losartan. So far there has been 3 case reports of losartan induced pancreatitis. Losartan is a class 1b medication associated with pancreatitis. Medications are classified into group based on number of cases reported, recurrence with re-challenge. Class 1 medications have the highest association with pancreatitis.

CASE DESCRIPTION/METHODS:
49 year old male with a past medical history of substance abuse, schizoaffective disorder, hepatitis C and hypertension presented to the hospital with epigastric abdominal pain radiating to the back for 2 days and was found to have elevated lipase of 1600 U/L with computed tomography suggestive of AP. He had no family history of pancreatitis. There was no recent alcohol use. Serum triglycerides, blood alcohol level and urine toxicology screen were negative. There was elevation in liver enzyme, Aspartate aminotransferase 148 U/L, Alanine aminotransferase 92 U/L, Alkaline phosphatase 149 U/L, total bilirubin 1.7 mg/dl. Magnetic resonance cholangiopancreatography revealed normal caliber common bile duct without filling defects. The elevated enzyme likely were due to underlying hepatitis C. Upon medication review, patient was found to be taking losartan for his hypertension since 2018. He was treated with intravenous fluids and pain control. His blood pressure medication was switched to amlodipine and was discharged after 4 days, uneventfully. Patient had a prior admission two months ago for AP while he was on losartan which was not discontinued and workup for gallstone, alcohol, hypertriglyceridemia, hypercalcemia or illicit substance use was negative.

DISCUSSION:
There have been only few case reports of losartan-induced AP. The exact mechanism of losartan causing pancreatitis is not understood. Drug induced pancreatitis is not well studied due to limited number of cases. Establishing diagnosis involves ruling out other common etiology as challenging with medication in ethically difficult. This case emphasizes the importance of reviewing the medication of patients with an unclear etiology of pancreatitis.
3037 Spontaneous Cystgastrostomy From Pancreatic Pseudocyst Erosion Into Gastric Wall Resulting in Gastrointestinal Hemorrhage
Authors: El Kurdi Bara , Babar Sumbal , Haddad Ibrahim , Aasen Tyler , El Iskandarani Mahmoud , Goenka Puneet 
Published: October 2019

INTRODUCTION:
Pancreatic pseudocysts are a common complication of pancreatitis. Spontaneous erosion of a pseudocyst into adjacent organs is rare, manifesting in a variety of clinical symptoms and presentations. We present a case of spontaneous fistulization of a pancreatic pseudocyst into the stomach resulting in life-threatening bleeding.

CASE DESCRIPTION/METHODS:
A 60-year-old gentleman with history of type 2 diabetes mellitus, hypertension and chronic pancreatitis with known pancreatic pseudocyst presented with multiple episodes of melena associated with fatigue, weakness and epigastric pain aggravated by food intake. He denied history of peptic ulcer disease but admitted to chronic NSAID use. Physical examination revealed a pale patient with mild generalized abdominal tenderness without signs of peritonitis. Melenic stools were noted on digital rectal exam. Labs were significant for critical normocytic anemia with Hgb 6.3 g/dL. CT scan of abdomen and pelvis showed an 11.7 × 9 cm lesion in the pancreatic body with calcified rim communicating with gastric antrum. Gastrograffin swallow showed contrast transfer from stomach into the pseudocyst. A CT-Angiogram of the abdomen and pelvis failed to reveal a source of bleeding or peripancreatic pseudoaneurysms. Patient underwent EGD which showed 1 centimeter antral fistula-opening representing a spontaneous cystogastric fistula. No ulcers were found. The patient eventually underwent surgical excision of pancreatic pseudocyst, antrectomy and Billroth-II reconstruction.

DISCUSSION:
Pseudocysts complicate 20-40% of chronic pancreatitis. They can cause pain, bowel obstruction, infection, or hemorrhage. Treatment is indicated when cysts become symptomatic or grow beyond 5 cm. However, pseudocysts often resolve by spontaneous drainage into the pancreatic ductal system. Rarely, they can rupture into the peritoneal cavity or erode into nearby hollow organs. Bleeding can be the result of pseudocyst erosion into nearby vessels or rupture of nearby pseudoaneurysms. While involvement of gastroduodenal, splenic, hepatic and inferior pancreaticoduodenal arteries has been reported, none of these sources could be identified in this case. Treatment can take the form of direct embolization or surgical hemostasis. In summary, we have presented a case of pancreatic pseudocyst with spontaneous cystogastric fistula formation accompanied by massive upper GI bleeding eventually treated by surgical excision and Billroth-II reconstruction.
3041 Eosinophilic Colitis: A Rare Entity
Authors: Madan Anand 
Published: October 2019

INTRODUCTION:
Eosinophilic colitis (EC) is a rare entity characterized by abnormal infiltration of colon mucosa by eosinophils without evidence of any secondary causes. Presentation may include asymptomatic state, chronic diarrhea, abdominal pain, rectal bleed, bowel obstruction or ascites. We present two cases of EC with very different presentations requiring minimal or no therapy.

CASE DESCRIPTION/METHODS:

CASE 1: 57 year old Filipino male presented with abdominal pain and new onset ascites. Paracentesis revealed elevated SAAG suggestive of portal hypertension. Imaging studies were negative for cirrhosis. Negative liver workup for chronic liver disease. Lab studies revealed microcytic anemia and peripheral eosinophilia of 10%. No eosinophilia noted in ascitic fluid. EGD showed LA Grade C esophagitis. Colonoscopy showed multiple polyps which were removed. Pathology from polyps showed markedly increased eosinophil infiltrate in mucosa and submucosa. There was no evidence of inflammatory bowel disease, Stool studies were negative for infectious etiology. No incriminating medications were found which could lead to above finding. The patient was treated with omeprazole and diuretics with complete resolution of symptoms. CASE 2: 27 year old female presented with chronic intermittent abdominal pain, nausea and diarrhea for 2 years. Her only medications were birth control pills. She had normal blood counts, electrolytes, liver, and renal function. Stool studies were negative for any infectious etiology. She had normal fecal fat and electrolytes. EGD and colonoscopy were unremarkable. Biopsies were negative for celiac disease, Helicobacter and eosinophilic esophagitis. Random colon biopsies showed benign colon mucosa with focal infiltration of colonic mucosa with eosinophils suggestive of eosinophilic colitis. There was no peripheral eosinophilia. Patient was started on probiotics with prompt resolution of symptoms.

DISCUSSION:
EC is a rare condition, included in the group of eosinophilic gastrointestinal disorders, characterized by eosinophil infiltration of colonic mucosa in the absence of any food allergies, parasitic/helminthic infections, drugs, IBD, celiac and autoimmune diseases. The treatment options include dietary modifications, steroids, mesalamine, immunomodulatory agents, fecal microbiota transplant and surgery. The evidence for most of treatment options is limited to case reports. One of our patients required no specific therapy while other one was treated successfully with probiotics.
3045 An Unusual Episode of Acute Diverticulitis Despite Concurrent Antibiotic Therapy
Authors: Baseer Yaseen 
Published: October 2019

INTRODUCTION:
Diverticulosis occurs when weak spots in the outer layer of colonic muscle weaken giving way to an inner layer of protruding pouches. The progression to diverticulitis occurs when these protruding pouches become inflamed and infected which may ultimately progress to systemic symptoms that include fever, pain, malaise, constipation and vomiting. It is estimated that 50% of the population develops diverticulosis by age 50 and 65% by age 80. Additionally, an estimated 15-20% of the population with diverticulosis will go on to develop diverticulitis. Mild cases of diverticulitis are treated with oral antibiotics and a liquid diet whereas severe cases are treated with IV antibiotics and bowel rest. Here, we present a case of a diverticulitis episode that developed while a patient was already being treated with antibiotics.

CASE DESCRIPTION/METHODS:
A 64 year old female with a history of endometrial cancer who presented to the hospital for one day history of abdominal pain associated with loose bowel movements. She stated she has had loose bowel movements since starting H. pylori antibiotics that included amoxicillin and clarithromycin 2 weeks prior to presentation. She had an esophagoduodenoscopy 3 months prior that revealed chronic gastritis without dysplasia as well as biopsy proven H. pylori. Her colonoscopy at the same time showed internal hemorrhoids and a single hyperplastic polyp. Her vital signs were unremarkable and she was afebrile. Her white blood cell count on presentation was 13.9. She had a CT scan of the abdomen and pelvis that revealed acute sigmoid diverticulitis and cholelithiasis without evidence of acute cholecystitis. She was subsequently admitted to the hospital and treated with rocephin and flagyl as well as bowel rest. Blood cultures, stool cultures and clostridium difficile cultures were negative. Patient recovered over the next couple of days with resolution of her symptoms and her WBC count.

DISCUSSION:
This purpose of this case is to highlight the current management and treatment options for diverticulitis. Current guidelines recommend antibiotics and bowel rest during acute episodes of diverticulitis. However, this case represents an unusual scenario where a patient develops acute diverticulitis despite concurrent treatment with antibiotics for ongoing H. pylori infection. Further randomized-controlled trials may help delineate treatment modalities for acute diverticulitis as current treatment guidelines may result in breakthrough diverticulitis episodes.
3046 C. diff Infections During Induction Chemotherapy
Authors: Chung Jae , Wazir Ali , Richter Seth , Naseer Usman , Rahman Haider , Fitzpatrick Michael 
Published: October 2019

INTRODUCTION:
Patient with acute myeloid leukemia (AML) are at increased risk of developing Clostridium difficile (C. Diff) colitis due to routine use of prophylactic antibiotics, the use of chemotherapy and neutropenia. These factors also add additional challenges to successful treatment. We report a case of fulminant C. Diff pancolitis to highlight these challenges.

CASE DESCRIPTION/METHODS:
65 year old male was found to have pancytopenia on routine blood work at primary care office after experiencing 15 pound weight loss over 1 month. He had a history of rheumatoid arthritis that was well controlled on medications and had no other symptoms. His initial CBC showed a WBC 0.4 k/mm3, Hgb 6.9 g/dL, & platelets 8 k/mm3. A subsequent bone marrow biopsy showed 50% myeloblast, flow cytometry and genetic testing showed normal cytogenetics with intermediate risk & (-) FLT 3 mutation. Patient underwent 7 + 3 induction & a 5 + 2 reinduction after day 14 bone marrow showed residual disease. Patient was placed on prophylactic voriconazole, acyclovir & Levaquin but still developed fevers during neutropenic nadir. Blood cultures showed polymicrobial sepsis from a GI source (with growth of Gemella haemolysans & Rothia mucilaginosa). He developed diarrhea & NAAT tested positive for C. Diff. An abdominal X ray showed dilated large bowel loops with ileus a subsequent CT scan confirmed pancolitis (Figures 1 and 2). Patient developed septic shock. He initially responded to fluid resuscitation and was started on oral vancomycin and IV flagyl. After 4 days patient had a PEA arrest and was transferred to ICU after ROSC. Patient passed away soon after as patient family opted for comfort measures.

DISCUSSION:
Patients with acute myeloid leukemia (AML) are immunocompromised with neutropenia either due to their disease or from the effects of their chemotherapy regimen. Neutropenic patients are at risk for life threatening infections & administration of prophylactic antibiotics is common practice for induction chemotherapy. Many chemotherapy agents have antimicrobial activity altering the gut biome. Research has shown cancer patients have decreased response to therapy, increased time to resolution of diarrhea, and increased relapse rates to C. Diff associated diarrhea. The key is to diagnose & treat early. Severe disease should be distinguished early. The 2018 IDSA guidelines recommends use of algorithms and criteria to aid in this process (Figure 3). Further research is needed to outline the optimum approach to treatment in this patient group.
3048 New Onset Ascites Related to Peritoneal Carcinomatosis
Authors: Grosch Gretchen , Jadav Puja , Evans Neil 
Published: October 2019

INTRODUCTION:
Peritoneal carcinomatosis (PC) is a metastatic feature in several gastrointestinal malignancies. As one of the most common presenting symptoms is new onset ascites, understanding the workup and typical findings of malignant ascites is crucial for appropriate and time sensitive diagnosis and treatment of such malignancies.

CASE DESCRIPTION/METHODS:
A 50-year-old female with past medical history significant for hypertension and alcohol abuse presented to the hospital with complaint of intermittent weakness and progressive abdominal fullness for one month. Her exam was notable for subconjunctival palor, abdominal ascites with generalized tenderness, and lower extremity edema. Labs showed leukocytosis and microcytic anemia, with hemoglobin of 5.9. CT abdomen/pelvis revealed cardiomegaly, moderate volume ascites, and diffuse body wall edema. Iron studies were obtained (low iron, low-normal ferritin) and the patient was transfused. A diagnostic paracentesis was completed with resultant SAAG of 0.6. Cytology revealed benign appearing mesothelial cells and histiocytes. Due to the patient's lack of insurance, GI was consulted for inpatient evaluation of iron deficiency. Colonoscopy showed a large (>10 cm) ulcerated lesion in the sigmoid colon with pathology consistent with moderately-differentiated adenocarcinoma. Repeat CT was obtained for staging purposes, showing diffuse peritoneal carcinomatosis, distal colon lesion, L4 vertebral sclerosis, and large volume ascites. The patient was discharged with plans to follow up with GI and oncology to discuss therapeutic options.

DISCUSSION:
Peritoneal carcinomatosis is defined as the dissemination of cancer cells throughout the periteoneum. About 8% of patients with colorectal cancer present with PC; most commonly with nonspecific symptoms such as fatigue, abdominal pain/fullness, and bowel obstruction. Since new onset ascites is common to PC, it is important to identify malignant ascitic fluid. Malignant ascites related to peritoneal carcinomatosis is mainly caused by subphrenic vessel obstruction and accounts for 7% of ascites cases. A diagnostic paracentesis is indicated, with typical fluid findings of WBC >500, SAAG <1.1, and total protein >2.5. Fluid cytology is important, however sensitivity is affected by the number and quality of specimens used, making the overall sensitivity only about 60-70%. After a diagnosis of malignant ascites is made, the patient should be counseled and referred for evaluation of available therapeutic options.
3056 A Case of NSAID-Induced Collagenous Colitis
Authors: Farhoud Adel , Al-Obaid Lolwa , Gleason Daniel , Hasan Imran 
Published: October 2019

INTRODUCTION:
Collagenous colitis is a disorder of chronic watery diarrhea. It has 2 main histologic forms. It is characterized by normal appearance of the colon on colonoscopy but abnormal histology. It is more likely to occur in elderly women and smokers and has been associated with certain medications such as NSAIDs, PPIs, Antipsychotics. Our case report demonstrates the importance of medication reconciliation when working patients up for diarrhea, and supports the fact that medications, such as those mentioned above can cause recurrence of symptoms, even after treatment.

CASE DESCRIPTION/METHODS:
A 68 year old female patient with a PMH notable for hypertension, GERD, and asthma was diagnosed with diarrhea-predominant IBS in 2015 treated with Rifaximin in the past. In 2015, she began to have 4-6 episodes of brown watery diarrhea daily, from a normal baseline. She underwent colonoscopy at the time, which was normal. She was treated with a 10 day course of Rifaximin with resolution of symptoms. 3 years later, she began to have diarrhea and abdominal cramping for which she made dietary changes with no improvement. She completed another 10 day course of Rifaximin with persistent symptoms. She was admitted to LHMC for weakness and diarrhea because of her inability to tolerate oral intake. Colonoscopy on 11/28 demonstrated ulceration in the hepatic and splenic flexures concerning for ischemic injury versus inflammatory bowel disease. Biopsies were consistent with collagenous colitis although there was neutrophilic cystitis concerning for a superimposed drug induced of infectious process. She was started on Budesonide with improvement in her symptoms before she returned 2 weeks later with diarrhea. Medication reconciliation demonstrated patient had been placed on Omeprazole and NSAID. This was discontinued however her symptoms persisted and she underwent repeat colonoscopy. Biopsies were consistent with Collagenous colitis.

DISCUSSION:
Collagenous colitis is a chronic inflammatory disease of colon. Presents with insidious onset of chronic watery non bloody diarrhea. Pathogenesis remains unclear. It has been associated with multiple medication classes, including medications that this patient was on. She had been treated with Budesonide with resolution of her symptoms, however re-initiation of both PPI and NSAID may have caused recurrence of her symptoms. Our case highlights the importance of vigorous history, chart and medication review when investigating a patient with diarrhea of unknown etiology.
3066 Recurrent Streptococcus bovis Bacteremia in the Absence of Colonic Neoplasm
Authors: Ramachandran Rajarajeshwari , Jani Niraj 
Published: October 2019

INTRODUCTION:
Associations between Streptococcus bovis (S. bovis) bacteremia and colorectal cancers and colonic adenomas have been reported in the medical literature since the 1970's. We are reporting an extremely rare case of recurrent Streptococcus bovis biotype II bacteremia in the absence of colonic neoplasm.

CASE DESCRIPTION/METHODS:
53-year-old man with diffuse large B-cell lymphoma – in remission (treated with chemotherapy and autologous stem cell transplantation), nesidioblastosis (treated with partial pancreatectomy/splenectomy) and hypertension was admitted to the hospital with severe sepsis. Of note, one month prior to his presentation, he was admitted to the hospital for S. bovis bacteremia. Examination: temperature 37.8°C, HR 104/minute, respiratory rate 28/minute, BP 101/51 mmHg and Spo2 98% on 4 liters nasal cannula. Laboratory data: white cell count 32.83 × 103/μL, hemoglobin 13.0 g/dL, platelets 210 × 103/μL, sodium 139 mEq/L, potassium 3.2 mEq/L, chloride 95 mEq/L, bicarbonate 22.6 mEq/L, creatinine 1.3 mg/dL, AST 124 IU/L, ALT 152 IU/L, alkaline phosphatase 139 IU/L, total bilirubin 0.3 mg/dL, lactic acid 6.6 mmol/L. Blood culture – positive for S. bovis. Infective endocarditis was ruled out by an echocardiogram. Patient was given intravenous antibiotic therapy and follow up blood cultures did not demonstrate any growth. Due to the association between S. bovis bacteremia and colonic malignancy, colonoscopy was performed. Patient was found to have a small, hyperplastic polyp in the cecum and diverticulosis involving the ascending, sigmoid and descending colon.

DISCUSSION:
S. bovis is a rare cause of bacteremia accounting for <1% of blood culture isolates. It has a high mortality rate of 26-70% and has been associated with colorectal malignancy, endocarditis, and hepatic dysfunction. There are two S. bovis biotypes (I and II) and the prevalence of colorectal neoplasm in patients with S. bovis biotype II bacteremia (23%) is substantially lower than biotype I (70%). Our patient had S. bovis biotype II bacteremia and did not have evidence of malignancy/adenoma(s) in the colonoscopy. To our knowledge this is the first case of recurrent S. bovis bacteremia reported in the medical literature in the absence of both colorectal cancer and colonic adenoma.
3068 Ischemic Colitis With Unresolved Ileus
Authors: Murthi Mukunthan , Chamarti Karthik , Murali Rangan 
Published: October 2019

INTRODUCTION:
Ischemic colitis (IC) is the most common form of ischemic injury to the gastrointestinal tract. This can result in inflammation and superficial injury to full thickness necrosis of colon. Most of the non-gangrenous IC resolve spontaneously while gangrenous IC requires operative intervention and is associated with high morbidity and mortality. Almost 90% of the cases of IC are in patients over 60 years of age. Ileus is a common finding in patients with IC and usually self-limiting except in cases where necrosis is present. We present a rare case of unresolved ileus resulting from non-gangrenous ischemic colitis.

CASE DESCRIPTION/METHODS:
A 90-year-old female with past medical history of Hodgkin's lymphoma in remission for the past five years, presented with nausea, vomiting and non-bloody watery diarrhea for the past four days. She visited the Emergency Department on the first day where she tested positive for E.coli urinary tract infection and was treated with ceftriaxone and nitrofurantoin. Over the last day, she did not have any bowel movements but continued to have right lower quadrant abdominal pain, abdominal distension, and nausea. Her WBC count was 34,000 cells/mm3 and C. difficile testing was negative. CT scan showed distended small bowel loops without transition point and decompressed colon, indicating ileus. She was put on NPO and nasogastric suction and started on broad-spectrum antibiotics. After four days, she continued to have distended abdomen with sluggish bowel sounds. Repeat CT scan of the abdomen showed no changes. She was eventually taken to the OR for exploratory laparotomy. Intraoperative findings showed edematous and thickened right colon with small bowel distension. Subsequent colonoscopy showed significant ischaemic changes in the right colon and the pathology result was consistent with ischaemic colitis with no signs of necrosis. She was started on TPN. Even after our best efforts, her condition continued to deteriorate and she developed sepsis and passed away on the tenth day.

DISCUSSION:
Ileus in the setting of non-gangrenous ischemic colitis is usually self-limiting. Protracted ileus is observed in cases with necrosis of the colon. Even with no evidence of necrotic disease, our patient's ileus failed to resolve after prolonged medical management. Our patient had multiple indicators of poor prognosis, including old age, isolated right-sided colon involvement, and absence of hematochezia, which could have contributed to her condition.