bluuebunny/crossref_metadata_2025_split huggingface dataset:
2588 You May Spread but Can't Hide! A Rare Case of Metastatic Renal Cell Carcinoma to the Small Bowel After Nephrectomy
Authors: Aggarwal Pankaj , Singh Tamneet , Diallo Souleymane Y. , Rampy Jacqueline , Thompson Adrianne K. , Perry William , Govani Shail 
Published: October 2019

INTRODUCTION:
Renal cell carcinoma (RCC) is a type of kidney cancer that rarely metastasizes to the small bowel. There are only a few reported cases. We present a rare case of metastatic RCC to the small bowel 13 years after nephrectomy.

CASE DESCRIPTION/METHODS:
A 70-year-old man with a history of RCC treated with nephrectomy 13 years prior presented to the hospital with melena and a hemoglobin of 10 g/dL. Upper endoscopy was unrevealing. Colonoscopy showed diverticulosis and scant blood in the cecum. After discharge, a capsule endoscopy showed bright red blood starting in the mid to distal small bowel. The patient later underwent a repeat capsule endoscopy which did not identify any further bleeding or a source of blood loss. The patient subsequently underwent an anterograde enteroscopy to the mid-small bowel without identifying a source GI bleeding. With oral iron supplementation, his hemoglobin normalized and the patient had no further episodes of melena. One year later, the patient presented to the hospital with abdominal pain and was found to have a distal small bowel obstruction and to be anemic with a hemoglobin level of 11 g/dL. A non-contrast CT abdomen and pelvis did not identify a cause of obstruction. After conservative management, patient was referred for MR enterography which showed a 5 cm enhancing mass in the terminal ileum (Figure 1). The mass was biopsied via ileocolonoscopy (Figure 2), which showed metastatic renal cell carcinoma, clear cell type. He subsequently underwent surgical metastasectomy (Figure 3). Surgical pathology confirmed metastatic RCC with no evidence of lymph node involvement.

DISCUSSION:
Metastatic RCC to the small bowel is rare and has mostly been described anecdotally thus far. Despite undergoing a presumably curative nephrectomy, this patient had a recurrence 13 years after surgery. Thus, this case adds to the growing body of literature to support late gastrointestinal metastasis from RCC as a potential cause of occult GI bleeding. Additionally, this patient's case is unique in that both capsule endoscopy and CT failed to identify the site of bleeding. Given the size of the mass, this case highlights the miss rate of capsule endoscopy. The poor distal small bowel prep likely reduced the ability to detect this distal small bowel lesion. Ultimately, the mass was identified via MR enterography. This case sheds light on an important issue regarding the utility and efficacy of capsule endoscopy compared to magnetic resonance imaging in the identification of small bowel neoplasms
2596 Diagnosis of Terminal Ileum Carcinoid Tumor Despite Prior Screening Colonoscopies—Making the Case for Routine Terminal Ileoscopy During Colon Cancer Surveillance: A Case Report
Authors: Shafi Amaan , Lankarani Daisy S. , Dhindsa Banreet , Ohning Gordon 
Published: October 2019

INTRODUCTION:
The term carcinoid is generally applied to well-differentiated neuroendocrine tumors originating in the tubular digestive tract, lungs or rare primary sites. Small bowel neuroendocrine tumors may be asymptomatic at presentation and found incidentally. Among symptomatic patients, 40% experience abdominal pain as an initial symptom. The pain is usually vague, nonspecific and misconstrued to represent irritable bowel syndrome for years before a diagnosis is made. A diagnosis may be delayed, or even missed, due to terminal ileum visualization not being a routine part of screening colonoscopy, a result of the perceived difficulty of the maneuver. We present the case of a female patient who was diagnosed with carcinoid tumor only after she became symptomatic despite having routine colonoscopy screening prior.

CASE DESCRIPTION/METHODS:
A 74-year-old female without significant past medical history initially presented to clinic with complaints of non-specific abdominal pain and intermittent non-bloody diarrhea. Vital signs and physical exam were unremarkable. The patient subsequently underwent a colonoscopy, during which she was found to have inflamed ileal mucosa. Biopsy was taken and microscopic findings revealed a tumor composed of small uniform cells demonstrating a festoon growth pattern with ovoid nuclei. Immunoperoxidase staining revealed the tumor cells to be positive for pankeratin, chromogranin and synaptophysin, confirming a diagnosis of carcinoid tumor. Patient has since been referred for surgical evaluation.

DISCUSSION:
Due to the high amount of patients being screened, there is an urgency now more than ever to minimize colonoscope advancement and mucosal inspection time. As depicted in our case, patients may go through more than one surveillance colonoscopy with a missed diagnosis, particularly in the terminal ileum. This is especially a concern in asymptomatic patients with carcinoid tumors. Though evidence has shown improvement in colonic diagnoses, completion of colonoscopy by passage through the ileocecal valve is not yet routinely performed in screening colonoscopies. Difficulty in intubation of the valve as well as an anticipated increase in procedure time have become barriers in establishing this as a standard. With practice, ileoscopy may be highly achievable in routine colonoscopies. This will allow for a decrease in missed diagnoses, early detection and thus more treatable cases overall.
2598 Jejunal Lymphocytic Enteritis: An Unusual Location for a Rare Condition
Authors: Dellatore Peter , Skole Kevin 
Published: October 2019

INTRODUCTION:
Lymphocytic enteritis (LE), a subclassification of microscopic enteritis (ME), is defined as abnormal infiltration of intraepithelial lymphocytes (IELs) in the gastrointestinal mucosa. Causes include gluten exposure, H. pylori (Hp) infection, small intestinal bacterial overgrowth, autoimmune conditions, irritable bowel syndrome, or medications such as proton pump inhibitor (PPI), NSAIDs, and selective serotonin reuptake inhibitors. A majority of cases are found in the colon or duodenum; we report a rare case of jejunal LE.

CASE DESCRIPTION/METHODS:
A 51-year-old man with untreated Hp and diabetic gastroparesis, on chronic pantoprazole, presented with chronic intermittent watery diarrhea, diffuse abdominal pain, nausea, vomiting, and generalized malaise. A CT showed jejunal mucosal thickening. The jejunal mucosa appeared normal by deep enteroscopy; a subsequent colonoscopy was also normal. Jejunal pathology demonstrated IELs with normal villous architecture consistent with LE; colon biopsies were negative for IEL. Laboratory tests were remarkable for iron deficiency anemia, but otherwise negative for other nutritional deficiencies, transglutaminase antibodies, or IgA deficiency. The patient received 10 days of solumedrol and concomitant Hp therapy; the PPI was then stopped. His diarrhea improved and repeat enteroscopy demonstrated resolution of jejunal LE.

DISCUSSION:
LE is a rarely diagnosed subclass of ME, but growing epidemiologic trend confirms that it will become a common condition in clinical practice. Multiple potential causes have been identified and treatment includes steroids, and/or addressing the underlying cause. Our patient had at least two potential causes: Hp and PPI use. Due to the unusual location of his LE and his severe illness, we treated multiple possible causes at the same time, with notable clinical and histologic improvement. This case demonstrates the success of standard treatment modalities for a unique anatomical location of a rare condition. With increasing disease prevalence, LE represents a novel entity that warrants further investigation. Subsequent care will be dictated by his clinical course, and repeat biopsies if necessary.
2601 Small Intestine Angioedema Due to Angiotensin Converting Enzyme Inhibitors: A Great Mimicker
Authors: Uy Pearl Princess , Yap John Erikson 
Published: October 2019

INTRODUCTION:
Angiotensin converting enzyme inhibitors (ACEI) are one of the most commonly prescribed anti-hypertensives. Angioedema, one of its known adverse effects, occur between 0.1% to 0.7% mostly affecting the lips, tongue, face and upper airways. Isolated small bowel angioedema due to ACEI is rare. We present a case of a middle-aged female with abdominal pain and imaging findings of ileitis which resolved after discontinuation of lisinopril.

CASE DESCRIPTION/METHODS:
A 48-year-old female with hypertension and organ limited granulomatosis with polyangiitis presents with a 1-year history of right lower quadrant abdominal pain and not associated with fever, weight loss, and diarrhea. Patient denies NSAIDs use but has been on lisinopril for 6 years. Upper endoscopy and colonoscopy were unremarkable. CT abdomen with contrast revealed focal segmental inflammation of the proximal ileum. Additional evaluations were negative including infectious etiologies, inflammatory bowel disease, ANCA, anti-transglutaminase antibodies, and c1-esterase inhibitor. Repeat CT abdomen 1 month after discontinuation of lisinopril showed interval complete resolution of the segmental ileal inflammation, and patient reports improvement of her abdominal pain.

DISCUSSION:
Angioedema of the small intestine is a rare adverse effect of ACEI which is one of the top causes of drug-induced angioedema. It is thought to be due to elevated bradykinin level resulting in vasodilation and increase vascular permeability resulting in edema. Patients may present with diarrhea, nausea, vomiting, abdominal pain and rarely, as acute abdomen requiring laparotomy. Symptoms usually occur 72 hours after starting ACEI but can develop weeks or years after and resolve 48 hours after stopping the medication. Laboratory tests are often unremarkable and radiologic studies reveal segmental thickening of the small intestinal wall, ascites and mesenteric edema which may mimic inflammatory bowel disease, mesenteric ischemia, or vasculitis. Treatment involves discontinuation of the offending drug. Given that patient has been on lisinopril for 6 years and the unremarkable laboratory tests results, it is very important to have a high index of suspicion for drug induced small intestine angioedema aside from ruling out other possible etiologies. Clinicians must review each patient’s medication list and their side effects since small intestine angioedema is rare and under recognized. Early diagnosis help prevent unnecessary investigations and surgical interventions.
2614 Astrovirus Enteritis in an Immunocompetent Adult in the Setting of Chronic Proliferative Synovitis
Authors: Pillai Priyamvada , Hajifathalian Kaveh , Wan David 
Published: October 2019

INTRODUCTION:
Astrovirus enteritis is a clinical entity seen mainly in children and immunocompromised adults resulting in severe diarrheal episodes. It is quite rarely implicated in acute gastroenteritis in immunocompetent adults with only few cases reporting its incidence. Here, we report a case of Astrovirus enteritis in an immunocompetent adult with chronic proliferative synovitis and positive ANA titers.

CASE DESCRIPTION/METHODS:
We present a 38-year-old woman with history of chronic proliferative synovitis who presented with acute nausea, crampy mid abdominal pain, and profuse non-bloody diarrhea after 12 hours of eating from a restaurant. The diarrheal episodes were associated with fevers up to 103oF with chills and rigors. The patient reported to have two recent sick contacts with similar diarrheal episodes and a course of amoxicillin 1 month ago for a dental indication. However, she denied any vomiting, recent meat, dairy or egg consumption or travel history. She had no past medical history of gastrointestinal complaints, immunosuppression or any new medications. Clinical examination only revealed mild abdominal diffuse tenderness. Initial clinical workup was remarkable for a mild leukocytosis, newly increasing AST and ALT, but normal total bilirubin, ALP and lipase levels. Microbiological investigation revealed positive Astrovirus in GI PCR, negative C. difficile assay and negative HIV status. An autoimmune workup revealed positive ANA titers of 1:80 in the setting chronic proliferative synovitis. The patient underwent supportive treatment for her diarrhea with Loperamide and IV fluids following which she improved clinically.

DISCUSSION:
Astrovirus is a positive single stranded RNA virus implicated in acute gastroenteritis in children and immunocompromised individuals. However, it has a low prevalence among healthy adults which is hypothesized to be due to acquired immunity gained from a prior childhood infection. In this patient, her chronic proliferative synovitis with raised ANA titers seems to have increased her predisposition to acquiring Astrovirus enteritis. Patients with chronic inflammatory conditions like SLE or synovitis seem to be more prone to viral infections due to their pro-inflammatory condition, making them more susceptible to infections that are otherwise cleared by the adult immune system. Hence, it is important to consider this clinical entity when assessing severe gastroenteritis in patients with pro-inflammatory status.
2617 Duodenal Leiomyosarcoma: A Rare Cause of Gastric Outlet Obstruction
Authors: Okoli Fidelis , Kantrowitz Michael , Zahir Ismail , Tsirlin Yuriy 
Published: October 2019

INTRODUCTION:
Intestinal leiomyosarcoma (LMS) is a rare cancer comprising 0.2% of all malignant tumors and involves the ileum in nearly half of cases. The remainder occur in the proximal duodenum and jejunum primarily, or metastatically from non-intestinal sites such as the uterus. We report this case of primary duodenal LMS complicated by gastric outlet obstruction.

CASE DESCRIPTION/METHODS:
A 57 year old woman presented with a two month history of worsening epigastric and right upper quadrant pain without nausea, vomiting, weight loss, or altered bowel habits. On physical exam she had marked epigastric tenderness. Abdominal contrast CT demonstrated multiple hypodense liver lesions measuring up to 2cm and a mildly dilated and thickened descending segment of the duodenum. Laboratory evaluation including tumor markers was normal. Without a clear primary malignancy source, the patient underwent percutaneous liver biopsy. Histopathology revealed high grade smooth muscle sarcoma, which stained positively for desmin, SMA, CD 57, and CD 34. Chemotherapy with gemcitabine and docetaxel was initiated per oncology. Within weeks, the patient developed worsening abdominal pain, nausea, and vomiting. CT imaging showed a mass projecting over the descending duodenum causing gastric outlet obstruction. After nasogastric decompression, the patient underwent an EGD. A friable, circumferential mass was seen emanating from distal duodenal bulb extending proximally to the second portion. A duodenal self expanding metal stent was inserted from just proximal to the ampulla to the distal antrum, effectively bridging the mass. Biopsy of the mass was consistent with high grade sarcoma, identical to the liver biopsy. Upper GI contrast series confirmed stent patency; patient tolerated an appropriately advanced diet, and was discharged home to continue outpatient chemotherapy.

DISCUSSION:
Based on our literature review, there have been no documented cases of gastric outlet obstruction secondary to duodenal LMS. Such tumors often present with abdominal pain and bleeding due to their highly vascular nature. In general, small intestinal malignancies are rare and often difficult to diagnose due to non-specific symptomatic progression resulting in delayed evaluation. Disease is often advanced to lymphatic spread or metastasis at diagnosis as was the case in our patient. A broad differential diagnosis should be considered in patients with unclear primary malignancies presenting with obstructive symptoms.
2618 The Immigrant With Chronic Abdominal Pain: A Diagnosis of Ascaris lumbricoides
Authors: Hashmi Irma , Shor Julia 
Published: October 2019

INTRODUCTION:
Ascaris lumbricoides (A. lumbricoides), a nematode affecting millions globally, is asymptomatic for years until development of high worm load when patients present with symptoms of small bowel obstruction. High suspicion is required for accurate diagnosis, especially when managing the immigrant patient. We present the case of a Pakistani immigrant who endorsed abdominal pain, lower extremity skin lesions and joint pain for several months prior to capsule endoscopy diagnosis with A. lumbricoides.

CASE DESCRIPTION/METHODS:
A 50-year-old Pakistani female with history of hypertension presented with chronic, bandlike, postprandial right upper quadrant abdominal pain associated with nausea. She also endorsed left lower extremity skin lesions and small joint pain. Basic laboratory values were normal except ALT 118. Extensive rheumatologic workup was also normal. Right upper quadrant ultrasound was benign. CT abdomen and pelvis with contrast showed irregular filling defects, with retroperitoneal and pelvic adenopathy; however, colonoscopy revealed no mass. Skin biopsy confirmed erythema nodosum (EN). A few weeks later, the patient re-presented with similar complaints and followed up in Gastroenterology clinic. EGD was without pathology, but capsule endoscopy revealed parasites in the small bowel, likely A. lumbricoides as both adult worm and blastocyst stages were seen in the small bowel. The patient was treated successfully with Albendazole.

DISCUSSION:
Infecting the pulmonary, hepatobiliary, and small intestine systems, A. lumbricoides is a common helminth infection, especially in endemic areas including the Western Pacific, South East Asia and Africa. Poor hygiene facilitates fecal-oral transmission. Humans ingest embryonated eggs, and larvae in the intestine migrate to the lungs where they are coughed up and swallowed to molt into adult form within the intestine. As the infection is largely asymptomatic, patients can carry the helminth for years. Skin manifestations, including EN, are a rare manifestation of ascariasis, with only a few case reports cited in the literature. Capsule endoscopy can be a diagnostic tool but is more expensive than stool testing. Treatment is with Albendazole. Infection with A. lumbricoides should be considered in immigrant patient populations presenting with chronic abdominal pain and atypical features such as erythema nodosum, as accurate diagnosis can lead to treatable disease.
2623 Isolated Duodenal Variceal Bleeding Secondary to Metastatic Carcinoid Tumor Obstructing the Superior Mesenteric Vein
Authors: Evans Nicole S. , Quezada Michael , Sahakian Ara , Hwang Caroline 
Published: October 2019

INTRODUCTION:
Gastrointestinal bleeding secondary to duodenal varices is an uncommon finding, and is typically seen in patients with portal hypertension due to cirrhosis. We report a case of a patient without evidence of liver disease who developed significant bleeding from isolated duodenal varices caused by mesenteric venous obstruction from a carcinoid mass.

CASE DESCRIPTION/METHODS:
A 71-year-old male with a history of a metastatic mesenteric carcinoid tumor presented with recurrent gastrointestinal bleeding. He was initially diagnosed with carcinoid of the mesentery several years prior, for which he underwent resection followed by Y40 ablation of liver metastases. He had been admitted multiple times at a local hospital for recurrent gastrointestinal bleeding, for which he had undergone extensive endoscopic evaluation. He was then transferred to our facility for a higher level of care. A double balloon push enteroscopy and endoscopic ultrasound were performed with findings of a large cluster of bleeding duodenal varices in the third portion of the duodenum not amenable to endoscopic intervention. CT abdomen and pelvis with contrast and CT angiography of the abdomen showed an irregular 3 cm calcified mass at the root of the mesentery. Additionally, several branches of the superior mesenteric artery and vein (SMA and SMV) were noted to be occluded near the mass. Interventional radiology (IR) performed an IR-guided transhepatic portogram revealing obstruction of the SMV at the level of the mesenteric mass. There appeared to be a large colic branch communicating with an abnormal cluster of varices near the third portion of the duodenum. Two overlapping covered stents were placed at the large colic branch into the SMV, decompressing the varices. The patient was started on plavix, propranolol, and octreotide depot and safely discharged home without further bleeding.

DISCUSSION:
Duodenal varices are an uncommon but potentially serious complication of portal hypertension, and are most often seen as a sequelae of liver disease. The development of duodenal varices as a result of venous obstruction secondary to a desmoplastic reaction induced by a carcinoid tumor has seldom been reported in the literature. This case illustrates a noteworthy example of bleeding ectopic varices in a patient without liver disease, a rare cause of obscure gastrointestinal bleeding.
2631 Angiotensin Converting Enzyme Inhibitor-Induced Isolated Angioedema of Small Bowel
Authors: Adusumilli Radha Kishan , Patel Manishkumar , Hong Gloria , Kulairi Zain I. 
Published: October 2019

INTRODUCTION:
Angiotensin-converting enzyme inhibitors (ACEi) are generally known to cause angioedema, with the face, tongue, and pharynx primarily involved. ACEi-induced small bowel angioedema is relatively rare occurring in 0.1 to 0.7% patients on ACEi.

CASE DESCRIPTION/METHODS:
Our case report is about a 34-year-old woman who was recently started on lisinopril and diagnosed with angioedema of the stomach and duodenum. The patient presented to our hospital with a 3-week history of nausea and a 2-day history of worsening epigastric pain. She also had one episode of non-bilious emesis and one episode of watery diarrhea. Her home medications included lisinopril 20 mg daily for hypertension, which she started taking 3 weeks ago. She was hemodynamically stable and physical examination revealed mild epigastric tenderness with no organomegaly, guarding or rebound tenderness. Laboratory values were significant for leukocytosis of 12,000, and normal complement and lipase levels. Abdominal computed tomography (CT) scan showed signs of findings of acute severe enteritis involving the duodenum and proximal jejunum, with no pancreatitis. Endoscopy revealed edema of the duodenum. Given the high suspicion for ACEi induced angioedema of the small bowel, her lisinopril was discontinued and the patient showed complete symptom resolution within 24 hours.

DISCUSSION:
ACEi-induced angioedema of the small bowel is a rare clinical presentation, however, it is an important differential diagnosis to consider when a patient taking an ACEi presents with nausea and abdominal pain. It is important to highlight angioedema of the small bowel can occur at any time after a patient starts taking an ACEi. Although ACEi-induced small bowel angioedema is relatively rare, its recognition is important as ACEi use is high and misdiagnosis can lead to frequent hospital visits and unnecessary surgery. The first line treatment being discontinuation of ACEi, there are other pharmacological options including icaibant, ecallantide which have unproven efficacy from the current trails. Fresh frozen plasma has shown to have success in cases where nothing has worked. The usual dose being used to treat are 2 to 4 units of fresh frozen plasma.