bluuebunny/crossref_metadata_2025_split huggingface dataset:
3111 Achalasia in a Patient Newly Diagnosed With HIV
Authors: Elkhouly Mohamed A. , Attar Bashar M. , Mutneja Hemant , Demetria Melchor V. 
Published: October 2019

INTRODUCTION:
Esophageal disease is common during HIV/AIDS infection and varies from esophagitis due to opportunistic infections as candida, cytomegalovirus and herpes simplex, to idiopathic ulcerations and non-specific motility disorders, but it has been suggested also that HIV infection itself can be the culprit of esophageal symptoms. We are presenting a case report of likely achalasia that was discovered in a patient newly diagnosed with HIV-1.

CASE DESCRIPTION/METHODS:
A 46-years-old male with no significant past medical history presented with 1 month history of recurrent attacks of nausea and non-bilious, non-projectile vomiting, 30-60 minutes following meals associated with anorexia, dysphagia and non-intentional weight loss of 10 lb. He did not have any fever, abdominal pain, diarrhea, constipation, hematemesis or melena. He was in a heterosexual relationship with no known contact to HIV infected patients. Examination was not evident of abdominal tenderness or any body swellings. Labs showed normocytic anemia with hemoglobin of 11.8 g/dl in addition to positive HIV-1 serology with viral load of 151,000 and CD4 count of 153. CT Chest was done showing sub-stantial dilation of the lower cervical, mid and distal esophagus with solid and gaseous contents. After 24 hours of “Nothing by mouth,” upper endoscopy was performed showing markedly dilated esophagus with esophageal mucosa covered with adherent food and secretions in addition to LA grade C esophagitis in the distal esophagus. Esophageal biopsy showed candida esophagitis with negative immunostains for CMV and HSV. He was started on HAART therapy and is awaiting manometry for confirmation of Achalasia diagnosis.

DISCUSSION:
It is accepted that HIV is aneuropathic virus and it has been related to loss of autonomic nerves in different parts of the body. Motor abnormalities have been identified in the esophagus, stomach and small intestine. The case report highlight that HIV maybe considered as possible infectious cause of achalasia.
3114 A Common Gastrointestinal Manifestation of an Uncommon Disease
Authors: Elkhattib Ismail , Aujla Amreet K. , Villavicencio Jaimy , Siddique Osama , Vaziri Haleh 
Published: October 2019

INTRODUCTION:
Inclusion body myositis (IBM) is a chronic progressive myopathy characterized by dysphagia in 10% to 73% of patients with one-year mortality of 31% in patients with symptoms of dysphagia. We present a case of a patient with IBM esophagitis causing severe weight loss and complete loss of ability to swallow with a discussion of potential management modalities.

CASE DESCRIPTION/METHODS:
The patient was a 77-year-old male with a past medical history of inclusion body myositis diagnosed at age of 57 and muscular dystrophy who presented with progressive dysphagia for several years and a significant weight loss of 40 pounds over last 8 months. He initially was able to tolerate small bites, however, he was not able to tolerate solids and his diet was modified to a mechanical soft diet. Prior to the hospital admission, the patient had an outpatient modified barium study (MBS) which revealed penetration and aspiration with thin and nectar thick liquids. An endoscopy was attempted for percutaneous gastrostomy tube placement but was unsuccessful due to the inability to pass through the upper esophageal sphincter. He subsequently underwent a fluoroscopy-guided percutaneous gastrostomy tube placement by an interventional radiologist.

DISCUSSION:
IBM is a chronic progressive inflammatory myopathy. Associated dysphagia can result in nutritional deficits, weight loss, aspiration pneumonia and decreased quality of life. The underlying mechanism for dysphagia is related to inadequate pharyngeal contraction, poor relaxation of the cricopharyngeal muscle, and reduced hyolaryngeal elevation. The management of dysphagia in IBM is challenging due to its steroid resistance nature. Multiple treatment modalities are used to treat dysphagia secondary to IBM, including conservative measures, intravenous immunoglobulin therapy, and balloon. Surgical intervention with cricopharyngeal myotomy has been suggested when conservative therapies fail or when severe weight loss and malnutrition are apparent. The later appears to be effective especially when hypertonicity of the cricopharyngeal muscle and impaired relaxation are present. A retrospective study of 26 patients with IBM has shown higher mortality in patients who required PEG placement compared to the ones who underwent cricopharyngeal myotomy. Per-oral endoscopic myotomy (POEM) showed success for spastic esophageal disorders such as diffuse esophageal spasm. At the meantime, no studies have implied the procedure for IBM esophagitis giving a great room for future studies.
3116 Dilated Rectum in Psychotic Patient—Stercoral Colitis Causing Complications
Authors: Patel Pranav D. , Chaudhari Jignaben , Mehmood Asif , Radadiya Dhruvil K. , Bergenstock Marika 
Published: October 2019

INTRODUCTION:
Constipation is common finding in hospitalized patient from nursing home, psychiatry unit or hospice facility. Assessment of abdominal symptoms in patient with psychiatric illness is challenging. Their medication compliance and lifestyle modification are not optimal due to limited insight. We present such case with constipation ended up with complicated hospital stay.

CASE DESCRIPTION/METHODS:
71-year-old male who is sent from inpatient psychiatry hospital for abdominal distention and an episode of bilious vomiting. His caregiver has notified patient has inadequate oral intake from last 2 weeks. His past medical history includes schizophrenia, hypothyroidism, gastroesophageal reflux disease, status post cholecystectomy, benign prostate hyperplasia and chronic constipation. Prior to admission he is on laxatives polyethylene glycol, senna and docusate but he is not taking regularly. Abdominal CT scan with IV without oral contrast revealed extensive stool burden with severely distended rectum 9.4 cm diameter (Figure 1), stercoral colitis, small intestinal focalization, esophageal thickening suspected esophagitis. Patient is required nasogastric tube placement, manual fecal disimpection, frequent enemas, multiple laxatives to improve constipation. His hospital stay is prolonged and further complicated with acute blood loss anemia due to upper gastrointestinal bleeding. EGD revealed reflux esophagitis, erosive gastropathy likely caused by vomiting, urinary retention secondary to constipation and concern of aspiration. Psychiatry evaluation is sought to adjust antipsychotic medication to help lessen constipation as side effect.

DISCUSSION:
There is substantial risk of gastrointestinal hypomotility in patient receiving first generation or atypical antipsychotics. Most of the antipsychotic medications have anticholinergic side effect leading to constipation. Other psychosocial factors that can contribute are limited water consumption, lack of physical activity, inexpressive to thirst or abdominal symptoms, labile mood hampering medication compliance. Such patients are likely to have higher rate of hospitalization and complications like reflux esophagitis, urinary retention, aspiration, risk of perforation or gastrointestinal bleeding like in this patient. Vigilant bowel movement record and early initiation of constipation treatment at living facility is important in such patients.
3120 Polyethylene Glycol-Based Bowel Preparation Induced Episodic Sinus Arrest: The Bezold-Jarisch Reflex
Authors: Rathbun John , Raizada Veena , Severson Elizabeth , Huang Andy , Ling Christina , Rustagi Tarun , Sheldon Mark 
Published: October 2019

INTRODUCTION:
The Bezold–Jarisch reflex (BJR) is a cardiac reflex that increases parasympathetic tone and inhibits sympathetic activity, resulting in a clinical triad of bradycardia, hypotension, and peripheral vasodilation. This reflex can be activated by chemical stimuli, such as anesthesia, or by reduced cardiac venous return. Inappropriate reflex bradycardia or asystole can occur.

CASE DESCRIPTION/METHODS:
A 51-year-old female with no past medical history underwent bowel preparation with a polyethylene glycol-based solution for a routine screening colonoscopy. Before anesthesia was administered, the patient became unresponsive and clonic with a 3-4 second sinus pause. On physical exam, the patient was dehydrated. Electrolyte findings were within normal limits, aside from sodium level of 123 mmol/L. The patient eventually recorded a sinus pause of 30 seconds and a transvenous pacemaker was placed for episodic sinus arrest. The Bezold–Jarisch reflex is a diagnosis of exclusion. The patient had a negative D-dimer, three non-detectable troponin levels and a CT pulmonary angiogram negative for pulmonary embolism. Two electrocardiograms showed normal sinus rhythm, with repeat showing sinus bradycardia; intervals were within normal limits. A transthoracic echocardiogram showed an ejection fraction of 65% with no valvular disease or structural abnormalities. After the patient was fluid resuscitated and electrolytes were optimized, no further episodes were recorded. The patient was fitted with an event monitor and discharged home with close follow up. She remained asymptomatic at outpatient appointment.

DISCUSSION:
The patient's bowel preparation for her colonoscopy resulted in hypovolemic hyponatremia, upregulating her renin-angiotensin-aldosterone system, whichvagally mediated her episodic sinus arrest via the Bezold–Jarisch Reflex. Given the increasing rate of colonoscopies, this case report highlights the importance of electrolyte-balanced hydration in preventing a potential BJR.
3124 Endoscopy in Patient With Situs Inversus Totalis
Authors: Yun Lisa S. , Clark August , Anderson Karl 
Published: October 2019

INTRODUCTION:
Situs inversus totalis (SIT) is the complete transposition of the abdominal and thoracic organs. Due to the inherent anatomic differences, patients with situs inversus may pose a unique challenge when undergoing endoscopic procedures because physicians are trained to maneuver the endoscope in a certain manner.

CASE DESCRIPTION/METHODS:
A 51 year old male presents with a 3 year history of intermittent rectal bleeding. He denies abdominal pain, constipation, and diarrhea.
On presentation, physical exam was normal. Although the patient was aware of his diagnosis of SIT at the time of endoscopy, he did not think it was necessary to inform physicians about his condition. In addition, multiple electrocardiograms had been read previously without complications. Laboratory evaluations were normal except for slightly elevated ALT and AST. EGD was performed and showed salmon-colored mucosa in the distal esophagus. Biopsies of the esophagus showed squamous epithelium with acute inflammation and reflux-associated changes, and no evidence of intestinal metaplasia. The stomach was diffusely erythematous and biopsies revealed chronic active gastritis with H. pylori-like organisms. Colonoscopy was normal with the exception of internal hemorrhoids. EGD and colonoscopy were both successfully performed in the standard manner. SIT was discovered during a liver ultrasound performed to further investigate the etiology of his elevated liver function tests.

DISCUSSION:
Situs inversus totalis may cause additional challenges for endoscopists. One study found that SIT prolonged cecal intubation times. Certain modifications to standard endoscopic technique have been proposed including turning the endoscope 180 degrees clockwise first in the stomach then again in the duodenum, as well as placing the patient in the right lateral decubitus position so that the maneuvers are performed inversely.
In our case, the endoscopist was able to successfully navigate the endoscopic procedures without special maneuvers or changes in position and was unaware of the diagnosis of SIT until after the procedure. In conclusion, endoscopies and colonoscopies are feasible in patients with SIT. Various modifications to the endoscopic technique have been suggested, but may not always be required, to safely perform these procedures on patients with SIT.
3125 CMV Infection Presented as Asymptomatic Inflammatory Polyp in Immunocompetent Patient
Authors: Shah Shashin , Hrad Valery , Nellis Eric 
Published: October 2019

INTRODUCTION:
Colonic manifestations of the CMV infection are significantly more common in immunocompromised patients than immunocompetent individuals. Typical endoscopic findings include inflammatory changes of the colonic wall with ulcerations. Though extremely rare, mass lesions in colon due to CMV infection have been previously reported [1,2]. We report a case of a large inflammatory polyp secondary to CMV in immunocompetent patient during colonoscopy.

CASE DESCRIPTION/METHODS:
A 71-year old asymptomatic male patient presented for colonoscopy after positive Cologuard test. He denied any gastrointestinal symptoms and had no significant previous medical history. On exam patient had an inguinal hernia. Previous colonoscopy evaluation more than 10 years ago was normal. Colonoscopy revealed a sessile ascending colon 15 mm polyp and 10 mm semi-pedunculated polyp in sigmoid (Figure 1), both of which were removed with hot snare. Histopathology report showed positive immunostaining for CMV in sigmoid polyp.

DISCUSSION:
CMV related colonic lesion in immunocompetent patient is an unexpected finding. We found only 3 previous reports in the literature [3-5]. Given the potential infectious pathophysiology of this polyp infectious disease referral was made. In addition to the endoscopic removal via polypectomy, antiviral therapy was described as an effective treatment modality in the case of assumed superimposed CMV infection of suture line inflammatory polyps [3].
3126 Buried Bumper Syndrome
Authors: Jiyani Rucha , Jacob Bobby , Khan Nausheer 
Published: October 2019

INTRODUCTION:
Feeding tube placement ensures appropriate delivery of enteral nutrition,however is associated with adverse effects which can occur at rate as high as 10%. Complications may be minor or fatal including death. Common complications include aspiration, wound infection, bleeding, perforation, necrotizing fasciitis and intestinal obstruction. Our case is a very rare early presentation of life threatening buried bumper syndrome.

CASE DESCRIPTION/METHODS:
56 year old Caucasian Male with history of benign esophageal stricture status post percutaneous gastrostomy tube (PEG) placement in 2016 and history of Bipolar disorder brought in by from nursing home to Emergency department for dislodgement of his PEG tube and complaint of abdominal pain and drainage from his gastric stoma. Interventional radiology attempted fluoroscopic guided PEG placement procedure, however procedure was aborted because an opacified contrast was noted in gastric lumen, which was suspicious for retained gastrostomy bumper. Further imaging was obtained with CT Abdomen/pelvis that revealed a metallic density projecting from the skin of the anterior abdominal wall to within the body of the stomach. Upper Endoscopy was subsequently performed but was limited due to a pinpoint stricture of esophagus was noted 30 cm from the incisors which could not betraversed by the upper endoscope. Laparoscopic removal of the buried bumper was performed with subsequent laparoscopic gastrostomy tube placement. Surgery and pathology report showed removed foreign body from stomach stated medical device consistent with gastric tube. Patient had successful removal of retained bumper with new placement of PEG tube. Patient tolerated procedure well without complication.

DISCUSSION:
Buried bumper syndrome is caused by migration of the internal bumper of the PEG into the gastric or abdominal wall. BBS presentation on average approximately is 18 months, depending on which kind of feeding tube has been used. Unfortunately, buried bumper syndrome presents with late stage and early presentation are usually rare. Implementation of post PEG placement follow up policies could have an impact in preventing these PEG tube related fatal complications. To our knowledge there are no guidelines, which recommend an interval of time for follow-up post PEG placement to assess for complications. We suggest that an optimal close follow up concord by each institution for status post PEG placement may prevent and minimize serious complication and provide better patient care.
3127 Blakemore? Wait More!
Authors: Voaklander Rebecca , Byrne Kathryn R. 
Published: October 2019

INTRODUCTION:
This is a case of a decompensated cirrhotic patient with a non-variceal upper GI bleed that was nearly treated with placement of a Sengstaken-Blakemore tube, which would likely have perforated her acutely ischemic esophagus.

CASE DESCRIPTION/METHODS:
A 62-year-old woman with decompensated alcoholic cirrhosis and a history of esophageal varices was brought to the ED for “coffee ground” emesis and lethargy. She relapsed into drinking alcohol two weeks before presentation and shortly thereafter developed abdominal pain. Three days before admission, she developed non-bloody emesis. On the day of presentation she had at least 10 episodes of clear emesis that eventually turned black. She had a history of esophageal varices requiring banding, most recently 5 years prior to admission. Her most recent EGD was 3 years ago, which was significant for portal hypertensive gastropathy and small varices that did not require banding. Initial vital signs were significant for a HR of 110 and BP of 77/37. Abdominal exam demonstrated normoactive bowel sounds, diffuse tenderness to palpation, no guarding, and no rebound tenderness. In the ED, patient had at least 2000 cc of “coffee ground” emesis and she was intubated for airway protection. Placement of a Blakemore tube was considered but ultimately decided against given that observed emesis was not bright red and emergent endoscopy would soon be performed. Initial labs were significant for: Hgb 14.4 platelets 106 lactate 24 pH 6.9 INR 1.5 creatinine 3.4 total bilirubin 2.8 AST 281 ALT 168.
Emergent EGD in the MICU revealed no esophageal or gastric varices, however severe erosive esophagitis and acute esophageal necrosis with a “black esophagus.” Patient underwent a chest CT and cardiothoracic surgery consultation. After a brief stay in the MICU with supportive care, patient was ultimately extubated, her diet cautiously advanced and she was discharged to home.

DISCUSSION:
This case illustrates the need to think critically about the etiology of a brisk GI bleed, as not all significant GI bleeds in cirrhotic patients are related to varices. A clinical clue indicating that this may not have been an active variceal bleed was that the large-volume emesis was coagulated rather than fresh blood. Furthermore, the objective data reflected a state of severe hypovolemia and ischemia but no anemia in spite of recurrent hematemesis. Placement of a Blakemore tube in the setting of acute esophageal necrosis could have resulted in a catastrophic outcome of esophageal rupture.
3130 Unexplained Thrombocytopenia Associated to the Use of PPI in a Patient With a Bleeding Peptic Ulcer Disease
Authors: Arroyo Mercado Fray M. , Likhtshteyn Michelle , Chokshi Tanuj , Reka Safak 
Published: October 2019

INTRODUCTION:
Proton pump inhibitors (PPIs) are used to suppress acid production and to promote hemostasis, which significantly reduces the risk of rebleeding in upper gastrointestinal bleeding [1]. Accumulating evidence indicates an association between PPIs and thrombocytopenia in patients treated for upper gastrointestinal bleeds [2-4].

CASE DESCRIPTION/METHODS:
A 38-year-old male with no significant past medical history presented to the hospital complaining of coffee ground emesis, hematochezia, dark stools and three episodes of syncope in the setting of daily naproxen use for one month. Vital signs revealed orthostasis without tachycardia or hypotension. Physical exam revealed a soft, non-tender, non-distended, abdomen with normoactive bowel sounds. Rectal exam was positive for melena but negative for hemorrhoids or any palpable masses. Initial laboratory workup was significant for a hemoglobin of 7.8, platelet count of 163, and BUN of 27. Intravenous (IV) PPI was administered for management of suspected bleeding PUD. The patient received packed red blood cells (PRBCs) with appropriate response to transfusion. Upper endoscopy revealed a pre-pyloric non-bleeding ulcer that was successfully treated. A significant drop in platelet count was noted on hospital day four which continued to decrease from 163 to 107. PPI route of administration was changed from IV to oral, resulting in an increase in platelet count to 116 by hospital day 7.

DISCUSSION:
PPIs are widely used for the treatment of PUD, GERD, Barrett esophagus, esophagitis, and gastritis. As the main medication used in the treatment of upper gastrointestinal bleeding, it is crucial to understand the effect of PPI therapy on platelets. Literature review suggests an association between thrombocytopenia and the use of PPIs [2-4]. However, further studies are needed to establish a direct association between PPIs and thrombocytopenia. In our case, thrombocytopenia was noted on hospital day 3 of PPI infusion. Route of administration of PPI was changed from IV to oral and thrombocytopenia improved steadily. Although the exact mechanism linking PPI therapy to thrombocytopenia remains unknown, it is important to be aware of this possibility. Close monitoring of platelet count is recommended upon initiation of PPI therapy.