bluuebunny/crossref_metadata_2025_split huggingface dataset:
2723 Abdominal Aortic Aneurysm: An Uncommon Cause of Gastric Outlet Obstruction
Authors: Taylor Rachel A. 
Published: October 2019

INTRODUCTION:
Gastric outlet obstruction is a highly uncommon presentation for abdominal aortic aneurysm.

CASE DESCRIPTION/METHODS:
A 65 year old male with past medical history of AAA, HCV treated with Harvoni, GERD with gastritis, and HTN presented with intractable nausea and non-bloody, bilious vomiting for 6 hours associated with sudden onset generalized abdominal pain. Patient reports that he had been having regular bowel movements and passing flatus in the days leading up to presentation. GERD had been previously well-controlled with a PPI. Physical exam revealed a 5 cm pulsating mass in the epigastrium. CTA demonstrated gross distension of both the stomach and the proximal duodenum. The abdominal aortic aneurysm measured 5.2 cm by 4.2 cm and extended over 10 cm in length; an increasingly large false lumen was also noted. There was no other obstructing lesion appreciated on CT, either intra- or extra-luminal. The enlarging aortic aneurysm impinged upon and caused the obstruction of the distal duodenum.

DISCUSSION:
An expanding abdominal aortic aneurysm can compress the duodenum against the mesenteric artery or abdominal wall, causing gastric outlet obstruction; this obstruction leads to patients presenting with nausea and vomiting. Aortoduodenal syndrome was first described in 1905 by Osler. There are a few dozen case reports of aortoduodenal syndrome in the literature. Any patients presenting with protracted vomiting and pulsatile abdominal mass should raise suspicion for aortoduodenal syndrome. Abdominal tenderness and distension are not common findings in this syndrome. CT is required to rule out an alternative cause of duodenal obstruction; diagnosis may be confirmed with upper GI series with contrast or upper endoscopy. Patient should be initially optimized with gastric decompression, fluid resuscitation, and electrolyte correction before preceding to definitive treatment. Previously, gastric bypass was the general treatment prior to the introduction of surgical aortic repair. Aortic aneurysm repair is the mainstay of therapy with endovascular repair becoming increasingly common.
2736 A Rare Case of Gastric Sarcoidosis
Authors: Prakash Sameer , Merza Nooraldin , Beggs Daniel 
Published: October 2019

INTRODUCTION:
Gastrointestinal involvement in sarcoidosis is quite rare, in which it either presents as systemic disease or as an isolated case. It can mimic other disease processes, including malignancy, gastritis, and peptic ulcer disease. We present a 28-year-old female who had weight loss, epigastric pain, and early satiety found to have symptomatic gastric sarcoidosis that rapidly improved with steroid treatment.

CASE DESCRIPTION/METHODS:
A 28-year-old with no past medical history presented to the emergency department with complains of epigastric pain, weight loss, and early satiety. She had onset of pain in epigastrium described “like ringing out a washrag”, better with eating and marked early satiety. She was found to have an iron level of 11 with period less heavy than years ago. Vitals showed Wt 142 lb, BP 118/66, Pulse 85, and O2 sat 98% on room air. Physical exam was significant for only epigastric tenderness and bilateral edema. Labs showed hemoglobin 8.9, MCV 57, iron level 11, Na 138, Cl 108, and CO2 20. EGD showed body and antrum with markedly thickened, pale appearing, firm/friable folds. Colonoscopy showed no abnormalities. Gastric fold biopsies showed noncaseating epithelioid granulomatous infiltrate suggestive of sarcoidosis. AFB and GMS fungal stains showed no microorganisms and H. Pylori was negative. The patient was initially started on prednisone 40 mg daily tapering dose and had near immediate resolution of symptoms with increase in weight.

DISCUSSION:
Sarcoidosis is a systemic disease characterized by pathognomonic formation of noncaseating granulomas with rare gastrointestinal involvement. Infection, malignant, and inflammatory causes must be ruled out as part of the broad differential before making diagnosis of sarcoidosis. Patients typically have symptoms of early satiety, nausea, and weight loss. Gross findings on endoscopy typically include mucosal nodularity, thickened and enlarged irregular folds, and deformity of the antrum. For recurrence of symptoms, surveillance endoscopy is warranted to examine extent of disease. As in our patient, there is excellent response to glucocorticoid treatment and patients should be monitored clinically with tapering doses.
2744 A Scary Case of Gastroenteritis
Authors: Dave Kairavee , Choksi Vivek , Cantave Rulz T. , Sorathia Sufian J. , Kaplan Steven R. 
Published: October 2019

INTRODUCTION:
Gas in the gastric venous system or the portal venous system is a critical finding and can be from a life threatening abdominal catastrophe as well as from benign conditions.

CASE DESCRIPTION/METHODS:
A 52 year old gentleman presented with nausea, vomiting and diarrhea for 2 days. He had multiple episodes of non bloody diarrhea for past two days and had an episode of vigorous non bilious/ non bloody vomiting. No fevers, chills or weight loss was reported. His medical history included diabetes mellitus type 2, hypertension, obstructive sleep apnea, depression and anxiety. On admission, his vitals were stable. The physical examination was completely benign. His laboratory data revealed mild leukocytosis of 13.3. Lactate was normal. There was no anemia or microcytosis. A CT scan of his abdomen was done which revealed gas in the gastric veins and the peri-gastric veins, which was very concerning. Urgent Surgical consultation was placed. The patient was admitted to step down unit and conservative management with hydration, anti emetics and supportive care was initiated. In the next 4 hours, the patient started feeling better and became asymptomatic. The CT of the abdomen was repeated. The entire patient care team was on high alert for a possible abdominal catastrophe/ischemia and need for emergent surgery. The repeat CT scan was done 6 hours later which revealed linear lucencies within the peripheral aspect of the left lobe of the liver, consistent with gas within the portal venous system. Urgent Infectious Disease consultation was called and piperacillin-tazobactam was initiated. At this time, the patient was asymptomatic, his vitals were stable, the lactate remained normal and the leukocytosis had resolved in the repeat laboratory analysis. Close monitoring was continued. The next day, the patient remained in the stable and asymptomatic. A third repeat CT scan of the abdomen revealed complete resolution of all the gas in the gastric and the portal venous system. The diet and activity were advanced gradually and the patient was discharged the same day.

DISCUSSION:
It is important to recognize that there are many benign causes of gastric venous gas and portal venous gas such as gastroenteritis. We believe that the mechanical trauma of retching and vigorous vomiting may have lead to this finding.
2748 The Apple Green GI Tract: A Rare Case of Gastrointestinal Amyloidosis
Authors: Ashamalla Michael , Wander Praneet , Pizzuti Jessica , Lech Diana , Rishi Arvind , Vitkovski Taisia , Greenberg Ronald 
Published: October 2019

INTRODUCTION:
Amyloidosis is a heterogenous disease, characterized by the extracellular deposition of an abnormal fibrillar protein, which disrupts tissue structure and function. Gastrointestinal involvement in amyloidosis is a rare entity that can result from mucosal and neuromuscular infiltration, or extrinsic autonomic neuropathy. Diagnosis is difficult as significant variation can exist within an individual type of amyloid and visceral involvement is rarely on a clinicians differential diagnosis. We present a case of gastrointestinal amyloidosis in a 62 year old Male who presented with nausea and vomiting.

CASE DESCRIPTION/METHODS:
62 year old Male with a past medical history significant for tobacco use presented to the Emergency Department (ED) with a chief complaint of nausea and non bloody-non bilious emesis of three weeks duration. He reported early satiety, abdominal bloating, and unintentional 40 pound weight loss over one year. Several days prior to his presentation, he developed bilateral lower extremity edema. He denied any nausea, hematemesis, dysphagia, abdominal pain, melena or hematochezia and never had a previous upper or lower endoscopy. On presentation to the ED, his vitals were stable. He was ill appearing with temporal wasting and his abdomen was soft, nontender, without hepatosplenomegaly. Laboratory data was notable for a Hemoglobin 9.8 (MCV 78), Albumin 1.7, and a positive fecal occult test. Gastroenterology was consulted and the patient underwent an upper endoscopy given red-flag symptoms. His endoscopy revealed an edematous GE junction, severe diffuse gastric erythema with erosions, congested and friable gastric body folds, deformed duodenal bulb and edematous second portion of duodenum suspicious for extrinsic compression. Endoscopic biopsies were obtained using cold forceps. Small bowel biopsies detected amyloid deposits supporting a diagnosis of AL (lambda)- type amyloid deposition. He was referred to Hematology/Oncology and was subsequently started on standard triple therapy including lenaolidmide, bortezemib, and prednisone.

DISCUSSION:
Biopsy proven amyloidosis of the gastrointestinal tract is rare. Because presentation is insidious, with multiple vague symptoms, the possibility of systemic amyloidosis is often overlooked, resulting in substantial delays in diagnosis. A high index of suspicion is therefore required. Staining for amyloidosis should be considered in patients undergoing gastrointestinal biopsy who have unexplained chronic gastrointestinal symptoms.
2750 Acute Neck Pain Masquerading as Acute Gastric Volvulus
Authors: Saghir Syed Mohsin , Shafi Amaan , Elias Michael , Pellnitz Matthew , Riaz Jahan Z. , Ohning Gordon 
Published: October 2019

INTRODUCTION:
Gastric volvulus is a rare cause of gastric outlet obstruction that if not recognized early can lead to ischemia, necrosis and death. Organoaxial is the most common type and is seen with secondary anatomic defects i.e. paraesophageal hernias, diaphragmatic hernias and diaphragm eventrations. It occurs in 60% of cases with 30% risk of strangulation. Risk factors include age >50 years, secondary anatomic defects, phrenic nerve paralysis and structural abnormalities of the stomach/spleen. Symptoms include abdominal pain, chest pain, retching and/or vomiting. Misdiagnosis occurs because of its nonspecific presentation. We describe a case of a patient who was admitted for suspect acute coronary syndrome and found to have an acute gastric volvulus.

CASE DESCRIPTION/METHODS:
75 yo m with pmh of HTN, who p/w sudden onset neck pain radiating to L arm, with N/V during activity. He denied chest pain, SOB or diaphoresis. Vitals were T 98 F, HR 85, BP 156/69, and RR 18. On exam pt had decreased breath sounds LLL, NT abdomen, and left paraspinal neck tenderness. Pertinent labs: WBC: 11. Chemistry with hypokalemia. Normal troponins. CXR showed L hemidiaphragm elevation and hiatal hernia. Neck imaging was normal. EKG was normal without st changes. Overnight the pt became altered with intractable neck pain, nausea and vomiting. Repeat cxr showed widened mediastinum. A stat CTA chest/abd/pelvis showed organoaxial gastric volvulus with fluid filled esophagus. EGD abnormalities lead to an ex-lap with gastrostomy, gastropexy and volvulus reduction. Pt did well and went to a rehab facility.

DISCUSSION:
Gastric volvulus often manifests with abdominal pain in addition to nausea and vomiting rather than neck or chest pain. There have been reports of cases mimicking acute coronary syndrome. Intractable neck pain without abdominal pain is an extremely rare phenomenon in patients with acute gastric volvulus. In order to establish a diagnosis in our patient, a high index of suspicion was imperative for identifying an atypical presentation of acute gastric volvulus. This was illustrated by ordering a CT chest as soon as he became more ill-appearing. In retrospect, the intractable neck pain could have been considered as referred pain from the elevated left hemidiaphragm in the setting of a known hiatal hernia. Literature search was heterogeneous and scarce. Thus, we recommend high index of suspicion for acute gastric volvulus in the setting of intractable neck pain in order to intervene earlier and avoid worse outcomes.
2781 Plexiform Angiomyxoid Myofibroblastic Tumor of the Gastric Cardia: An Uncommon Tumor With an Even Less Common Location
Authors: Gardner Ramsey , Dukes Seth , Dustin Albert , Johnson Jeptha , Weeks Sharon , Laczek Jeffrey T. 
Published: October 2019

INTRODUCTION:
Plexiform angiomyxoid myofibroblastic tumor (PAMT) is a rare gastric tumor of stromal origin with unique immunohistochemical characteristics that differentiate it from other more common gastric stromal tumors. Since its first description in 2007, nearly all have been localized to the gastric antrum. We present a case of a symptomatic PAMT in the gastric cardia successfully treated with resection.

CASE DESCRIPTION/METHODS:
A 51 year old female complained of left sided abdominal pain, nausea, and early satiety. Esophagogastroduodenoscopy showed a 3 cm endophytic sub-epithelial mass in the posterior wall of the gastric cardia. Follow-up endoscopic ultrasound revealed an 18 mm × 33 mm hypoechoic mass contiguous with the muscularis propria (MP). Biopsies revealed a myxoid lesion composed of bland spindle cells, consistent with a PAMT. The patient was considered for resection given the proximity to the GEJ. Unfortunately, endoscopic management was unsuccessful and the patient subsequently underwent laparoscopic gastric wedge resection sparing the GEJ. Histologic exam revealed bland spindled cells within an eosinophilic fibromyxoid stroma with eosinophilic cytoplasm. While SMA and desmin stains were positive, C-Kit (CD117), DOG-1, and S-100 stains returned negative, confirming a PAMT. The patient’s postoperative course was uneventful at the six week follow-up with resolution of abdominal pain, nausea, and early satiety.

DISCUSSION:
PAMT is a rare benign tumor most commonly located in the antrum. Although patients are often asymptomatic, ulceration with bleeding, and obstruction are reported. It presents as a submucosal mass ranging from 2 cm – 15 cm. Diagnosis is histological with a nodular to plexiform growth pattern with well-circumscribed islands of spindle cells located within the MP and possible extension into the submucosa with ulceration. The tumor is composed of bland spindled cells separated by loose stroma with myxoid to fibromyxoid material. Cells are indistinct with eosinophilic cytoplasm, bland nuclei with inconspicuous nucleoli. Limited is known about progression of a PAMT but they appear to be slow growing with a good prognosis. Treatment largely consists of surgical resection, although endoscopic mucosal resection has been reported. This case presents a rare location of this rare tumor highlighting the importance of considering it with proximal gastric lesions.
2792 A Retrospective Study of Probiotic Use in Patients With Chronic Pancreatitis
Authors: Aponte-Pieras Jose , Wassef Wahid 
Published: October 2019

INTRODUCTION:
Chronic pancreatitis is a debilitating condition that develops following recurrent episodes of pancreatitis. It increases morbidity, decreases quality of life and leads to high utilization of medical resources. There is no definitive medical treatment. Studies have shown that gut microbiota may play a role in pancreatitis as bacterial and endotoxin translocation can contribute to severity. Bacteria such as lactobacillus, and bifidobacterium have been noted to be lower in chronic pancreatitis while enterobacteriaceae species were identified at higher levels in those. Probiotics can increase concentrations of bifidobacteria, lactobacilli and streptococci, preventing overgrowth of non-commensals. We are focused on researching new strategies to prevent disease progression and decrease length of hospital stay.

METHODS:
Retrospective chart review of a database of 86 chronic pancreatitis patients and probiotic use. All patients were cohorted based on severity of disease as rated on EUS using a scale of 1-5 with grades 1-3 grouped as “non-severe” and 4-5 as “severe.” We chose a null of 0.05 with a 95% confidence interval for statistical significance. Relative risk assessments were conducted on the rate of severe chronic pancreatitis in users of probiotics versus negative control.

RESULTS:
Our initial results revealed that 34% of patients had used probiotics since diagnosis of chronic pancreatitis on EUS. The rate of severe pancreatitis for the cohort of probiotic users was 0.241, and that for negative control was 0.298. A relative risk assessment for our population found a relative risk of 0.81 (95% CI, [0.379-1.727]; P = 0.2922) for the rate of severe chronic pancreatitis given exposure to probiotics. The result suggested a potential effect from probiotics on decreasing the risk of having severe chronic pancreatitis but was not statistically significant.

CONCLUSION:
There was no significant association between probiotic use and severity of chronic pancreatitis. We cannot exclude that probiotics may have a protective or therapeutic immunomodulatory effect on the microbiome of patients with chronic pancreatitis. This study is limited to a chart review in order to determine the extent of probiotic use in patients and cannot verify compliance with probiotics. We cannot report a correlation between probiotic use and severity of chronic pancreatitis.
2794 Subtotal Cholecystectomy Outcomes
Authors: Chum Christopher , Mun Michael , Bernstein Michael , Trillo John , Chaudhury Samiran Roy , Choudhry Mohammad K. , Rasheed Ahmed Daniyaal 
Published: October 2019

INTRODUCTION:
Subtotal cholecystectomies have become a viable alternative to converting laparoscopic cholecystectomies to open cholecystectomies in complicated gallbladder etiologies. There are two subtypes of subtotal cholecystectomies: fenestrating and reconstituting. Fenestrating subtotal cholecystectomy requires an internal suture of the cystic duct with removal of most of the gallbladder. Reconstituting subtotal cholecystectomy creates a gallbladder remnant. Bile leak is a common adverse outcome of subtotal cholecystectomies. ERCP is the standard intervention for high output bile leaks.

METHODS:
This was a retrospective analysis of patients at Coney Island Hospital who underwent any cholecystectomy during January 2010 to December 2018. The inclusion criterion was patients who underwent subtotal cholecystectomy. The exclusion criteria was any patient who underwent prior ERCP or sphincterotomy. We reviewed patient’s age, initial WBC, alkaline phosphatase, total bilirubin, AST, ALT, total output of JP drain, duration of JP drain, and hospitalization length. Data was analyzed using XTabs, ANOVA, and T-test using Prism and SAS software.

RESULTS:
1423 cholecystectomies performed at Coney Island Hospital during this period. Of these, 106 were subtotal cholecystectomies: 11 were reconstituting and 96 were fenestrating. 34 subtotal cholecystectomies required ERCP intervention. Fenestrating subtotal cholecystectomies were associated with higher total bile output from JP drain and longer duration of JP drain. Cases requiring ERCP intervention were associated with larger bile output from JP drain, higher total bilirubin, and longer hospitalization duration. 68 of the fenestrated subtypes were left with an open cystic duct without internal closure.

CONCLUSION:
ERCP has been demonstrated to be an effective intervention in treating post operative bile leaks in cases showing large JP drain output and increased total bilirubin on initial presentation. However, a majority of subtotal cholecystectomies can be managed without intervention. We noted that 68 of the 96 fenestrating subtotal cholecystectomies had the cystic ducts remain open instead of the traditional internal suture. Cystic duct obliteration or severe inflammation may impede suturing. Regardless, close monitoring of JP drain output is recommended. Our research concludes that there are better outcomes with reconstituting subtotal cholecystectomies and fenestrating subtotal cholecystectomies in which there was an internal suture placed at the cystic duct.
2798 Meta-Analysis and Systematic Review of Initial Endoscopic Therapy for Cholangitis
Authors: Lee Alice A. , Buitrago Carlos A. , Chang Patrick , Hiramoto Brent , Hilson Liam , Kankotia Ravi J. , Yeh Jeffrey , Nguyen Stefan , Schilperoort Hannah M. , Wani Sachin , Buxbaum James L. 
Published: October 2019

INTRODUCTION:
The initial endoscopic treatment of ascending cholangitis is controversial. It has been proposed that management should be limited to decompression alone while the alternative is to additionally perform sphincterotomy and/or stone removal to address the underlying etiology. Our aim was to compare the effectiveness and safety of endoscopic decompression alone to decompression combined with other endotherapy for ascending cholangitis.

METHODS:
We systematically searched Embase, Medline, the Cochrane Library, and ClinicalTrials.gov from inception to April 22, 2019. Studies were screened by two independent reviewers using Covidence software and standardized extraction forms. We included trials that compared endoscopic decompression and decompression combined with other endotherapy. Our primary outcome was the odds of effective decompression by decompression alone versus combined with other endotherapy. Our secondary outcome was the odds of adverse events (post ERCP pancreatitis, hemorrhage, mortality). Pooled odds ratios and proportions were estimated using the random effects model for the two approaches.

RESULTS:
10,508 abstracts and 256 full text documents were reviewed. Six comparative reports of decompression alone versus decompression with other endotherapy were included in the meta-analysis. These studies capture the results for 462 patients; 205 underwent endoscopic (stent or nasobiliary) decompression alone and 257 decompression plus other endotherapy.
There was no difference in success of cholangitis therapy for decompression combined with sphincterotomy and other therapeutic maneuvers as opposed to decompression alone (OR 1.3 [95% CI 0.3-5.6]); there was also no difference in mortality (OR 0.4 [0.4-7.3]). There were more adverse events for decompression combined with sphincterotomy and other maneuvers (OR 2.5 [1.0-6.5]) driven by a higher rate of bleeding (OR 9.1 [2.4-34.7])(Figure 1); there was no difference in rates of post ERCP pancreatitis (OR 0.7 [0.2-2.1]).

CONCLUSION:
In cholangitic patients, the addition of therapeutic maneuvers including sphincterotomy to biliary decompression is associated with higher rates of adverse events and particularly bleeding compared to decompression alone. Nevertheless, the included studies did not account for adverse events during subsequent ERCP to remove biliary stones in those initially managed with decompression alone. In cholangitic patients who are coagulopathic or would not tolerate adverse events, decompression alone should be considered.