bluuebunny/crossref_metadata_2025_split huggingface dataset:
2722 Thinking With the Gut: An Unfortunate Case of Metastatic Gastric Cancer
Authors: Hussaini Zeba , Amer Kamal , Asif Bilal , Tofani Christina 
Published: October 2019

INTRODUCTION:
Metastatic brain tumors represent 20-40% of intracranial neoplasms [Table 1]. Although rare, the incidence of brain metastasis from the gastrointestinal (GI) tract has increased likely secondary to prolonged survival of patients with GI cancers. Symptoms of metastatic spread parallels space-occupying lesions in brain: confusion, headache, visual disturbances, nausea, vomiting, altered mental status, gait abnormalities, seizures, and decreased consciousness. Current literature estimates 0.63% of gastric adenocarcinoma (GA) cases metastasize to the brain1. Here, we present an unusual case of metastatic brain spread of GA.

CASE DESCRIPTION/METHODS:
59-year-old male with history of hypertension, tobacco use, GERD, and gastric cancer who presented with a one-week history of headaches, nausea and vomiting, and decreased visual acuity. His gastric cancer had previously been treated with neoadjuvant chemotherapy, radiation and partial esophagectomy with repeat screening via computed tomography (CT). A CT of his head showed vasogenic edema in the right frontal lobe, raising concern for metastatic disease versus primary CNS lesion [Figure 1]. A magnetic resonance imaging (MRI) brain showed an enhancing mass in the anterior-inferior right frontal lobe with metastatic disease as well as leptomeningeal carcinomatosis [Figure 2]. He underwent right frontal burr-hole for stereotactic biopsy of the right frontal tumor. Pathology was consistent with metastatic adenocarcinoma. He was started on IV steroids and began whole brain radiation therapy. He was not a surgical candidate and was unstable for chemotherapy. His family transitioned him to comfort care measures after which he shortly passed.

DISCUSSION:
Gastric cancer is the fourth most common cancer worldwide and the second most common cause of cancer-related death. Current literature estimates GA incidence rate to be 6.7/100,000 persons with a mortality rate of 3.4/100,000 persons in the United States. Risk factors include H. pylori, male sex, Asian/Pacific island ethnicity, obesity, smoking, and a diet rich in smoked, salted, pickled foods. Our patient demonstrated an unusual case of metastatic GA without evidence of visceral metastases. His case was further complicated as he had screening CT scans at six month intervals which had been within normal limits until his presentation. His case unfortunately demonstrates the ominous prognosis of patients with brain metastasis, prompting the need for increased surveillance and brain imaging.
2724 Systemic Fungemia Following Gastric Ulcer Perforation in a Patient With Hepatocellular Carcinoma: A Case Report and Review of Literature
Authors: Qayyum Farhan , Alom Md S. , Chowdhury Nazif , Bank Lesile 
Published: October 2019

INTRODUCTION:
The frequent overgrowth of Candida in the intestinal microbiota has made candidemia one of the most common bloodstream infections in the United States. Such infections are capable of infecting organs leading to several threatening conditions such as fungal endocarditis, meningitis, osteomyelitis, or Candida endophthalmitis. In rare occurrences, Candida species overgrowth has also been theorized to promote perforations of gastric ulcers.

CASE DESCRIPTION/METHODS:
We are reporting the case of a 56-year-old immunocompromised male with a history of cirrhosis of liver secondary to Hepatitis C, hepatocellular carcinoma and gastric ulcers who presented with generalized abdominal pain and distention. Physical exam showed him to be in moderate distress with diffuse severe tenderness to palpation with guarding and rebound tenderness. A CT of the abdomen revealed pneumoperitoneum, and a subsequent diagnostic laparoscopy discovered a 5 mm gastric ulcer perforation with an opening into the antrum of the stomach. Following surgical repair of the perforation, blood and peritoneal fluid cultures revealed the growth of Candida galbrata. Despite aggressive antifungal therapy, the patient expired due to multisystem organ failure.

DISCUSSION:
While most gastric perforations are caused by complications with peptic ulcer disease, nonsteroidal anti-inflammatory drugs, or certain neoplasms, studies have shown that Candida overgrowth may also promote the perforation of a pre-existing ulcer. Fungal overgrowth most frequently occurs in immunocompromised patients or those on certain medications. Patients with a Candida infection are at an increased risk for organ failure, surgical site infections, a prolonged hospitalization, and a significantly higher mortality rate.
2725 Electrode Perforation Into Stomach Complicating Gastric Electrical Stimulation
Authors: Kobeszko Matthew , Bardezbanian Bryce , Berkelhammer Charles 
Published: October 2019

INTRODUCTION:
Gastric electrical stimulation is not FDA-approved, but available on a compassionate basis in the management of refractory gastroparesis. We describe a patient with refractory gastroparesis treated by gastric electrical stimulation who developed the rare complication of electrode migration into the lumen of the stomach.

CASE DESCRIPTION/METHODS:
A 31 year old female with idiopathic gastroparesis was refractory to maximal medical therapy including polypharmacy and feeding jejunostomy. Her gastric emptying was delayed with only 78% gastric emptying after 4 hours on gastric emptying scan (normal > 90%). A gastric electrical stimulator was placed 4 years prior to presentation, on a compassionate use basis. A battery change was required 2 years later. Settings were gradually increased to maximal, at 5 mA, pulse width of 360 us, rate 40 Hz, cycle on 2 seconds, cycle off 3 seconds. Two years later she complained of stabbing epigastric pain, and a recurrence of her gastroparesis symptoms, with nausea, vomiting, coffee ground emesis, and early satiety. On physical exam she was afebrile and non-toxic, with mild epigastric tenderness. CT showed a non-specific 3.7 cm fluid density adjacent to the stomach around the gastric pacemaker lead. Upper endoscopy revealed that two of the leads had penetrated into the gastric lumen. Gastric retention of food was also noted, even though the patient had been nothing by mouth for 12 hours prior to the procedure. Surgery confirmed that 2 of the gastric pacemaker leads had eroded into the stomach. The leads were removed, and new leads placed more proximally in the stomach. A surgical pyloroplasty was also performed. The patient did well in the 18 months of post-operative follow-up.

DISCUSSION:
Lead perforation into the stomach following gastric electrical stimulation is rare. As far as we are aware, there are 3 previously reported cases. In addition, there is one report of electrode perforation into the small bowel. We speculate that higher energy settings, and longer duration of cycles on may be a risk factor for this complication. Sudden epigastric pain, recurrence of gastroparesis symptoms, and a fluid collection at the electrode insertion site, may be clues as to the development of this rare complication.
2727 A Fatal Case of Disseminated Gastric Mucormycosis With Emphysematous Gastritis
Authors: Rotundo Laura 
Published: October 2019

INTRODUCTION:
Gastric mucormycosis is a life-threatening opportunistic fungal infection that presents in immunocompromised individuals, such as those with diabetes mellitus, hematologic malignancies, sepsis, or chronic steroid use. Concomitant emphysematous gastritis is a rarely documented condition that can occur due to mucosal infiltration and is associated with increased mortality.

CASE DESCRIPTION/METHODS:
This is a case of a 24-year-old man with Stage 1 testicular cancer (non-seminomatous germ cell tumor) on cycle 2 of cisplatin/ etoposide who was found unconscious following a syncopal episode. He was intubated for worsening hypoxic respiratory failure secondary to klebsiella aspiration pneumonia, requiring sedation and paralytics for seven days. On day 12, he was noted to have significant bright red blood per rectum and his hemoglobin decreased from 9.9 to 7.3. CT abdomen revealed significant intramural emphysema within the stomach (Figure 1). Emergent upper endoscopy revealed severe gastritis with mucosal sloughing and transmural necrosis involving 90% of the stomach. Rush biopsies revealed mucormycosis; he was started on amphotericin and isavucionazonium. He underwent laparoscopic total gastrectomy with E-J anastomosis two days later. Five days later, he was noted to have large bloody output from his abdominal drains with resultant hypovolemic shock. He was urgently taken to the operating room, where he had a cardiac arrest and died. Autopsy findings revealed fungal hyphae disseminated throughout the abdominal cavity and an exudative hematoma extending to the diaphragm, liver, transverse colon, pancreas, and spleen.

DISCUSSION:
Mucormycosis presents in the gastrointestinal tract in less than 10% of reported cases [1]. It is typically associated with upper gastrointestinal bleeding in immunocompromised patients. Furthermore, disseminated mucormycosis can result in vascular invasion, significant blood loss and multiorgan failure. Given that the finding of emphysematous gastritis is very rare since mucormycosis is not a gas-forming infection, sudden onset massive hematochezia and abdominal pain in at-risk individuals should raise concern for ischemic bowel necrosis from invasive mucormycosis. Because it carries a grave prognosis, rapid recognition and intervention of mucormycosis and its complications is necessary to avoid mortality.
2728 An Unexpected Cause of a Gastric Ulcer
Authors: Rojas Patricia Guzman , Gonzaga Ernesto Robalino , Catania Jelena , Moquete Mario 
Published: October 2019

INTRODUCTION:
Mucormycosis is a rare rhino-orbital-cerebral fungal infection. The GI tract is involved in approximately 7% of the patients; however, this incidence may not be exact since several cases have been diagnosed postmortem. Within the GI tract, the stomach is the most frequently compromised organ, followed by the colon.

CASE DESCRIPTION/METHODS:
46-year old man presented to the ED with 1-week history of diffuse, crampy abdominal pain. His pain was associated with nausea, non-bloody vomiting, anorexia and watery non-bloody diarrhea for the past 3 days. His PMH is significant for HIV, well controlled on ART and DM complicated with gastroparesis. Laboratory results showed a CD4 of 540, normal WBC, A1C of 10.3% and negative infectious stool studies. The patient was admitted to the hospital and was placed on supportive treatment. Due to persistence of his symptoms, a CT of the abdomen was done showing gastric wall abnormalities (Figure 1). GI was consulted and a decision to perform an EGD was made. The EGD showed a large ulcerated irregular area in the stomach fundus (Figures 2 and 3). Biopsies were taken showing positive fungal stain compatible with mold from the order Mucorales. The patient was started on amphotericin B and then underwent a total gastrectomy with roux en Y reconstruction. Pathology results confirmed biopsy findings and culture was positive for Rhizopus species.

DISCUSSION:
Mucormycosis is an opportunistic infection that mainly occurs in immunocompromised states like DM, uncontrolled HIV infection and hematopoietic and solid organ transplant. GI invasion caused by Mucorales does not have a clearly understood mechanism; however, many authors propose that this starts after ingestion of fermented foods. Fungal hyphae can invade the blood vessels, leading to local ischemia, ulceration, infarction and necrosis of the affected tissue. Patients can present with nonspecific symptoms, which can delay the diagnosis, leading to mortality in 85% of the cases. EGD elucidates large ulcers that can be associated with emphysematous changes, as in our patient, but the diagnosis is made by fungal cultures of biopsies, since histopathological examination can be misleading. Treatment is based on amphotericin B or posaconazole, but surgical resection is necessary for cure. We report this case to increase awareness of mucormycosis as a cause of gastric ulceration in an immunosuppressed patient. Surgical treatment is encouraged, since delays are related to high mortality rates.
2730 Unexpected Cause of Globus Pharyngeous: Gastric Leiomyosarcoma
Authors: Gonzaga Ernesto Robalino , Guiance Irene Riestra , Parikh Jignesh , Vanar Vishwas 
Published: October 2019

INTRODUCTION:
Soft tissue sarcomas (STS) are derived from smooth muscle cells and typically arise in adipose tissue, blood vessels or structural tissue surrounding the organs of the body. One of the most common types of STS is leiomyosarcoma (LMS) which account for 11% of all sarcomas diagnosed. Gastric LMS are exceptionally rare and make up 0.1% of all mesenchymal tumors of the stomach.

CASE DESCRIPTION/METHODS:
A 72 year-old male presented to the gastroenterology clinic with complains of globus pharyngeus, migrating abdominal discomfort and a 4-month 18 pound weight loss. Endoscopy revealed a large bloody friable mass in the posterior wall of the stomach. Biopsy demonstrated atypical spindle cell proliferation. Immunohistochemistry was positive for Smooth Muscle Actin (SMA), desmin and CD34; cKIT and DOG1 was negative. He was diagnosed with high grade LMS of the stomach with no metastasis after unremarkable positron emission tomography scan. The patient underwent total gastrectomy with splenectomy en-bloc resection to achieve wide negative margins.

DISCUSSION:
This case highlights an unexpected cause of globus pahryngeus: Gastric LMS which is important to differentiate from gastrointestinal stromal tumor (GIST) as its management and prognosis differ. LMS represent 0.1% of all gastric tumors, and 3% of all gastrointestinal malignancies. In contrast, GIST has annual incidence of 11-14.5 per million population. LMS and GIST appear similar on gross assessment and clinical symptoms and need to be differentiated via immunohistochemical staining. LMS are actin and desmin reactive with DOG1.1 typically being absent. Further, LMS lack cKIT and PDGFRα mutations that are seen in GIST. Management of GIST with tyrosine kinase is potentially lifesaving, whereas no such treatment exists for LMS where the cornerstone of treatment is surgery. Chemotherapy and radiation have been shown to be only helpful for palliative measures. They are intrinsically aggressive tumors and 90% are moderate to high grade at time of diagnosis with evidence of metastatic disease. We are far from understanding the pathology of LMS and its risk factors. This case confirms our present understanding of LMS; as shown by positive markers as well a diagnosis of high grade tumor on presentation. However, it also challenges our current understanding of LMS in its unusual symptomatology and lack of metastatic disease. Due to its low incidence, it is crucial to report cases such as this in order to further our understanding of the tumor.
2738 A Rare Cause of Dyspepsia: Gastric Sarcoidosis
Authors: Gala Khushboo , Luckett Robert T. , Shah Nihar 
Published: October 2019

INTRODUCTION:
Dyspepsia is one of the most commonly addressed gastrointestinal problems in the outpatient settings, globally thought to affect 7-45% of the population. The majority of cases with dyspepsia are functional, as defined by the Rome Criteria, and have no organic cause. A rare cause of organic dyspepsia is gastric sarcoidosis, with only 40-60 cases described in literature so far. We present a case of new onset dyspepsia secondary to sarcoidosis.

CASE DESCRIPTION/METHODS:
Our patient was a 48 year-old African American female with a history of pulmonary sarcoidosis, which had been treated with systemic steroids and methotrexate and had been stable off medications. During a routine healthcare visit, she reported new onset of nausea and heartburn for one month, failed trial of PPI and then was referred for an EGD. Endoscopy showed grade A gastro-esophageal junction esophagitis and erosive gastritis. Biopsies of gastric antrum and body showed severe active chronic gastritis with non-necrotizing granulomatous inflammation, with negative staining for fungi, mycobacteria and H pylori, diagnosed as gastric sarcoidosis.

DISCUSSION:
Dyspepsia is a constellation of upper GI symptoms, including the presence of upper abdominal pain or discomfort with or without other symptoms such as nausea, belching and vomiting. Less than 30% of cases of dyspepsia are found to have an organic cause, the most common of which are chronic peptic ulcer disease, gastroesophageal reflux (with or without esophagitis) and malignancy. Among the rarer causes is sarcoidosis. Sarcoidosis is a multi-systemic disease characterized by the histological presence of non-caseating granulomas, which commonly has pulmonary manifestations. Gastrointestinal involvement is extremely uncommon in sarcoidosis and usually asymptomatic, with only 0.1-0.9% of all cases of GI sarcoidosis displaying symptoms. The mainstay of diagnosis is endoscopy with biopsy showing the characteristic non-caseating lesions, after ruling out infections and other etiology. Management consists of immunosuppressive therapy, including corticosteroids. Although rare, it remains the second most common cause of granulomatous gastritis in developed countries and should be kept in mind investigating GI symptoms especially in patients with preexisting disease. Our case also highlights the importance of appropriate upper endoscopy evaluation in cases of new-onset dyspepsia.
2739 A Rare Case of Multifocal Gastrointestinal Stromal Tumor
Authors: Kaushik Chandni , Bilal Mohammad , Parupudi Sreeram 
Published: October 2019

INTRODUCTION:
Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors most often located in the stomach and proximal small bowel although they can occur in any part of the gastrointestinal tract and occasionally in omentum, mesentery, and peritoneum. GISTs are traditionally thought of as solitary tumors that rarely present with multiple lesions. We present a unique case of multifocal GIST that was incidentally found on imaging.

CASE DESCRIPTION/METHODS:
A 44-year old woman with no prior medical history presented to the emergency department with a one-day history of left lower quadrant abdominal pain. A CT scan of abdomen and pelvis demonstrated acute diverticulitis, and incidentally a 6.2-cm heterogeneously enhancing exophytic mass along the inferior margin of the gastric body was seen. In addition, two lesions measuring 3.4 cm and 1.1 cm were seen adjacent to the gastrohepatic ligament (Figure 1). The patient’s abdominal pain improved with intravenous antibiotics. Gastroenterology was consulted given the mass lesions, and an endoscopic ultrasound was performed which showed three distinct heterogeneously hypoechoic masses (Figure 2), and fine needle biopsy (FNB) was performed. All three lesions were biopsied using three separate needles to avoid cross-contamination. Pathology of all three lesions was consistent gastrointestinal stromal tumor (GIST). Immunohistochemical staining was positive for DOG1 (Figure 3). The patient has been established with medical oncology for neoadjuvant therapy with Imatinib.

DISCUSSION:
Many GISTs are incidentally discovered on imaging or endoscopy. They are more frequently associated with early satiety, bloating, and bleeding although larger tumors can cause pain and symptoms of obstruction. Multifocal GISTs are exceedingly rare, other than exceptions in pediatric population, metastatic spread and hereditary syndromes. Newer studies suggest patients with multifocal GISTs may actually have multiple primary GISTs rather than metastatic spread, and molecular characterization can allow for proper staging and treatment planning. Multifocal GISTs have also been reported in patients with neurofibromatosis (NF) type I. However, our patient did not have any symptoms or signs suggestive of NF. It is important for gastroenterologists to know that multifocal GISTs can present in adults, and if suspicion is high, all lesions should be evaluated individually, and smaller lesions should not be attributed to metastasis unless proven otherwise.
2740 IgG₄-Related Disease: A Gastric Mass With an IgG4 Surprise
Authors: Lopez Dylan , Cepeda Cristina , Desmedt Cleo , Lalonde Christian P. , Montes Rogerio , Menjivar Juan J. , Mendez Oscar , Mendez Diego 
Published: October 2019

INTRODUCTION:
IgG₄-related disease is a rare autoimmune syndrome that causes fibrosis of glands, most commonly of the pancreas and biliary tract1,3. The overall prevalence is unknown, with an estimated less than 1:100,000 of the general population typically found in middle-aged males2,3. Diagnosis is made with IgG₄ levels at least 2x the upper limit of normal and dense lymphoplasmacytic infiltrate, however, it may be seen with normal IgG₄ levels6. Although rare, it can present similar to GI malignancies and should be considered in the differential for patients with autoimmune disease1,3,4,5. Here we present one of those unusual cases.

CASE DESCRIPTION/METHODS:
A 65-year-old lady with PMH of DM2 and Sjogren's Syndrome (SS) who presented to the hospital with intractable nausea, vomiting, and failure to thrive for over 1 month. The physical exam, labs that included CMP, LFTs, and serology was unremarkable; previous EGD revealed diffuse thickening of the gastric submucosa. Biopsy via open gastrectomy revealed chronic inflammation with multiple IgG₄ plasma cells and no signs of lymphoma, suspicious for IgG₄-RD. After the partial gastrectomy, serum Na levels were 162, which improved with DDAVP and was later confirmed to be diabetes insipidus (DI). Further workup and imaging were negative and baseline IgG and IgG₄ levels were 1178 and 61, respectively. Treatment included steroid therapy and DDAVP which improved her symptoms and preceded an uneventful hospital course.

DISCUSSION:
IgG₄-RD is a disease with numerous presentations based on the organs involved. It presents as a GI-specific illness due to its affinity for the pancreas and biliary tract1,2,3. As seen in our patient, although rare, it may also affect the stomach, form mass lesions and cause symptomatology similar to a GI malignancy3,5. In patients with autoimmune diseases, where GI malignancy is considered, it is reasonable to include IgG₄-RD in the differential. IgG₄-RD may mimic symptoms of SS, and therefore case-patients with SS should also be considered for IgG₄-RD. This patient also experienced DI which may be a manifestation of IgG₄-RD, as the syndrome may affect the pituitary4. This case is one of the few instances reported to have pituitary involvement after the onset of multiorgan involvement4. Like other autoimmune disorders, IgG₄-RD is responsive to steroid therapy or rituximab. Therefore, a timely diagnosis can help slow down or prevent symptomatic manifestations, as seen in the case. Clinicians should be aware of this clinical presentation.