bluuebunny/crossref_metadata_2025_split huggingface dataset:
2687 A Rare Case of Organoaxial Volvulus of the Stomach
Authors: Lopez Michell , Then Eric O. , Ofosu Andrew , Are Vijay S. , Culliford Andrea , Gaduputi Vinaya 
Published: October 2019

INTRODUCTION:
Gastric volvulus is an uncommon and potentially life-threatening clinical entity characterized by rotation of the stomach along its long or short axis provoking variable degrees of gastric outlet obstruction. Clinical presentation varies between acute and chronic volvulus. Here we present a rare case of chronic organoaxial volvulus presenting with dysphagia.

CASE DESCRIPTION/METHODS:
The patient is an 87 year old male with a medical history of hypertension, obstructive sleep apena, multi-nodular goiter (with thyroid resection resulting in vocal cord paralysis) who was referred to the gastroenterology clinic for dysphagia. The patient states he had dysphagia to solids for one year. The patient denied associated nausea, vomiting, hematemesis, hematochezia, constipation or unintended weight loss. Complete blood count and comprehensive metabolic panel at that time were unremarkable. Physical exam was also unremarkable. Given his symptoms a barium swallow was ordered to further evaluate his gastrointestinal tract. This was done and showed no evidence of esophageal obstruction or esophageal mass, but did incidentally find organoaxial rotation of the stomach. The patient was scheduled to undergo upper esophagogastroduodenoscopy, but was non-compliant with the appointment and lost to follow up.

DISCUSSION:
Acute gastric volvulus usually presents with sudden onset abdominal or chest pain, severe retching with occasional vomiting, and epigastric distention. Chronic gastric volvulus on the in contrast can present with a complete absence of symptoms to non- specific symptoms, such as abdominal pain, dyspepsia, dysphagia, acid reflux, nocturnal cough, hiccups, non-bilious vomiting, weight loss, and anemia. Diagnosis of gastric volvulus is conventionally achieved with chest radiograph, upper barium studies or CT- scan. Regardging treatment of acute symptomatic gastric volvulus, nasogastric decompression is usually the first step, followed by surgery. Some patients at high risk for surgery, mainly elderly, can also be treated endoscopically with adequate decompression and reduction of the stomach and placement of a gastrostomy tube to gastropexy the stomach to the abdominal wall.
2690 Omental Infarct: A Rare Cause of Acute Abdomen
Authors: Singh Tejveer , Jarodiya Vijay , Khan Zarak H. , Misra Preeti , Iljas John 
Published: October 2019

INTRODUCTION:
Omental infarct is a rare cause of acute abdominal pain resulting from vascular compromise of the greater omentum. This condition usually has a nonspecific clinical presentation with right lower quadrant being the most common location and is usually managed conservatively. We present a rare case of idiopathic omental infarct.

CASE DESCRIPTION/METHODS:
35-year-old obese caucasian male with past medical history significant for hypertension and GERD presented to the emergency department with chief complaint of right lower quadrant pain which started 3 days ago without any precipitating event. Initial labs were unremarkable with vital signs only significant for elevated blood pressure. CT of the abdomen and pelvis with contrast showed significant inflammation in the right side of the abdomen most likely representing omental infarct. On call general surgeon was consulted who suggested no acute surgical intervention and patient to be managed medically with ciprofloxacin and metronidazole. On call vascular surgeon was consulted; advised there was no immediate need for anticoagulation as there was no evidence of acute vascular issues such as embolization and/or dissection involving the celiac or the superior mesenteric arteries. Following day, the patient improved clinically and was discharged with total of 10 days of antibiotic treatment and to follow-up outpatient with general surgeon.

DISCUSSION:
Omental infarct is a rare cause of acute abdominal pain. Clinical presentation includes sudden onset of acute abdominal pain located mostly in the right lower quadrant with tenderness and absence of any other GI symptoms. Omental Infarction can be isolated event or in succession to omental torsion. A diagnosis of primary/idiopathic omental infarct is made when no identifiable etiology is determined. Secondary causes of omental infarction include hypercoagulability, vasculitis, abdominal adhesions, cysts, and tumors. Other contributing factors include obesity, local trauma, heavy food intake, coughing, sudden body movements, laxative use, and hyperperistalsis. CT of the abdomen may show focal area of fat stranding, swirling of omental vessels, omental torsion, and/or hyperdense peripheral halo. The disease is often self-limiting and managed conservatively. Complications such as abscess can occur which may require surgical or radiologically-guided drainage.
2694 Median Arcuate Ligament Syndrome: The Ambiguous Cause of Abdominal Pain
Authors: Zackria Rasiq , Hwang Andrew W. , Sagami Justin 
Published: October 2019

INTRODUCTION:
Median Arcuate Ligament Syndrome (MALS) is often under-diagnosed due to its rarity and overlap of symptomatology with other abdominal pathologies. The pathology involves the median arcuate ligament compressing the celiac artery leading to chronic, postprandial abdominal pain, nausea, vomiting, and weight loss. Making the diagnosis is complicated by a lack of sensitive diagnostic modalities.

CASE DESCRIPTION/METHODS:
A 69-year-old female with a history of emphysema, scoliosis, and interstitial cystitis presented for severe postprandial abdominal pain, nausea, vomiting, and anorexia from fear of food. She had a standing diagnosis of chronic ischemic mesenteric colitis for years. On examination, she had diffuse abdominal tenderness with radiation down to her upper thighs, nausea, vomiting, and cachexia. The initial labs were unrevealing. CT abdomen demonstrated severe arteriosclerosis of the celiac artery with 75% stenosis, as well as moderate stenosis of SMA, IMA, and bilateral renal arteries. Despite an inconsistent physical exam, vascular surgery agreed with the reading of ischemic colitis and suggested that a celiac stent be placed. Upon further review of the CT and an interdisciplinary conference, her images were determined to be consistent with celiac artery compression. The patient is to be scheduled for the release of the median arcuate ligament with a possible celiac nerve block.

DISCUSSION:
When suspecting MALS, a triad of postprandial abdominal pain, weight loss, and abdominal bruit may be the only findings to suggest the diagnosis. With our patient not having a bruit and imaging showing severe stenosis, this only made the diagnosis of MALS even more discrete. Imaging may show a narrowing of the celiac artery for further clues followed by confirmation testing via:
• Inspiratory/Expiratory ultrasonography – may show an increased visible compression of the artery during expiration with the increased blood flow velocity.
• Gastric Tonometry – physiological testing, as well as measurements of arterial PaCO2 levels before and after exercise, may also be used to predict the success of decompression.
• Ganglion Nerve Block – percutaneous celiac ganglion block, using an anesthetic to block nerve fibers of celiac plexus, which may be diagnostic and therapeutic.
This case presents the difficulty of diagnosing MALS due to its overlap with the more common ischemic colitis. Having a keen clinical suspicion with a better understanding of the workup for MALS may prevent misdiagnoses and misguided therapies.
2698 Spontaneous Vasogenic Gastric Necrosis
Authors: Putnam Tyler , Turse Erica , Kadkhodayan Kambiz 
Published: October 2019

INTRODUCTION:
Gastric ischemia is a potentially lethal condition which can lead to necrosis, perforation, and overall increased mortality. To our knowledge, this is the first report of spontaneous vasogenic gastric necrosis. We present a patient with spontaneous idiopathic vasogenic gastric necrosis leading to a positive outcome.

CASE DESCRIPTION/METHODS:
75-year-old female presented with a three day history of diffuse progressive abdominal pain, nausea, and bilious emesis. Physical exam was remarkable for diffuse abdominal tenderness, hyperactive bowel sounds and guarding. Labs revealed WBC 15.6 thousand/ul and Lactic Acid 2.9 mmol/L. CT abdomen showed gas in the gastric wall and portal vein (Figure 1). Upper endoscopy revealed diffuse necrotic gastric tissue without perforation (Figure 2). After noting this, the patient was taken to the OR where a total gastrectomy with roux-en-y esophagojejunostomy was performed. Pathology showed active chronic gastritis with ulceration and focal hemorrhagic necrosis, ruling out malignancy and H.pylori. The patient recovered well and was discharged to a short-term care facility.

DISCUSSION:
Spontaneous ischemic gastric necrosis is a rare and potentially life-threatening if improperly managed. Mortality rate is high for gastric ischemia (33-41%) and even higher for perforation (50-80%)3-4. 75% of cases are from local vascular causes, others being obstruction or hypoperfusion2. Commonly patients present with abdominal pain, GI bleeding and confusion4. The pathophysiology of acute idiopathic gastric mucosal damage is unclear. One hypothesis describes an overwhelming amount of gastric acid, bile salts and ischemia causing a marked decrease in mucosal blood flow to gastric tissue1,5. Given the acuity and rapid clinical progression, it's imperative to have a high degree of clinical suspicion when evaluating such patients. In this case, a prompt diagnosis and early management led to a positive outcome.
2699 An Uncommon Cause of Vomiting and Abdominal Pain in Pregnancy
Authors: Barlass Usman , Rzepczynski Allison , Naqshband Shezray , Lee Salina 
Published: October 2019

INTRODUCTION:
Anisakis is a zoonotic parasitic disease that infects marine mammals. Gastrointestinal anisakiasis is caused by consumption of undercooked or raw seafood infected by nematodes of the Anisakis species. While it is common in Asia it is an uncommon infection in North America with only a few reported cases. Here we present a case of gastric anisakiasis in a pregnant woman complicating the diagnosis and management.

CASE DESCRIPTION/METHODS:
A 32 year old newly pregnant female presented to the infectious disease clinic with acute onset abdominal pain and emesis. She reported finding two mobile “worms” in raw salmon, after ingesting six ounces of the fish, a day before. A specimen was sent to the microbiology laboratory with the preliminary read concerning for roundworm. Given the concern for anisakiasis, pregnancy status and risk of perforation, she was directly admitted for upper endoscopy. This revealed a thin, translucent, 20 mm × 1 mm worm burrowed into the greater curvature of the proximal antrum. The worm was removed in entirety with cold biopsy forceps and sent to microbiology. Biopsies were taken from the site of burrow. Pathology was consistent with mild gastritis with focally increased eosinophils and no remnant of the parasite. The worm was identified as anisakis species. The patient’s symptoms resolved spontaneously. Her pregnancy limited evaluation of the remainder of her G.I tract for evidence of infection. Since she had no symptoms of obstruction, she was discharged with instructions to complete a bowel purge upon returning home.

DISCUSSION:
Gastric anisakiasis is uncommon in the U.S. In addition, this case was complicated by the patient’s pregnancy, precluding the use of imaging techniques such as CT scans to help narrow the diagnosis in suspected anisakiasis and exonerate complications. Obstruction is a commonly reported complication for which there has been reported success with Albendazole therapy, undesirable in this case, being pregnancy category C. Another reported and somber complication includes perforation from the burrowing of untreated parasites. To minimize adverse outcomes with imaging and antiparasitic therapy, our patient underwent curative endoscopic therapy followed by a bowel purge to empirically purge remaining parasites from the distal G.I tract. With globalization of cuisine and increasing consumption of raw fish in the west, physicians should have a heightened suspicion of parasitic infections such as anisakis given the significant sequalae of untreated infection.
2705 Incidental Finding of Gastric Adenocarcinoma on Random Gastric Biopsy: A Call for Methodical Examination of the Gastric Mucosa
Authors: Tetangco Eula Geralyn , Coles Michael , Little Leonard , Schubert Moonkyung 
Published: October 2019

INTRODUCTION:
Gastric cancer is the 5th most common neoplasm and the 3rd most deadly cancer worldwide. Adenocarcinomas account for 95% of cases. It is more prevalent and has a higher mortality in males. We present a case of gastric adenocarcinoma detected incidentally on random gastric biopsy.

CASE DESCRIPTION/METHODS:
A 73-year old white male underwent upper endoscopy for reflux. He had a 55-pack year smoking history, no significant alcohol use, and normal BMI. Esophagogastroduodenoscopy (EGD) revealed a 4 mm hypopigmented area in the incisura and was otherwise normal. Random gastric biopsies included the area. One of 6 specimens revealed intramucosal adenocarcinoma in a background of intestinal metaplasia, and H. pylori organisms. It involved the lamina propria and was suspicious for invasion. On repeat EGD 11 days later, previous biopsy sites were seen showing some fibrosis, likely given the short interval between endoscopies. Frozen section biopsy of the incisura confirmed cancer. Due absence of a visible lesion, the site was biopsied extensively and tattooed prior to surgical referral. The patient underwent distal gastrectomy with Roux en Y reconstruction and lymphadenectomy. The surgical specimens showed no residual malignancy, negative and viable margins, and benign lymph nodes. Quadruple therapy successfully eradicated H. pylori.

DISCUSSION:
The incidence of gastric cancer in North America is 5.6 per 100,000, higher than that for esophageal cancer. The 5-year survival rate in the US is 31%, reflecting that most diagnoses are made when the cancer has metastasized. This rate increases dramatically to 94% and 88% when stage IA and IB tumors are surgically treated, respectively. Early gastric cancer can be subtle in appearance and may be missed during routine endoscopy. Retrospective studies comparing examination time for EGD reveal that endoscopists with longer mean exam (longer than 7 min in the US, 3 min in Korea) detect more neoplastic lesions than shorter exams. The European Society of Gastrointestinal Endoscopy to recommends an examination time of 7 minutes from intubation of the esophagus to extubation. This case highlights (1) that a comprehensive systematic exam must be consistently performed to investigate the entire stomach, (2) the importance of NBI with near focus mode to closely examine mucosal vascularization and pit pattern in order to diagnosis of a small malignant lesions, and (3) the need for targeted biopsies to be placed in separate jars.
2707 Gastric Mucosa-Associated Lymphoid Tissue Lymophoma Treated by Endoscopic Mucosal Resection
Authors: Kim Seong-Taeg , Young Na Soo 
Published: October 2019

INTRODUCTION:
Primary low-grade gastric Mucosa-associated lymphoid tissue (MALT) lymphoma is a distinctive type of B-cell lymphoma. Endoscopic appearances of low-grade gastric MALT lymphoma are quite varied and polypoid or subepithelial type (exophytic) is rare. Here, we reported the case of H. pylori negative gastric MALToma presenting as an exophytic subepithelial tumor, diagnosing and treating by endoscopic mucosal resection (EMR).

CASE DESCRIPTION/METHODS:
A 53-year-old man was referred to our hospital because of a large subepithelial tumor of the stomach, which was incidentally found on an endoscopy for a routine checkup in outside hospital. Initial outside endoscopic biopsy was a simple chronic gastritis. Physical examination and laboratory results were unremarkable. On endoscopic examination, a 2.0 cm sized round and hard exophytic subepithelial tumor was seen on the great curvature side of high body of the stomach. The tumor showed a well-demarcated smooth border without any erosion and ulceration. An abdominal pelvic CT demonstrated an enhancing subepithelial tumor without regional lymphadenopathy, such as gastrointestinal stromal tumor. EUS showed a hypoechoic and heterogeneous mass in the 2nd and 3rd layer with ill-defined internal margin. EMR was done for both the definite diagnosis and the treatment without complications because the tumor had a semipedunculated morphology. Results of a histopathologic examination of the resected tumor showed diffuse lymphocytic proliferation in the submucosa mimicking a subepithelial tumor with lymphoepithelial lesions. Dense lymphocytic infiltration composed of mainly B cells forming vague follicular colonization. Immunohistochemical stain of cytokeratin also showed presence of lymphoepithelial lesions. The Ki-67 was positive in 7%. Histologically, no H. pylori was observed in the luminal side. Finally, the patient was diagnosed as a H. pylori–negative extranodal marginal zone B-cell lymphoma (MALToma) (stage EI1). No additional treatment such as chemotherapy or radiation was performed. The follow-up endoscopic examination showed no recurrence until 2 years after EMR.

DISCUSSION:
We suggest that EMR may be an alternative treatment modality in the diagnosis and the treatment of gastric MALT lymphoma in cases of submucosal or polypoid morphology type, especially when H. pylori is negative. Further study in terms of feasibility, efficacy, and long-term safety of EMR as a curative treatment would be warranted.
2716 A Rare Case of Gastric Glomus Tumor
Authors: Ghimire Subash , Yang Tsujung , Shah Harshil , Sarker Ashit , Srivatana Ukorn 
Published: October 2019

INTRODUCTION:
Glomus tumors are benign mesenchymal neoplasms found predominantly in the extremities. Involvement of the GI tract is rare (<2%). Stomach is the most common site in GI tract.(1) Clinical presentation is usually nonspecific and diagnosis is made based on pathological study after surgical resection. We describe the case of a 35 year old male presenting with upper GI bleeding found to have glomus tumor during endoscopy.

CASE DESCRIPTION/METHODS:
A 35 years old male with past medical history of musculoskeletal low back pain, who was on meloxicam for past several weeks presented to the hospital with complaints of black tarry stool and lightheadedness. This was associated with weight loss. On examination, he was hemodynamically stable, was found to have pallor, there was no icterus. He had mild epigastric tenderness. Esophagogastroduodenoscopy (EGD) was done that showed moderate inflammation with edema, erythema, friability and granularity around the gastric body and the gastric antrum. It revealed a large submucosal non-circumferential mass in the gastric body with no bleeding and no stigmata of recent bleeding (Figure 1). Contrast enhanced CT scan was obtained that revealed a 3 cm enhancing soft tissue mass. Endoscopic ultrasound (EUS) showed an intramural lesion in the body of stomach that appeared to originate from within the muscularis propria (layer 4) (Figure 2). Fine-needle aspiration (FNA) was performed that was positive for neoplastic cells. He underwent laparoscopic resection of gastric mass (3 cm × 3 cm). Biopsies showed a basaloid proliferation of cytologically bland cells growing in nodules with focal areas of fibrosis, some tumor cells showed cytoplasmic clearing. Tumor cells were positive for smooth muscle actin, calponin, h-caldesmon, synaptophysin, desmin. Final diagnosis of glomus tumor of the stomach was made.

DISCUSSION:
Diagnosis of glomus tumor should be considered in a patient with gastric submucosal mass. The diagnosis is usually by pathology and immunohistochemistry (2). Most of the tumors are benign in nature, malignant changes are rare. They need long term follow up to look for recurrence.
2718 Gastric Pneumatosis in the Setting of Underlying Gastric Ulcer: An Uncommon Case Report Presentation
Authors: Figueredo Carlos , Boroda Konstantin , Hertan Hilary 
Published: October 2019

INTRODUCTION:
Gastric Pneumatosis (GP) is a rare entity that is usually caused by emesis with forceful retching and inoculation of intraluminal gas into the stomach wall. GP is divided into two subtypes: emphysematous gastritis (EG) and gastric emphysema (GE). EG is a result of both direct inoculation and hematogenous dissemination of gas forming bacteria in the setting of immunosuppression, alcoholism, diabetes mellitus, and NSAID use. The clinical outcome tends to be septic shock and death. GE is less fatal and is diagnosed radiographically as air within the stomach wall. Conservative management is the treatment of choice. GE is commonly associated with gastric outlet obstruction, pulmonary injury, and other traumatic events.

CASE DESCRIPTION/METHODS:
A 56-year-old male nursing home resident, with Wernicke’s encephalopathy was sent to the ED after multiple episodes of hematemesis. On presentation, vital signs of HR:116, RR: 26. Physical exam exhibited diffuse abdominal tenderness, distension, decreased bowel sounds with noted involuntary guarding, but no rebound or rigidity. Decline in mental status and respiratory failure, prompted intubation. Initial labs showed leukocytosis of 15.2, normal Hb of 16.2, and AKI with Creatinine: 2.93. CT scan revealed severely distended stomach with gastric pneumatosis; distended small bowel loops, with a decompressed distal ileum and no discrete transition zone. CT showed also showed a large stool burden in the colon (Figure 1). EGD was initially deferred given high risk of gastric perforation. The patient was treated with bowel rest, NG tube decompression, IV fluids, PPI drip, and empiric Ceftriaxone and Metronidazole. Consequently, CT scan with IV contrast repeated on day 4 showed resolution of GP with patent mesenteric vasculature (Figure 2). EGD done on same day with evidence of diffuse moderate inflammation characterized by congestion (edema) in the entire stomach, and one non-bleeding linear gastric ulcer in the upper body, with a clean ulcer base (Forrest Class III) (Figure 3). Biopsies showed signs of chronic inflammation and reactive changes, as well as focal intestinal metaplasia in stomach antrum.

DISCUSSION:
Self-resolution of gastric pneumatosis after medical management is consistent with the benign course of GE, with reported positive clinical outcomes and low risk of recurrence. In this case, the patient’s gastric ulcer and vomiting associated with constipation contributed to his gastric emphysema. Absence of hepatoportal venous gas was a good prognostic sign.