bluuebunny/crossref_metadata_2025_split huggingface dataset:
1246 Patients With Eosinophilic Gastritis and/or Eosinophilic Gastroenteritis Endure a Lengthy Path to Diagnosis and Experience Persistent Symptoms After Diagnosis
Authors: Chehade Mirna , Gehman Lauren , Rasmussen Henrik S. 
Published: October 2019

INTRODUCTION:
Eosinophilic gastritis (EG) and eosinophilic gastroenteritis (EGE) are chronic diseases characterized by elevated eosinophils in gastrointestinal (GI) tract biopsies. Patients with EG and/or EGE (EG/EGE) suffer from a decreased quality of life due to debilitating GI symptoms, a lengthy path to diagnosis, and lack of safe and effective treatment options. Here we utilize a large, highly representative claims database of ∼300 million US individuals to characterize the real-world diagnosis and management of adult patients with EG/EGE.

METHODS:
EG/EGE patients were identified by having ≥1 claim with a diagnosis code for EG and/or EGE (ICD-10-CM code K52.81) from Aug 2008 to Oct 2018 from Symphony Health's PatientSource® data. This analysis is focused on 3,458 unique adult patients (≥18 years) who had continuous claims data coverage for ≥3 years before and ≥1 year after EG/EGE diagnosis.

RESULTS:
Mean time from initial symptom presentation to EG/EGE diagnosis was 46.9 months; factors contributing to delayed diagnosis included delayed gastroenterologist referral, delayed endoscopy (Table 1), failure to diagnose on first endoscopy (39% of patients) and lack of routine biopsy/histopathology (65% of endoscopies). In the 12-month period following EG/EGE diagnosis, a majority of patients (56%) continued to experience GI symptoms, including abdominal pain, diarrhea and vomiting. Symptoms were documented by a healthcare provider at a mean frequency of 3.3 times per year. Overall, 32% of patients were treated with systemic corticosteroids (most commonly prednisone or prednisolone) and 6% received enteric-coated topical steroids (budesonide). Patients treated with systemic corticosteroids received a mean of 3.3 prescriptions per year, with the majority (59%) receiving more than one prescription per year. Persistence of GI symptoms was not related to treatment with systemic corticosteroids (Table 2).

CONCLUSION:
Patients with EG/EGE endure a lengthy path to diagnosis, and many continue to experience chronic, persistent GI symptoms after confirmed diagnosis despite frequent treatment with systemic corticosteroids. The lack of standard diagnostic processes and therapeutic options may prolong patient suffering due to uncontrolled symptoms. This study highlights the need for heightened disease awareness, standardized diagnostic criteria, and availability of safe and effective treatment options to improve the care of patients with EG/EGE.
1247 Development of a Patient Reported Outcome (PRO) Questionnaire to Assess the Symptoms of Eosinophilic Gastritis and Gastroenteritis (EG/EGE-SQ©)
Authors: Hirano Ikuo , Dellon Evan S. , Murray Joseph , Peterson Kathryn A. , Banderas Benjamin , Woolley J. Michael , Ollis Sarah , Foley Catherine , Love Emily , Shields Alan , Shaw Camilla , Rasmussen Henrik S. 
Published: October 2019

INTRODUCTION:
Patients with eosinophilic gastritis and/or gastroenteritis (EG/EGE) experience significantly reduced health-related quality of life related to the symptoms and signs of their disease. There is a need to develop a PRO questionnaire for clinical research in EG/EGE. The objectives of this study were to develop a symptom questionnaire (drafted using literature and clinician input to determine preliminary measurement concepts) and then (1) identify, describe, and substantiate signs, symptoms, and impacts of EG/EGE from the perspective of adults with the condition via concept elicitation methods; and (2) evaluate the properties of the questionnaire and make modifications via cognitive debriefing methods.

METHODS:
Interviews were conducted, transcribed, coded, and analyzed. Eligible adults with EG/EGE first participated in a concept elicitation segment where they described their experiences with EG/EGE, continuing until saturation was achieved, adding symptoms to the draft symptom questionnaire as needed. This was followed by a cognitive debrief to assess the appropriateness of the draft symptom questionnaire, where patients assessed readability, comprehensibility, relevance, and comprehensiveness. The questionnaire was modified based on patient feedback, then re-evaluated to confirm its appropriateness.

RESULTS:
In total, 16 interviews were conducted and 24 signs and symptoms were reported during concept elicitation. The most frequently reported (Figure 1) were abdominal pain, nausea, diarrhea, vomiting, and abdominal cramping; while abdominal pain, nausea, and diarrhea were the most bothersome to patients. Saturation was achieved after 12 interviews. In the cognitive debriefing, revisions included the addition of a vomiting frequency item and revision of the early satiety item for clarity. Response options were modified to instruct the participants to assess each symptom “at its worst”. For the final version of the EG/EGE-SQ©, participants were able to read, comprehend, and provide appropriate responses, and reported that the resulting questionnaire was comprehensive for their condition.

CONCLUSION:
The results of this research support the content validity, including comprehensiveness and interpretability, of the EG/EGE-SQ© which offers the potential for use in clinical research to assess symptoms in patients with EG/EGE. Future research is needed to assess its psychometric properties including reliability and validity, responsiveness, and potential for use in pediatric populations.
1255 Chronic Peptic Ulcer Disease Resulting in Cholecystoduodenal Fistula
Authors: Dharmadhikari Neal D. , Roussel Breton , Piascik Daniel , Adrain Alyn L. 
Published: October 2019

INTRODUCTION:
Cholecystoduodenal fistulas are rare communications between the gallbladder and duodenum. Though they are most often formed as a complication of cholelithiasis, duodenal ulcers are a less common etiology of bilioenteric fistulas. This case report shows this rare finding diagnosed with direct visualization by endoscopy.

CASE DESCRIPTION/METHODS:
A 75-year-old man with a medical history of atrial fibrillation, remote alcohol abuse, and diabetes presented with anemia. On presentation, his blood pressure was 92/45 and other vital signs were stable. A rectal examination revealed hematochezia and melena. His workup revealed a hemoglobin of 5.6 g/dl, BUN 64 mg/dl, and creatinine 3.76 mg/dl. He was appropriately resuscitated with blood transfusions. An endoscopy showed esophagitis and a non-bleeding cratered duodenal ulcer with pigmented material in the first part of the duodenum. This ulcer appeared to have several fistulous openings into another structure with bridges of tissue in between. A CT and an MRCP confirmed a duodenal ulcer with cholecystoduodenal fistula. He was treated conservatively with proton pump inhibitors (PPI) and had planned outpatient follow-up with surgery and gastroenterology.

DISCUSSION:
Endoscopy is the diagnostic gold standard for peptic ulcer disease (PUD) and is indicated in patients presenting with anemia and clinical evidence of gastrointestinal bleed. Cholecystoduodenal fistulas are an extremely rare complication of PUD. Unlike this case, most bilioenteric fistulas form as a consequence of gallbladder pathology, such as complications of cholecystitis or cholelithiasis, rather than PUD. Furthermore, this case is unusual in that bilioenteric fistulas are most often diagnosed by imaging rather than endoscopic visualization. This patient likely had chronic PUD that caused perforation and the eventual formation of the fistula. Uncomplicated cholecystoduodenal fistulas are often asymptomatic which can make them difficult to diagnose. Conservative management with PPIs is the preferred treatment for PUD-related bilioenteric fistulas and this patient was ultimately discharged on PPI therapy with outpatient follow up. This case highlights a unique endoscopic finding of a cholecystoduodenal fistula in a patient who presented without any complaints and found to have anemia and PUD. In addition, it supports PPIs as a conservative treatment for bilioenteric fistulas secondary to PUD.
1257 Pancreatic Pseudocyst-Portal Vein Fistula: A Rare Life-Threatening Complication of Pancreatitis
Authors: Ali Sara I. , Patel Jigar , Larson Scott 
Published: October 2019

INTRODUCTION:
Pancreatitis is an acute inflammatory process that can results in activation of systemic inflammatory cascade. The pancreas is encased by vasculature which can be directly and indirectly affected. The aim of this case is to provide insight into a rare complication of pancreatitis.

CASE DESCRIPTION/METHODS:
35-year-old male with history of alcohol abuse presented to the emergency room with three days of severe epigastric pain. Denied symptoms of overt gastrointestinal bleeding. On admission, vital signs were temperature of 99.2°F, heart rate 115 beats/min, blood pressure of 120/72 mmHg. Initial laboratory evaluation demonstrated hemoglobin of 6.6 g/dL, lipase of 1,910 U/L, alanine transaminase 152 U/L and aspartate transaminase 167 U/L, alkaline phosphatase 681 U/L and direct hyperbilirubinemia 9.2 mg/dL. A computed tomography (CT) of the abdomen showed a large well-circumscribed cystic lesion with hypodense fluid in the peripancreatic C-loop with linear hyperdensity in the center, suggestive of a clot, and with direct communication to a dilated non-opacifying portal vein along with cavernous transformation. These findings were suggestive of a hemorrhagic pancreatic pseudocyst with fistulization of the main portal vein and portal vein thrombosis. The cystic lesion was compressing the common bile duct, measuring 1.1 cm, leading to hyperbilirubinemia. Portovenography did not show active opacification of the cystic lesion and, therefore, the cyst was percutaneously aspirated and 25 cc of light brown fluid removed. Fluid analysis revealed an amylase of 10,196 U/L. Given persistent hyperbilirubinemia, patient was taken for ERCP with biliary stent placement resulting in resolution of jaundice. His clinical course was further complicated by development of ascites and secondary peritonitis which was managed with antibiotics.

DISCUSSION:
Pancreatic pseudocyst with portal vein fistulization is an extremely rare complication of pancreatitis. The proposed mechanism of fistulization is believed to be due to high pancreatic enzyme contents of the pseudocyst eroding into adjacent structure. The release of digestive enzymes into a patent portal vein may directly cause intravascular thrombosis. Alternatively, it is hypothesized that fistulization usually occurs after portal vein thrombosis. No clear consensus exists on management with high mortality and morbidity secondary to hemorrhage, septic shock, and lipolysis. Our patient improved with conservative management of the pseudocyst with a decrease in cyst size.
1259 From Pancreatitis to Takotsubo: A Rare Complication of Acute Pancreatitis
Authors: Abe Temidayo , Ajose Taiwo , Chang Eric Y. , Atem Ngum Kikah , Abe Tolulope , Bilal Muhammad , Simien Melvin 
Published: October 2019

INTRODUCTION:
Takotsubo cardiomyopathy or stress cardiomyopathy (TCM) is a transient reversible form of cardiomyopathy. It is characterized by reduced ejection fraction and signs of myocardial ischemia and often precipitated by acute emotional or physical stressors. We present a rare case of TCM in a postmenopausal woman triggered by acute alcoholic pancreatitis.

CASE DESCRIPTION/METHODS:
A 57-year-old female with a history of alcohol abuse and diabetes mellitus presented to the emergency department with a two-day history of severe diffuse abdominal pain with radiation to the back. Associated symptoms included nausea and vomiting. Vital signs were within normal limits. Physical examination was significant for a mildly tender abdomen. Laboratory findings revealed leukocytosis of 14.6 and lipase of 882. All other chemistry and complete blood count labs were within normal limits. CT abdomen without contrast revealed peripancreatic fat stranding suggestive of acute pancreatitis. The patient was admitted for IV fluid resuscitation and pain management. On day 2 of admission, the patient became dyspneic and desaturated to 82% on room air. Stat chest x-ray showed flash pulmonary edema. Bedside ultrasound revealed a dilated IVC. Troponin (0.97) and BNP (1627) levels were elevated, concerning for acute heart failure exacerbation. EKG revealed no acute ischemic changes. The patient was aggressively diuresised with significant improvement in respiratory status. Transthoracic echocardiography (TTE) revealed a left ventricular ejection fraction (LVEF) of 40% with basal segment hyperkinesis but apical akinesis consistent with stress-induced cardiomyopathy. Follow up coronary angiography revealed normal coronary vessels. The patient was started on guideline-based heart failure therapy and was discharged to home in stable condition. A repeat TTE obtained 4 months later revealed unchanged LVEF and persistent apical akinesis in the setting of persistent alcohol use. Guideline directed therapy was continued and the patient was counseled on alcohol cessation.

DISCUSSION:
Acute pancreatitis induced TCM is rare. Our case further confirms the heterogenicity of TCM, including non-classical stressors such as alcohol abuse which may delay myocardial recovery.
1279 Not Your Standard Food Impaction: An Unusual Presentation of Ampullary Obstruction
Authors: Malik Neena , Yang Julie 
Published: October 2019

INTRODUCTION:
The following case highlights a rare cause of biliary duct obstruction from food impaction of a large duodenal diverticulum containing the ampulla.

CASE DESCRIPTION/METHODS:
A 74-year-old woman presented with abdominal pain. The patient reported acute onset of epigastric abdominal pain on the morning of presentation. Laboratory values were notable for an alkaline phosphatase of 807 U/L, an aspartate aminotransferase of 948 U/L, an alanine aminotransferase of 1245 U/L, and a total bilirubin of 3.7 mg/dL. CT abdomen and pelvis demonstrated marked intrahepatic and extrahepatic biliary ductal dilation with a common bile duct of 19 mm, as well as a 5 cm periduodenal cystic lesion containing a soft tissue density suggestive of a duodenal diverticulum, although the cystic lesion did not opacify with oral contrast despite the duodenal lumen containing contrast. An endoscopic retrograde cholangiopancreatography (ERCP) was performed. Once the duodenoscope was advanced into the duodenum, the ampulla was not identified, however a large diverticulum with impacted, solid food was seen. Multiple attempts were made to break the bezoar into smaller pieces with only partial success. The ampulla was thought to be entirely located within the diverticulum and was unable to be identified due to the obstructing bezoar, therefore, the ERCP was aborted. The patient underwent a repeat ERCP four days later. The food debris had partially cleared and the major papilla was seen on the rim of a large duodenal diverticulum. No biliary strictures or stones were seen and a plastic stent was successfully placed into the common bile duct.

DISCUSSION:
This case illustrates an uncommon presentation of a common medical problem. Approximately 75% of duodenal diverticula are located in the second portion of the duodenum and can be described as periampullary, if originating within 2 to 3 cm from the ampulla, or ampullary if containing the papilla. The true prevalence of periampullary or ampullary diverticula is not known, however, it is suggested that the prevalence ranges from 0.16 to 22%. Most duodenal diverticula are found incidentally on imaging or endoscopic examinations and are oftentimes asymptomatic, however complications can occur. Common complications include diverticulitis, hemorrhage, perforation, as well as obstruction, as seen above. This case demonstrates the possible, albeit rare, complications of duodenal diverticula and the need for awareness amongst gastroenterologists to avoid misdiagnosis and prompt treatment.
1298 Pancreatic Adenocarcinoma Presenting as Acute Large Bowel Obstruction
Authors: Abadier Michael J. , Abadier Andrew E. , Abadier Wahid J. 
Published: October 2019

INTRODUCTION:
Acute large bowel obstruction is a rare presentation of pancreatic carcinoma with only 7 cases described in the literature. When located in the head of the pancreas, pancreatic adenocarcinoma commonly presents with abdominal pain, weight loss and jaundice. Pancreatic masses in the body and tail tend to have an insidious onset and may only present with vague abdominal pain. In the case described, a patient presenting with 2 weeks of constipation was found to have a large bowel obstruction in the setting of locally invasive pancreatic adenocarcinoma.

CASE DESCRIPTION/METHODS:
A 64-year-old woman with past medical history of chronic constipation presented to the emergency department with a chief complaint of constipation for 14 days. During these 14 days the patient had developed increasing abdominal distension as well as nausea, vomiting and abdominal pain. Vital signs were unremarkable except for a heart rate of 132. Physical examination was significant for an uncomfortable appearing woman with a diffusely tender and distended abdomen. Laboratory studies showed a leukocytosis of 16.2/uL. CT scan of the abdomen revealed findings suggestive of a primary colon carcinoma of the splenic flexure with upstream colonic obstruction and likely invasion of the pancreatic tail and spleen. General surgery and Gastroenterology were consulted who recommended colonoscopy for evaluation of the presumed mass at the splenic flexure, however, on the day following admission the patient's clinical status deteriorated. The patient was taken for emergent exploratory laparotomy at which time a markedly distended cecum and right colon were noted. The mass was found to involve the splenic flexure posteriorly as well as the tail of the pancreas and spleen. The patient underwent En Bloc resection of the splenic flexure, spleen and pancreatic tail. Pathology revealed moderately differentiated pancreatic ductal adenocarcinoma and the patient was started on FOLFIRINOX chemotherapy.

DISCUSSION:
There have been 3 cases resulting in large bowel obstruction due to local invasion and 4 cases causing obstruction in the setting of metastatic disease. In this case report, we describe an acute obstruction caused by local invasion of pancreatic tail adenocarcinoma. Usual suspects of large bowel obstruction include colorectal carcinoma, volvulus, adhesions, strictures from diverticulitis and hernias. We believe that although rare, once should consider pancreatic carcinoma as part of the differential for large bowel obstruction.
1313 B Cell Lymphoma Masquerading as a Pancreatic Mass With Pancreatitis
Authors: Cox Michael , Darwin Peter , Sood Asheesh , Ayre Rebecca 
Published: October 2019

INTRODUCTION:
We present a case of a 42 year old female with Stage IV B cell lymphoma initially presenting with acute pancreatitis.

CASE DESCRIPTION/METHODS:
A 42 year old female presented to the ER with acute pancreatitis. Initial CT Imaging demonstrated a mass in the pancreatic head concerning for pancreatic adenocarcinoma and diffuse lymphadenopathy concerning for metastatic disease. EUS demonstrated peripancreatic lymphadenopathy with invasion into the pancreatic head. After initial treatment of the pancreatitis, diagnostic workup found non-Hodgkin's lymphoma obstructing the pancreatic duct. Despite her extensive tumor burden the patient had no symptoms prior to her presentation with acute pancreatitis. Her Ca19-9 was elevated, probably secondary to her recent acute pancreatitis. Her tumor responded to dose adjusted R-EPOCH (Rituximab, Etoposide, Prednisone, Oncovin, Cyclophosphamide, and Hydroxydaunorubicin).

DISCUSSION:
Non-Hodgkin's Lymphoma secondarily involving the pancreas initially presenting as acute pancreatitis is extremely rare. Only about 0.5% of all pancreatic tumors are lymphomas, and although 50% of patients with non-Hodgkin's lymphoma present with extranodal disease, pancreatic involvement represents only about 0.2% to 2% of cases. Primary pancreatic lymphomas are extremely rare but more often present with acute pancreatitis than secondary pancreatic non-Hodgkin's lymphomas. To our knowledge, there are less than 15 reported cases of non-hodgkin's lymphoma with secondary involvement of the pancreas presenting as acute pancreatitis. This case demonstrates the need to keep the differential diagnosis broad in the evaluation of pancreatic masses causing pancreatitis even in what seems to be a straightforward case.
1319 The Elephant in the Room: A Rare Cause of Gastric Outlet Obstruction
Authors: Murthi Mukunthan , Murali Rangan 
Published: October 2019

INTRODUCTION:
Gastric outlet obstruction (GOO) is characterized by the inability of the gastric contents to pass beyond the proximal part of duodenum. We describe an unusual case of GOO caused by compression of the duodenum by gall bladder hydrops (also called gallbladder mucocele). This is only the fourth such case reported in literature.

CASE DESCRIPTION/METHODS:
The patient is a 59-year-old healthy Caucasian male who presented to the ER with complaints of persistent nausea and non-bilious vomiting for 2 weeks. He also had mild but persistent abdominal pain for the same duration and retrosternal burning pain for over 1 week. The patient had no previous medical or surgical history except for chronic gastroesophageal reflux disease treated with Prilosec. On physical examination, the patient had right upper quadrant tenderness with positive Murphy's sign. His routine lab workup revealed a high WBC count. Other lab values were normal. He underwent ultrasonogram which showed a distended gallbladder measuring 10 cm. CT scan revealed the enlarged gallbladder appearing to compress the duodenum. His upper gastrointestinal endoscopy showed LA grade C erosive esophagitis and a normal looking second portion of duodenum. He subsequently underwent laparoscopic cholecystectomy. The surgery specimen showed distended gallbladder measuring 12 cm in length with thinning of the walls and a 1 cm stone in the body. He had complete resolution of his symptoms after surgery and remained asymptomatic during his follow-up two weeks later.

DISCUSSION:
Gall bladder mucocele is most commonly due to prolonged obstruction of the cystic duct by gallstones. Acalculous cholecystitis can also lead to mucocele formation. Long-standing gallbladder outlet obstruction can lead to the collection of bile. Resorption of bile salts by gall bladder mucosa occurs over time, resulting in accumulation of clear watery and mucoid residue. Ultrasonography is extremely sensitive for diagnosis. The standard treatment is laparoscopic cholecystectomy, with open cholecystectomy an alternate in large-sized gallbladders. In poor surgical candidates, percutaneous drainage of the gallbladder may be considered. Among the three previously reported cases where the distended gallbladder caused GOO, one was treated with percutaneous biliary drainage as the patient was unfit for surgery and one other case was treated with laparoscopic cholecystectomy. The third case was treated initially with medical therapy leading to resolution of symptoms followed by cholecystectomy.