bluuebunny/crossref_metadata_2025_split huggingface dataset:
1465 A Rare Cause of Infective Ileocolitis: Brucella Abortus
Authors: Abu-Rajab Tamimi Tarek I. , Allan Wasim , Almustafa Sahar 
Published: October 2019

INTRODUCTION:
Brucellosis is the world's most widespread zoonotic disease. It is a systemic infection that can involve many organs. The gastrointestinal manifestations of human brucellosis are relatively uncommon and nonspecific such as diarrhea and abdominal pain. Reports of documented specific gastrointestinal lesions caused by Brucella species are rare.

CASE DESCRIPTION/METHODS:
A 31-year-old male presented with complaints of intermittent fever, chills, and night sweats of 11-month duration. His symptoms were associated with lower abdominal pain and intermittent bleeding per rectum. On physical examination, the patient had mild tenderness to palpation at the lower abdomen. Laboratory tests revealed normal liver enzymes and normal complete blood count. Stool testing for ova or parasites, Clostridium difficile toxins, and stool cultures for pathogenic microorganisms were all negative. Serology testing for Brucella agglutinin titer was positive for Brucella abortus at 1:160; blood culture for Brucella were negative. A pan CT scan revealed hepatomegaly and few sclerotic bony lesions involving thoracic vertebrae. A colonoscopy was performed which showed multiple aphthous ulcers at the terminal ileum (TI) with normal intervening mucosa. There were multiple aphthous ulcers in the cecum, ascending colon and transverse colon. The descending colon, sigmoid colon and rectum appeared normal. Microscopic examination of biopsies from the TI showed focal active ileitis with focal ulceration including infiltration of the lamina propria by mixed acute and chronic inflammatory cells including many eosinophils. Biopsies from the right colon showed focal active colitis with focal ulceration including focal cryptitis and preserved crypt architecture. The patient was diagnosed with brucellosis with ileocolonic involvement, and treated with trimethoprim/sulfamethoxazole and rifampicin given orally for 6 weeks. Four weeks after starting treatment, the patient reported resolution of his fever, abdominal pain and bleeding per rectum. The patient is scheduled to undergo a repeat colonoscopy to evaluate for resolution of ileocolitis endoscopically.

DISCUSSION:
We report an extremely rare cause of infective ileocolitis due to brucellosis. This appears to be only the fifth well-documented case of brucella colitis; and the first case describing ileocolitis due to brucellosis. Although rare, ileocolitis should be considered in the work-up of patients with brucellosis who have abdominal pain, diarrhea or bleeding per rectum.
1479 Luminal Colonic Metastases From Primary Urothelial Carcinoma
Authors: Gladys-Oryhon Jordan , Sial Moaz , Umar Shifa , Goswami Raktima 
Published: October 2019

INTRODUCTION:
Urothelial carcinoma often manifests with painless gross or microscopic hematuria. Significant risk factors are mainly environmental including tobacco use, occupational exposures, and recurrent urinary tract infections. Metastatic disease often progresses via direct soft tissue invasion or lymphatic spread, with a paucity of reported cases of luminal colonic metastases. Here we describe a patient with concerning history for malignancy with multiple risk-factors, found to have luminal colonic metastases from primary urothelial carcinoma.

CASE DESCRIPTION/METHODS:
A 51 y/o African-American male with medical history significant for HFrEF 15%, HTN, tobacco and alcohol abuse presented for outpatient colonoscopy, referred by his primary care physician for 6-month history of diarrhea and 30 lb weight loss. No prior colonoscopy performed. Family history was significant only for lung cancer in his paternal uncle. Colonoscopy was initially attempted with adult colonoscope, but was exchanged for an adult endoscope following inability to traverse >20 cm, secondary to thickened rectal folds also appreciated on rectal exam (Figure 1). Findings were significant for one 4 mm sessile polyp of the transverse colon and segmental moderately congested, erythematous mucosa throughout the entire colon (Figures 1 and 2). Pathology revealed new urothelial cancer with diffuse luminal colonic metastases. He completed staging work-up, found to have diffuse blastic, osseous bony metastases and was initiated on chemotherapy with further progression of his disease.

DISCUSSION:
Urothelial cancer often spreads via direct soft tissue invasion or lymphatic spread. Interestingly, our patient presented with advanced disease with atypical luminal colonic metastases, in the absence of direct invasion or soft tissue mass. The pathogenesis of metastasis remains unclear, but is likely related to lymphatic spread. In a thorough review of the literature, no other case of luminal colonic metastases from urothelial primary has been described. Any new change in bowel habit, warrants further evaluation with colonoscopy to rule out carcinoma of colonic or metastatic origin.
1510 Positive Fecal Immunochemical Testing in Detection of Mantle Cell Lymphoma With Gastrointestinal Involvement
Authors: Khiew Yii Chun , Dhawan Ishita , Modi Mitul B. , Bhattacharyya Siddharth , Nunes Frederick A. 
Published: October 2019

INTRODUCTION:
Current colorectal cancer (CRC) screening guidelines are directed at early detection of adenocarcinoma via stool testing or direct endoscopic or radiologic visualization. Compared to a colonoscopy, fecal immunochemical Testing (FIT), a non-invasive test that detects hemoglobin in stool by immunoassay, has similar CRC detection rates. We report a case of mantle cell lymphoma (MCL) involving the gastrointestinal tract (GIT) in a patient diagnosed through routine CRC screening.

CASE DESCRIPTION/METHODS:
A 70 year-old male with a history of diverticulitis was referred for urgent colonoscopy following a positive FIT. He reported a seven-month history of right upper quadrant abdominal pain, pruritus, and a 19 pound unintentional weight loss. He denied fever, night sweats, melena, hematochezia, and family history of malignancy. Physical exam did not reveal splenomegaly and lymphadenopathy. Notable labs included normocytic anemia and a normal LDH. Colonoscopy showed congested, nodular and thickened mucosal folds in the terminal ileum, ascending colon, and cecum. Random biopsies revealed diffuse atypical lymphoid infiltrates in a multiple lymphomatous polyposis pattern with cyclin D1, CD5 and CD20 immunohistochemical positivity consistent with MCL. PET-CT detected bone marrow and diffuse lymph node involvement. He tolerated six cycles of lymphoma-directed chemotherapy with complete metabolic response on imaging.

DISCUSSION:
Extranodal disease at primary presentation accounts for 25% of patients with MCL. Microscopic gastrointestinal involvement in MCL at presentation is widely underestimated and has been documented in up to 80% of cases at the time of diagnosis, suggesting that MCL has a propensity to home to the GIT. Clinically, most patients with MCL with GIT involvement are asymptomatic, but can also present with abdominal pain, altered bowel habits, and gastrointestinal bleeding. To date, annual FIT testing has been used solely as a screening test for CRC. The role of non-invasive stool testing such as FIT, and its detection of other primary malignancies involving the gastrointestinal tract besides CRC, has not been studied and requires further investigation.
1548 Double Intussusception Deception
Authors: Singh Kanwardeep , Gabriel Joseph G. , Bains Nimrat , Young Mark F. 
Published: October 2019

INTRODUCTION:
We report a case of colo-colic intussusception caused by sigmoid adenocarcinoma with concomitant incidental entero-enteric intussusception in a middle aged female. Intussusception in adults is a known rarity, but it is important to note that more than 60% of large bowel intussusceptions are caused by a neoplasm.

CASE DESCRIPTION/METHODS:
A 50 year old female presented with intermittent abdominal pain for 2 months, worsening with oral intake and associated with abdominal distension and obstipation. Computed tomography of the abdomen & pelvis showed two areas of intussuscepted bowel in the left upper quadrant. One was thought to be an incidental loop of the jejunum. The other representing the splenic flexure and was causing obstruction within the small and large bowel proximal to this lesion. With the diagnosis of intussusception, exploratory laparotomy was performed. A mass was palpated at the splenic flexure, and this was found to originate at the sigmoid colon, leading to left hemicolectomy and transverse colostomy. The histological diagnosis of the mass was well-differentiated adenocarcinoma stage IIIb. The patient later underwent adjuvant chemotherapy with Capecitabine plus Oxaliplatin.

DISCUSSION:
Large bowel intussusception can be due to benign, malignant, or idiopathic etiologies. As the incidence of intussusception in adults is low, surgical exploration is imperative.
1551 The Vasculitic Mimic: Polyarteritis Nodosa Initially Presenting With Colonic Involvement
Authors: Lorio Eric , Vizuete John A. 
Published: October 2019

INTRODUCTION:
Polyarteritis nodosa (PAN) is a necrotizing vasculitis of the medium and small vessels which presents with gastrointestinal symptoms in up to 24.1% of patients, most commonly in the small bowel. Here we present a case of isolated colonic involvement in a patient without prior systemic immune illness or HBV.

CASE DESCRIPTION/METHODS:
A 62 year old man with no significant past medical history was admitted with 10 days of worsening abdominal pain and constipation. At the time of admit, labs were notable for CRP 178, leukocytosis, and creatinine 1.13. He began to pass multiple bloody, mucoid bowel movements and hemoglobin fell to as low as 6.9 g/dL, requiring transfusion. CT noted segmental colitis in the distal and sigmoid colon with proctitis. Stool pathogen panel was negative and ensuing colonoscopy showed circumferential edematous, erythematous, slightly granular mucosa from splenic flexure to rectum with areas of friability. Rectosigmoid biopsy demonstrated focal architectural distortion with a mild increase in lymphoplasmocytic inflammation and basal plasmocytosis. The patient was administered IV methylprednisolone with a prednisone taper for the presumed diagnosis of indeterminate inflammatory bowel disease (IBD). He returned 3 days later with increasing pain, tenesmus, and new findings of fever and multiple mucoid, bloody bowel movements per day. Increased stool burden proximal to the same area of colitis was seen on MRE, and colorectal surgery was consulted. Full thickness rectal biopsy revealed mucosal erosion to the muscularis layer and reactive changes thought to be due to rectal prolapse. Despite conservative therapy, he presented again 2 weeks later endorsing continued periumbilical abdominal pain, now with hgb 8.2 and WBC 18. Repeat CT showed evidence of acute appendicitis and persistent colitis, prompting emergent appendectomy with descending colostomy. Surgical pathology revealed diffuse ischemic colitis due to polyarteritis nodosa with areas of ischemic necrosis and focal bowel wall rupture in the sigmoid colon. Acute periappendicitis was also found in the appendiceal tissue, but PAN was notably absent.

DISCUSSION:
Delayed diagnosis of vasculitic colitis can lead to life-threatening complications. Here we present a case showing how PAN can mimic both IBD and ischemic colitis. Response to high dose steroids, the common initial treatment for both IBD flares and PAN, further confounded the diagnosis. This case highlights the need for consideration of PAN in unclear cases of colitis.
1580 Endometrioid Adenocarcinoma Presenting With Hematochezia and an Extraluminal Rectal Mass
Authors: Fiore Benjamin D. , Mellor Thomas E. , Fick Daryl B. , Fawley Ryan K. 
Published: October 2019

INTRODUCTION:
We present a case of primary endometrioid adenocarcinoma with invasion of the rectosigmoid colon, highlighting the importance of colonoscopy, biopsy, cross-sectional imaging, and a multidisciplinary approach to the management of extraluminal lesions.

CASE DESCRIPTION/METHODS:
A 47-year-old female with a history of lymphangioleiomyomatosis (LAM) was admitted for abdominal pain, hematochezia, tenesmus, and proctalgia following 7 months of abnormal bowel habits and 20 pounds of unintentional weight loss. Review of symptoms was negative for abnormal uterine bleeding. Examination revealed tenderness on palpation of the lower abdominal quadrants, and grossly bloody stool with digital rectal exam. Computed tomography (CT) of the abdomen and pelvis with contrast demonstrated circumferential rectal wall thickening with enhancement. Colonoscopy revealed an ulcerated extraluminal rectosigmoid mass, and biopsies were obtained. Magnetic resonance imaging (MRI) demonstrated a large heterogeneous mass involving the uterus and rectum with no discernable fascial plane. Initial pathology reported invasive adenocarcinoma without a primary origin delineated. A multidisciplinary conference prompted additional immunostaining of the sample, confirming endometrioid adenocarcinoma. The patient was diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IVa endometrioid adenocarcinoma and underwent surgical management with adjuvant chemoradiation. Genetic testing demonstrated heterozygosity with a pathologic variant in the MutL homolog 1 (MLH1) gene consistent with Lynch Syndrome. Surveillance positron emission tomography scanning 6 months later revealed no evidence of disease recurrence.

DISCUSSION:
Extraluminal lesions are notoriously difficult to diagnose with endoscopy alone. In this case, cross-sectional imaging with CT and MRI was unable to differentiate the origin of the lesion, and pathologic examination without the clinical context of the extraluminal nature of the tissue obtained on colonoscopy delayed the definitive diagnosis. This case highlights the importance of a multidisciplinary approach to cases of suspected extracolonic malignancies with colonic invasion in order to expedite definitive diagnosis and treatment. There are no reports of concomitant Lynch Syndrome and LAM in the literature and the clinical significance is unclear. Further study may be helpful in elucidating potential links between these two uncommon conditions.
1593 Skeletal Muscle (SM) Metastasis: A Rare Initial Presentation of Metastatic Colon Cancer
Authors: Tai Cheng-Hung , Park Connie , Bhardwaj Richa , Jean Ryan Des , Harshan Manju , Ilyas Nazish , Swaminath Arun 
Published: October 2019

INTRODUCTION:
Colon cancer is the third most common type of cancer globally and approximately 20% patients diagnosed with colon cancer will already have metastatic disease at the time of diagnosis. The liver is the most common site of metastasis, followed by lung, nervous system and bones. Only 15% of patients with stage IV colon cancer will have metastases to locations outside these sites. Here we report a rare presentation of metastatic colon cancer with skeletal muscle (SM) metastases.

CASE DESCRIPTION/METHODS:
81-year-old male with peripheral artery disease and diabetes mellitus presented with severe right shoulder pain and shortness of breath. Lab work revealed iron deficiency anemia with a hemoglobin of 5.8 g/dl. CT of the chest revealed an 8.2 cm mass in the right lower lung lobe. Positron-emission tomography-CT (PET-CT) revealed increased activity in the right lung, right supraspinatus, gluteus maximus, and right adductor magnus muscles (Figure 1). He then underwent biopsy of the right supraspinatus muscle, which revealed a poorly differentiated metastatic adenocarcinoma with immunohistochemistry (IHC) positive for CK7, and negative for CK 20, CDX-2, TTF-1, NKX3.1 and Napsin A. Colonoscopy revealed a 5 cm friable ulcerated mass in the cecum (Figure 2) with biopsy showing poorly differentiated adenocarcinoma with morphology similar to the muscle mass. Patient subsequently received palliative chemotherapy and underwent a palliative right hemicolectomy. IHC staining of the resected mass was similar to that of the biopsied right supraspinatus muscle (Figure 3). Patient ultimately transitioned to hospice.

DISCUSSION:
Muscle metastasis from solid tumors is very rare, accounting for less than 1% of overall metastases. This is in part due to the fact that muscles produce antitumor factors and its sarcolemma or cell membrane acts as a physical barrier against tumor cells. Muscle metastases are more common in primary lung, stomach, or genitourinary tumors and portend poor outcomes due to advanced disease stage. This case appears to be one of the few reported cases of metastatic colon cancer presenting with SM metastases and emphasizes the importance of considering metastatic colon cancer in the differential of SM lesions. It also highlights the importance of PET-CT and IHC in establishing diagnosis and hence guiding appropriate therapy.
1597 An Unexpected Cause of Colonic Ulcers in a Young Chinese Male Resulting in a Total Colectomy—Intestinal Behcet's Disease
Authors: Kuang Jonathan , Lin Huiyu 
Published: October 2019

INTRODUCTION:
Behçet's disease (BD) is an uncommon immune-mediated inflammatory disorder. Gastrointestinal (GI) BD may affect any part of the GI tract but most commonly manifests in the ileocecal region. The diagnosis of GIBD is challenging and complications can be severe.

CASE DESCRIPTION/METHODS:
A 32-year-old Chinese male with HLA-B27 positive spondyloarthropathy was undergoing treatment with golimumab and methotrexate. He had a history of retinal vasculitis, erythema nodosum and was taking isoniazid for latent tuberculosis (TB). He was admitted for 1 day of right iliac fossa pain with occasional tongue ulcers but no fever or bloody stools. Abdominal computed tomography scan (CTAP) showed inflammatory changes in the ileocecal region. Colonoscopy with biopsies revealed an inflamed terminal ileum but no other colonic abnormalities; TB and cytomegalovirus biopsies were negative. He was discharged with antibiotics. He re-presented 4 weeks later with recurrent abdominal pain and 7-kg weight loss. CTAP showed worsening ileocecal thickening. The patient declined a colonoscopy only to be readmitted 5 days later for similar symptoms. Repeat colonoscopy showed large discrete round punched-out ulcers with overlying slough in the cecum, transverse, and left colon, with intervening normal mucosa. Biopsies showed extensive ulceration, acute inflammatory infiltrate with 1 non-caseating granuloma and intraluminal thrombi in submucosal arterioles/venules, raising the suspicion of gut vasculitis. Intravenous hydrocortisone and heparin were started. He developed worsening abdominal pain and a repeat CTAP showed pneumoperitoneum. Emergency surgery revealed multiple colonic perforations with feculent peritonitis necessitating total colectomy with end ileostomy. Histology revealed acute mucosal ulceration, areas of transmural necrosis, inflammation at perforation sites and luminal thrombi in the blood vessels around inflamed areas. A diagnosis of GIBD was made based on his constellation of symptoms. Treatment included prednisolone, cyclophosphamide, and he was later transitioned to azathioprine.

DISCUSSION:
In this immunosuppressed host with arthropathy presenting with abdominal pain, the key differentials of TB, Crohn's disease and GIBD are challenging to distinguish as there is significant clinical overlap. Endoscopic features may be helpful but are not pathognomonic of GIBD. This case highlights the diagnostic and management difficulties in GIBD and need for heightened awareness as outcomes in GIBD are potentially catastrophic.
1600 Follicular Lymphoma Presenting as a Colon Polyp
Authors: Gajjar Bhavesh A. , Aasen Tyler , Goenka Puneet 
Published: October 2019

INTRODUCTION:
Follicular lymphoma (FL) is the second most common type of Non-Hodgkin's lymphoma (NHL).  There are two types of follicular lymphoma, nodal and extranodal. The gastrointestinal (GI) tract is the most common site of extranodal NHL and accounting for 30%-40% of all extranodal NHL. GI-FL comprises of only 1 to 4% of GI-NHL with less than 400 reported cases.  GI-FL primarily involves the duodenum, distal ileum, and stomach. A colon is an uncommon place for GI-FL with less than 20 cases reported in the literature. We present a case of GI-FL identified on colonoscopy as a pedunculated polyp.

CASE DESCRIPTION/METHODS:
A 72-year-old female was seen for a positive stool occult test. She denied blood in the stool, abdominal pain, any weight loss, fatigue, night sweats, fevers, and diarrhea. She had occasional constipation which resolved with a stool softener. Physical examination was unremarkable without any palpable lymph nodes or organomegaly. During the colonoscopy, a 1.5 cm benign appearing pedunculated polyp in the mid-transverse colon was found (Figure 1).  Primary histology of the polyp revealed lymphoid aggregates compatible with a lymphoid polyp. Diagnosis of GI-FL was later confirmed by immunohistopathological staining. Positron emission tomography (PET) scan showed aortocaval lymphadenopathy. The diagnosis of follicular lymphoma grade 2 stage IV is made. The oncologist has scheduled a bone marrow biopsy with consideration to immunochemotherapy.

DISCUSSION:
Colonic GI-FL is quite a rare disease with increasing incidence. Most patients are asymptomatic and diagnosed during endoscopy. The most common endoscopic appearance is 1 to 2 mm whitish polypoid nodules scattered or confluent together forming large nodules. Other appearances of GI-FL may include mass lesions with or without ulcer, lymphomatous polyposis, or polyps. These endoscopic features are also seen in lymphoid hyperplasia, MALT, mantle cell lymphoma. Immunohistopathological testing is the only way to confirm the diagnosis. GI-FL stains positive for CD10, CD19, CD20, and CD22, and bcl-2. It stains negative for cyclin D1 and CD5. PET scan is used for initial staging and surveillance of disease. GI-FL is an indolent lymphoma with favorable survival outcomes. A “watch and wait” approach is typically adopted. GI-FL presenting as a pedunculated polyp is an extremely rare presentation. Clinicians should be cognizant of endoscopy and immunohistopathological features of GI-FL.