bluuebunny/crossref_metadata_2025_split huggingface dataset:
2589 Disseminated Salmonella Species-Induced Septic Shock: A Case Report
Authors: Singh Annapoorna , Zafar Yousaf , Makovec Anthony 
Published: October 2019

INTRODUCTION:
Nontyphoidal Salmonellosis is the leading cause of foodborne illness in the U.S., causing approximately 1.4 million infections annually. Most cases of Salmonellosis are due to ingestion of contaminated food items such as eggs, dairy products, and meats. We present a case of septic arthritis presumably after an episode of gastroenteritis that disseminates into Salmonella bacteremia in a patient without any of the risk factors for Salmonella bacteremia. This case suggests that Salmonella bacteremia can occur not only in patients with common risk factors but also patients with no obvious risk factors.

CASE DESCRIPTION/METHODS:
81-year-old African American male with past medical history of end stage renal disease, congestive heart failure, hypertension, myocardial infarction, and cerebrovascular accident presents to the ED with new onset left lower extremity pain in the posterior aspect of the knee after completing dialysis earlier in the day. He was later admitted to the hospital for concern of a septic joint. On admission, his temperature was 97.4 degrees F, heart rate was 86 beats per minute, respiratory rate was 16 breaths per minute, and blood pressure was 130/70 mmHg. Basic metabolic panel showed electrolyte disturbances including hypochloremia of 94 mEq/L, creatinine of 7.2 mg/dL, and low GFR for an African American male of 9. Complete blood count showed a hemoglobin level of 16.1 g/dL and normal leukocyte count of 5.89 TH/uL. Arthrocentesis was done three days in a row, which all initially grew gram negative rods that were later determined to be Salmonella species. The patient was becoming hypotensive and was transferred to the critical care unit and was started on pressor support. Blood cultures were drawn on the second day of admission for concern of systemic infection, grew Salmonella species. Patient was weaned off pressor support and was discharged from the hospital in stable condition.

DISCUSSION:

Salmonella is typically a bacteria species that colonize the gastrointestinal tract, there is a chance of bacteremia if Salmonella spreads from the intestines to the mesenteric lymph nodes and then to nearby organs or the bloodstream directly. In our patient with septic arthritis of the knee joint due to Salmonella, the bacteria must have traveled from the gastrointestinal system through the mesenteric lymph nodes into the bloodstream and then reaching the knee joint, where it colonized and caused infection. Early intervention with broad-spectrum antibiotics is key in preventing mortality.
2592 When Is It More Than Hiccups? Understanding the Diagnosis and Treatment of Superior Mesenteric Artery Syndrome
Authors: Mbolu George U. , Mallipudi Rajiv , Miryala Rekha , Nathan Swami 
Published: October 2019

INTRODUCTION:
Superior mesenteric artery (SMA) syndrome is defined as an upper gastrointestinal mechanical obstruction caused by compression of the 3rd part of the duodenum between the SMA anteriorly and the aorta posteriorly that has an incidence of 0.1-0.3%. This is due to loss of the intervening mesenteric fat pad and classically seen in young females in anorexic or hyper-emetic states with rapid weight loss and progressively worsening postprandial epigastric pain, hiccups, abdominal fullness and vomiting.

CASE DESCRIPTION/METHODS:
An 83-year-old male with a history of hypertension and coronary artery disease presented to the ED with complaints of persistent hiccups for 1-week duration associated with drooling, decreased appetite, inability to lie flat, and significant weight loss over several months. He was hemodynamically stable and afebrile but noted to have diffuse abdominal tenderness with distension, firmness on palpation and hypoactive bowel sounds. Significant lab values were Cr 3.5 mg/dL, BUN 63 mg/dL, lactate 9.2 U/L, 11,500 white blood cells/UL and abdominal X-ray revealed mildly dilated air-filled loop of bowel in the right side of the abdomen. He was started on IV fluids and nasogastric tube was placed for suction and decompression. Given lactic acidosis in the setting of bowel obstruction and acute kidney injury, a CT abdomen and pelvis without IV contrast was done which revealed significant gastroduodenal distention to the level of the SMA at the 3rd portion of the duodenum (Figures 1 and 2). An EGD was done to rule out endoluminal causes of duodenal obstruction. However, endoscopy showed gastroesophageal reflux disease with esophagitis and extrinsic compression of the 3rd part of the duodenum, thus confirming a diagnosis of SMA syndrome (Figure 3).

DISCUSSION:
While SMA syndrome is typically treated with adequate nutrition, nasogastric decompression, and proper positioning of the patient after eating, this was not an option for this patient. Given the severe gastroduodenal distension, progressive weight loss, poor gastric motility and extensive fluid collection in the stomach, the patient underwent a gastrojejunostomy for gastric fluid drainage. There were no complications and he has remained asymptomatic for the past year. This unique case stresses the importance of keeping a high clinical suspicion of SMA syndrome in the setting of severe weight loss with gastroduodenal distension and hiccups, as well as the prompt use of CT and endoscopy to diagnosis and assess the surgical approach.
2595 Metastatic Urothelial Carcinoma to the Duodenum: An Unusual Cause of Duodenal Stenosis
Authors: Kobeszko Matthew , Samra Mahmud , Blumenstein Brian , Elkhatib Imad 
Published: October 2019

INTRODUCTION:
Bladder cancer typically presents within the confines of the bladder wall with less than 4% of cases spreading to distant lymph nodes and organs. We present a unique case of gastric outlet obstruction with early satiety and weight loss secondary to usual mass effect from metastatic bladder cancer in the duodenum.

CASE DESCRIPTION/METHODS:
An 81-year-old male presented with two weeks of bilious vomiting, early satiety, and 20 lb weight loss. Medical history significant for prostate cancer status post prostatectomy with biochemical recurrence and bladder cancer status post radical cystectomy. On physical exam, he had mild epigastric tenderness. Labs were significant for metabolic alkalosis, acute kidney injury, and normal liver function tests. MRI of the abdomen showed diffuse thickening of the duodenal wall. He subsequently underwent an esophagogastroduodenoscopy (EGD), which revealed gastric outlet obstruction at the second portion of the duodenum. An endoscopic ultrasound (EUS) was performed which revealed no pancreatic head mass. However, a two centimeter hypoechoic thickening of the second portion of the duodenum with resultant peri-duodenal biopsies via fine needle aspiration revealed metastatic urothelial carcinoma. Patient was managed conservatively with nasogastric tube placement. With gradual improvement to a soft diet, he was discharged home with plans for outpatient palliative chemotherapy. However, he was readmitted two weeks later with similar complaints and underwent an exploratory laparotomy and palliative gastrojejunostomy. The patient was discharged on a soft diet and plans for platinum chemotherapy.

DISCUSSION:
Bladder cancer ranks as the ninth most frequently-diagnosed cancer worldwide. It typically spreads via the lymphatic and hematogenous routes with the most common sites involving: regional lymph nodes, liver, lung, and bone. Metastasis to the duodenum is extremely rare and to the best of our knowledge is only reported in 4 cases in the literature to date. Three of these cases presented as duodenal obstruction and one case presented as a massive upper GI bleeding. We describe an uncommon presentation of gastric outlet obstruction from bladder metastasis to the duodenum in a patient whose cancer was in remission. Tumor metastasis should be considered in a patient with a history of cancer and presenting with gastric outlet obstruction despite a normal EGD. We also highlight the utility of EUS as a safe and minimally invasive procedure to establish the diagnosis.
2597 An Unusual Case of an Asymptomatic Intramural Duodenal Abscess
Authors: Prado Eric E. , Rodrigues Medora , Serrao Steve , Imbertson Erick 
Published: October 2019

INTRODUCTION:
Duodenal abscesses are seldom reported in medical literature. Most recently, a case of an intramural duodenal abscess was reported in 1995 complicated by a perforated peptic ulcer without accompanying peritoneal signs. The lack of signs or symptoms raises for concern for missed intervention and a subsequent high mortality. These abscesses seem to have an association with perforated peptic ulcers. Here we discuss an unusual case of a duodenal abscess in a patient with melena.

CASE DESCRIPTION/METHODS:
A 83-year-old gentleman with a past medical history atrial fibrillation and cholecystectomy status post stent placement presented to Loma Linda Veterans Affairs Hospital with a new one month onset of generalized abdominal pain and melena following addition of edoxaban. Hemoglobin was noted at 12.9 g/dl down trending from 13.8 g/dl one month prior. The scheduled diagnostic EGD was then performed which showed bleeding gastropathy and two small 2 mm ulcers in the body of the stomach. In the duodenum, we noted mucosal irregularity in the bulb (Figure 1) with purulent drainage consistent with an abscess. This was probed with the biopsy forceps resulting in more purulent drainage continued (Figure 2). A biopsy was taken with mildly edematous duodenal mucosa showing reactive changes and expansion of lamina propria by inflammatory cells consistent with an inflammatory process.

DISCUSSION:
There is limited literature for the management of duodenal abscesses. The patient did not exhibit any warning signs such as; abdominal tenderness, guarding, fever, or leukocytosis. There is a potential association with chronic inflammation and duodenal abscesses and the previously stated association with peptic ulcers.
2599 Retained Video Capsule Due to Stricturing Crohn's Disease Safely Diagnosed With Use of Magnetic Resonance Imaging (MRI) in a Pregnant Patient
Authors: Brandt Daniel R. , Judge Thomas A. , Chaaya Adib 
Published: October 2019

INTRODUCTION:
Videocapsule endoscopy (VCE) is a noninvasive technology that provides diagnostic imaging of the small intestine. We present a case where MRI was safely utilized to diagnose a retained VCE in a pregnant patient. There is a lack of literature on the use of VCE in pregnancy as well as the use of MRI to diagnose retained VCE. Our case highlights the use of MRI to diagnose a retained VCE during pregnancy without any harmful effects to the patient or fetus.

CASE DESCRIPTION/METHODS:
A 16-year-old woman with a 4-year history of Crohn's disease presented at 24 weeks gestation with six months of achy, left upper quadrant (LUQ) abdominal pain associated with a 20-pound weight loss. On presentation, the patient was depressed, withdrawn and provided limited history. Exam demonstrated a thin young female with gravid uterus and LUQ tenderness. Labs were notable for ESR >100 mm/h and CRP 4.1 mg/L. An MRI was performed to aid diagnosis and minimize risk of radiation to the fetus. This revealed artifact at the anterolateral aspect of the left mid-abdomen (Figure 1). CT enterography confirmed foreign body in the left mid small bowel, likely jejunum, compatible with retained videocapsule (Figure 2). There was an adjacent segment of small bowel with suspected stricture (Figure 3). Additional history was then revealed by the patient's mother. She had undergone VCE six months prior. Shortly after, pregnancy testing was positive and imaging to confirm passage of the VCE was deferred. Subsequently, her pain worsened. Antegrade double balloon enteroscopy was attempted but could not reach the videocapsule. She underwent exploratory laparotomy revealing an intra-abdominal phlegmon and a loop ileostomy was performed. Patient delivered a healthy infant at 34 weeks. Resection of phlegmon and retrieval of foreign body were performed post-partum.

DISCUSSION:
Capsule retention is a potential complication of VCE, with a rate of 2.6% in patients with known or suspected Crohn's disease compared to an overall retention rate of 1.4%. Pregnancy is a relative contraindication to VCE due to a lack of safety data on whether the electromagnetic field of the capsule-recorder-system could harm the fetus. There is also feared theoretical complication of performing MRI while a capsule is within the gastrointestinal tract due to migration of the capsule and the potential for bowel injury or perforation. Our case reinforces the theory that 1.5 Tesla MRI can be safely performed in pregnancy with retained VCE without harm to patient or fetus.
2600 A Typical Presentation of a Rare Disease: Clostridium difficile Enteritis After Total Abdominal Colectomy
Authors: Bundschuh Mark , Moleski Stephanie 
Published: October 2019

INTRODUCTION:
Clostridium difficile enteritis (CDE) is rare, but is increasingly diagnosed among those who have undergone colectomy. After colectomy, colonic-type bacterial flora including Clostridium difficile are able to colonize, and under the right circumstances, infect the small bowel. The reported mortality of CDE is high, likely due in part to the emergence of a virulent strain of Clostridium difficile, NAP1/BI/027. Physicians should have a high index of suspicion for CDE, particularly among patients with antibiotic exposure after colectomy.

CASE DESCRIPTION/METHODS:
A 50-year-old-woman with a previous history of Clostridium difficile infection (CDI) and colonic inertia status post total abdominal colectomy with ileorectal anastomosis three months prior presented with waves of left lower quadrant abdominal pain, abdominal distention, nausea, and vomiting. In the three weeks prior to admission, she completed courses of Amoxicillin and Trimethoprim-sulfamethoxazole for UTI. CT abdomen/pelvis with contrast showed 20 cm of circumferential thickening of the distal small bowel with associated free fluid and mesenteric inflammation proximal to unaffected ileorectal anastomosis. Laboratory evaluation was notable only for mild leukocytosis (12,000 cells/µL) with no bands. On admission, the patient had a nasogastric (NG) tube placed for abdominal decompression. A Bisacodyl suppository was prescribed, and the patient had a bowel movement that resulted positive for Clostridium difficile toxin DNA PCR. The patient was diagnosed with CDE. She was initially started on NG Vancomycin 150 mg every 6 hours for a first recurrence of CDI, which was then escalated to 500 mg every 6 hours with the addition of IV Metronidazole. This resulted in resolution of symptoms and ileus.

DISCUSSION:
Our patient had several CDE risk factors including a prior history of colectomy and recent antibiotic exposure. In addition to CDE risk factors, our patient also had two CDI risk factors - chronic acid suppression and previous history of CDI. Additional research is needed to determine if other typical CDI risk factors also play a role in the development of CDE. In patients with altered gastrointestinal anatomy or obstruction, it may be challenging to confirm the diagnosis using stool-based PCR toxin studies. Abdominal CT scan may be helpful in making the diagnosis. Much like our patient, previous studies have demonstrated circumferential edema and mesenteric stranding of the small bowel as common radiologic features of CDE.
2607 Small Intestinal Helminths on a Capsule Endoscopy Capture
Authors: Tsipotis Evangelos , Kolli Sindhura , Aamar Ali , Reddy Madhavi 
Published: October 2019

INTRODUCTION:
Intestinal helminth infection is a well known cause of occult GI bleed and iron deficiency anemia, most commonly seen in developing countries. With the introduction of capsule endoscopy in the diagnostic algorithm of occult GI bleed, reports of intestinal helminths identified during capsule study have been published. [1] We present the case of a patient with iron deficiency anemia and occult GI bleed found to have helminth infection.

CASE DESCRIPTION/METHODS:
A 77-year-old Puerto Rican female patient was sent for evaluation of iron deficiency anemia. She was asymptomatic, denying any melena, hematochezia or hematemesis. Her Hb was 8.1 mg/dL, MCV of 83 fL with low iron levels. Fecal occult blood test was positive. EGD and colonoscopy were negative. Outpatient video capsule showed helminths in the ileum, but unable to identify speciation. Multiple stool workups were negative for ova and parasites. Strongyloides serology was negative. Patient empirically received 400 mg of albendazole daily for 3 days and iron tablets.

DISCUSSION:
Helminth infection is most commonly seen in developing countries. Intestinal helminths are transmitted from the soil to the human intestine leading to inflammation of the small intestine or colon, ulcers, anemia secondary to iron and B12 deficiency, eosinophilia, and obscure gastrointestinal bleed. Diagnosis begins with microscopic examination of feces, blood test (serology and blood smear) and imaging ( X-ray, magnetic resonance imaging, and computed tomography).[2]. If worm burden is minimal, then concentrated feces with formalin is recommended. PCR has a higher sensitivity and specificity. When stool studies are negative with high suspicion of helminth infection or the patients present for evaluation of obscure gastrointestinal bleed, conventional endoscopy is the next sequential diagnostic measure. [2] The introduction of capsule endoscopy has assisted the diagnosis of helminth infection in patients with persistent symptoms or anemia and negative esophagoduodenoscopy and colonoscopy. Helminths identified in capsule endoscopy should be categorized and treated based on their macroscopic characteristics if stool studies are falsely negative. If identification is not possible, empiric treatment with monitoring of the response to anemia and repeat capsule endoscopy might be indicated.
2610 Metastatic Melanoma Mimicking Enteritis
Authors: Alimirah Maryam , Bhatti Faiza 
Published: October 2019

INTRODUCTION:
Metastasis of melanoma to the gastrointestinal tract is rarely identified in clinical practice. We relay the case of a patient presenting with abdominal pain and leukocytosis with CT imaging initially suspicious for infectious or inflammatory bowel disease, but later confirmed to be small bowel melanoma. This report highlights the unpredictable nature of melanoma and underscores the need to be cognizant of imaging and endoscopy limitations in identifying disseminated disease.

CASE DESCRIPTION/METHODS:
A 59-year-old man with no past medical history presented to the ED with a one-day history of nausea associated with severe right lower quadrant abdominal pain. Labs showed leukocytosis to 20 K/uL. CT of the abdomen and pelvis showed significant wall thickening of a long segment of distal small bowel loop with adjacent fat stranding. He was discharged with antibiotics for presumed infectious enteritis and with gastroenterology follow up. Patient underwent ileocolonoscopy one month later that was significant for multiple polyps but otherwise normal appearing ileum and biopsies were negative for colitis or ileitis. Two months later, during follow up, patient underwent MR enterography which showed large mass measuring 9.0 × 7.1 × 7.4 cm in size in the small bowel, correlating with area of thickened bowel noted on CT previously (Figure 1). Patient underwent exploratory laparotomy with resection of small bowel mass with pathology positive for melanoma (Figure 2). Primary site was identified shortly thereafter as a cutaneous lesion in area of right upper back.

DISCUSSION:
Delayed diagnosis in this case hinged on unrevealing colonoscopy and CT findings describing only distal small bowel wall thickening concerning for enteritis due to infection or inflammatory bowel disease. Bender et al reported a sensitivity of 66% for contrast-enhanced CT in demonstrating intestinal metastatic deposits. A less common radiographic manifestation of metastatic melanoma infiltrating the serosa described in the literature includes segmental circumferential bowel thickening that can mimic the appearance of Crohn’s disease or intestinal enteritis, a characteristic that might explain the CT findings described in our patient. Also of note is the inability of endoscopy to uncover serosal metastases which is especially concerning as it is common for intestinal melanoma metastases to grow extraluminally.
2611 An Unlikely New Home for Metastatic Melanoma
Authors: Tan Christopher , Yanchak Teresa , Ramirez Jonathan 
Published: October 2019

INTRODUCTION:
Symptomatic gastrointestinal involvement from primary malignant cutaneous melanoma represents only 1–4% of melanoma cases but is found in 60% of autopsies in patients who have had a primary cutaneous melanoma. We present a case of metastatic melanoma with initial symptomatic cecal involvement as demonstrated by colonoscopy and subsequent jejunal involvement discovered using single balloon enteroscopy. Our case illustrates that presenting symptoms for metastatic lesions in the gastrointestinal tract are often nonspecific but despite this, metastatic melanoma with gastrointestinal involvement should be considered in any patient that’s been diagnosed with a primary cutaneous melanoma.

CASE DESCRIPTION/METHODS:
A 61-year-old male presented with one-week history of melena. An iron panel was obtained which revealed iron deficiency anemia. The patient’s past medical history was significant for previously excised cutaneous melanoma. Initial colonoscopy demonstrated a malignant appearing mass in the cecum with an immunoprofile consistent with metastatic melanoma on biopsy. Patient was unable to tolerate initial chemotherapy and continued to have chronic blood loss anemia. The patient had a follow up pill cam endoscopy which showed slow oozing lesion noted in the duodenum. Subsequent single balloon enteroscopy was performed showing a non-obstructive, polypoid and ulcerated appearing proximal jejunal mass which was found to be melanoma on biopsy.

DISCUSSION:
Malignant melanoma is the most common metastatic tumor to the gastrointestinal tract. The propensity of the primary tumor to metastasize is dependent on Clark staging. Detection of small bowel lesions is often difficult. Small bowel lesions may present diffusely, as mural nodules, or “target” lesions on radiograph. Endoscopically, lesions may appear as ulcerated melanotic nodules, submucosal masses with ulcerations, or mass lesions with necrosis and melanosis. However, if the lesions involve the serosa or mesentery they can be missed on endoscopy. Various treatment modalities exist for metastatic melanoma of the GI tract including but not limited to surgical resection, immunotherapy, and chemotherapy.