bluuebunny/crossref_metadata_2025_split huggingface dataset:
1960 Life-Threatening Gastrointestinal Bleeding Secondary to Kaposi’s Sarcoma of the Duodenum
Authors: Ibrahim Hanan , Ghanimeh Mouhanna Abu , Al Saheli Zaid 
Published: October 2019

INTRODUCTION:
Kaposi’s sarcoma is common in patients with AIDS. Gastrointestinal involvement is not uncommon. However, a life-threatening bleeding is rare.

CASE DESCRIPTION/METHODS:
A 58-year-old bisexual male with a history of AIDS presented to the clinic with progressive dyspnea, dizziness and unintentional weight loss. He was found to be tachycardic and hypotensive. Physical exam revealed a non-tender, non-pruritic, dark purple skin lesions over his body, face and scalp. The patient was admitted for further evaluation. His initial labs revealed a Hb of 6.2 g/dl and a CD4 count of 120 cells/µL. CT scan of the abdomen and pelvis showed multiple enlarged lymph nodes in the peri aortic, right external iliac and porta-cava areas. He was initiated on HAART and a skin biopsy was performed. While inpatient, Hb dropped to 5.8 g/dl, which responded appropriately to 2 units of pRBCs. However, Hb dropped again and the patient started to have melena and hematochezia for which he was transferred to the ICU for close observation and resuscitation. A continuous infusion of pantoprazole 8 mg/hour was initiated. An EGD and colonoscopy were performed after resuscitation. The EGD showed erosive esophagitis, multiple non-bleeding gastric ulcers with a flat pigmented spot and non-bleeding duodenal erosions. The stomach and duodenum were biopsied. The colonoscopy showed old clotted blood in the entire examined colon. The patient underwent a second look EGD due to persistent melena and Hb drop which showed clotted blood in the gastric fundus, as well as a large, cratered gastric body ulcer, along the greater curve with adherent clot. Most of the clot was removed without bleeding or high-risk stigmata. Over the next few hours, the patient became hemodynamically unstable with increasing amounts melena. The interventional radiology team was consulted, and an urgent selective embolization was performed to the right gastroepiploic artery which was coursing through the ulcer. The patient stabilized and was eventually discharged with a plan of outpatient follow up. The biopsies from skin, stomach and duodenum showed proliferating spindle cells forming slit-like vascular channels within the lamina propria. HHV-8 immunostaining was positive.

DISCUSSION:
Involvement of the GI tract by Kaposi’s sarcoma is usually asymptomatic but hemorrhages, even though uncommon, have been reported. An adequate endoscopic sampling is crucial to avoid false negative results. However, severe bleeding may occur due to the hypervascularity of the lesion.
1963 Non-Cirrhotic Hepatocellular Carcinoma Presenting as Bleeding Rectal Varices
Authors: Magee Jared S. , Francis Jonathan P. 
Published: October 2019

INTRODUCTION:
Anorectal sources account for 15–20% of hospital admissions for acute lower gastrointestinal bleeding (LGIB). Rectal varices are common in patients with portal hypertension, however, clinically significant bleeding occurs in only 0.5–5%. Management of rectal varices is described in several case reports but no standardized therapy exists due to the low incidence. Here we describe a case rectal varices treated by collateral vein embolization during an initial presentation for noncirrhotic hepatocellular carcinoma.

CASE DESCRIPTION/METHODS:
A 69-year-old African American male presented for weakness in the setting of 3 days of hematochezia. Medical history was notable for prostate cancer status post radiation therapy, prior hepatitis B exposure and hepatitis C status post Harvoni with sustained virologic response. Physical examination was notable for normal vital signs and gross blood on glove during rectal exam. Labs revealed a hemoglobin of 11.6 g/dl, and BUN of 18.0 mg/dl. CT abdomen was performed and notable for asymmetric rectal wall thickening, an ill-defined mass at the hepatic dome and expansion of the portal veins. He was admitted for colonoscopy in the setting of hematochezia. Liver MRI was completed, showing an abnormal heterogeneous right hepatic lobe with extensive portal vein thrombus and a 1.1 cm exophytic nodular LI-RADS 5 lesion. Tumor markers were notable for a normal CEA, and an Alpha-1-fetoprotein of >55,000 ng/ml. Colonoscopy was performed to evaluate the rectal findings on CT, revealing large rectal varices with a prominent nipple sign. Interventional radiology (IR) was consulted for embolization of a venous shunt draining bilateral hemorrhoidal veins and obtained a liver biopsy, resulting in grade II-III Hepatocellular carcinoma (HCC). Patient would ultimately fail sorafenib and lenvatinib therapy due to liver toxicity and continued tumor growth without recurrence of LGIB.

DISCUSSION:
HCC in the absence of cirrhosis has been documented in several patient populations to include chronic hepatitis B and more recently NASH. Portal vein thrombosis (PVT) is common in HCC with an incidence of 34–50%, and frequently leads to varix formation. Rectal varices are less common than esophageal and gastric varices, however can still result in life threatening hemorrhage. Given the low incidence, there are no established guidelines to define management strategies for bleeding rectal varices. Currently long term management is directed by physician expertise and available services.
1967 Unexplained Massive Recurrent Upper GI Bleeding: A Case of Missed Connection
Authors: Qamar Khola , Tiwari Abhinav 
Published: October 2019

INTRODUCTION:
Erosion of an aortic prosthetic graft into the surrounding gastrointestinal structures leads to formation of Aortoenteric fistula (AEF). It occurs after months to years after aortic surgery and may be related to graft infection and can result in torrential Gl bleeding. Here we present a case of recurrent GI bleeding, the cause of which initially remained obscure despite repeated endoscopies.

CASE DESCRIPTION/METHODS:
61 y old male with PMH of peripheral vascular disease and femoropopliteal bypass on ASA and Eliquis presented with 3 days of passing black-tarry stools and dizziness. Initial hemoglobin was 7 gm/dL (normal baseline). Urgent EGD up to 2nd part of duodenum revealed clot in the stomach without any lesion or source of bleeding. EGD was repeated the next day due to ongoing melena, which again was nonrevealing. CTA also did not show any active bleeding. Eliquis was discontinued and the patient was discharged. 2 days later, he presented with ongoing melena and dizziness. EGD, however, this time revealed aortic graft eroding into 3rd part of the duodenal wall. He was transferred to a tertiary care center for repair of the fistula.

DISCUSSION:
AEF is an uncommon but life-threatening complication of aortic reconstructive surgery. Due to the anatomic proximity, most cases involve the duodenum, with the proximal suture line of an aortic prosthesis. It is imperative to inquire about the history of aortic reconstruction patients presenting with Upper GI bleeding, as these patients are considered to have an AEF until proven otherwise. In our case, the remote history of aortic reconstructive surgery was not put in the clinical perspective and aortic graft was overlooked on the CT scan. Both MRI and CT can fail to diagnose AEF and EGD has 50% sensitivity. Endoscopy should include the fourth portion of the duodenum. Prompt recognition and repair of fistula in highly critical for patient survival.
1968 Where Did the Problem Stem From? An Unusual Case of Hematemesis and Hematuria
Authors: Bhardwaj Meera , Hong Simon , Berkowitz Daniel 
Published: October 2019

INTRODUCTION:
Accidental foreign body ingestion is a common problem encountered in emergency departments. Most of the time foreign bodies pass through the GI tract without any sequela; however, perforation can occur in up to 1% of cases. Here we discuss a case of a perforated viscus presenting with hematemesis and hematuria.

CASE DESCRIPTION/METHODS:
A 61 year old woman with type 2 diabetes presented to the emergency room with new onset abdominal pain, hematemesis and hematuria an hour after eating dinner at home. A CT scan was obtained on admission and was notable for periduodenal lymphadenopathy, thickening of the duodenal wall, and dense material in the right renal calyx. Upper endoscopy showed a clot in the duodenal sweep, which was unroofed to reveal a sharp foreign body that was embedded in the small bowel wall and protruded 1.5 cm into the lumen. The foreign body was removed with a snare and the mucosal defect was closed with an endoclip. On gross examination, the foreign body measured 6 cm in total length and had a dried stem-like appearance. A CT scan was repeated to evaluate for suspected perforation, which demonstrated gas around the first and second portions of the duodenum and right-sided hydroureter. The patient was managed conservatively with antibiotics, with resolution of abdominal pain. However, due to persistent hematuria, patient underwent a renal angiogram, which showed a right renal artery aneurysm for which the patient required angioembolization, cystoscopy for evacuation of clots in the bladder, and right uretral stent placement. The patient did not have any further hematemesis or hematuria, and pathology of the foreign body returned as plant-based material suspected to be a dried stem.

DISCUSSION:
In cases of GI foreign bodies, the culprit sharp objects are often chicken or fish bones, paper clips, or dental tools. In this patient, we report a case of plant matter causing viscus perforation through the duodenum and into the right kidney, presenting as simultaneous hematemesis and hematuria. Plant matter may not appear on radiographic images and might be missed on preliminary radiographic evaluations. Furthermore, this case highlights the anatomic proximity of the duodenum to the right kidney, specifically the renal calyx. Simultaneous presentation of abdominal and urologic symptoms may suggest a duodenal source. This should cue endoscopists to pay extra attention to the duodenal sweep, which can be overlooked during endoscopy.
1986 An Unusual Case of Massive Duodenal Diverticulum Bleeding: A Challenging Treatment Approach
Authors: Chaar Abdelkader , Shiari Aryan , Zamora-Sifuentes José , Bill Katherine , Barawi Mohammed 
Published: October 2019

INTRODUCTION:
Duodenal diverticula are relatively common findings in the small bowel with reported prevalence ranging between 0.6–22%. The vast majority of them are asymptomatic and found incidentally. We present an unusual case of hemorrhagic shock resulting from bleeding duodenal diverticula.

CASE DESCRIPTION/METHODS:
A 46-year-old male with history of alcohol abuse presented with 1-day history of multiple episodes of hematochezia and dark tarry emesis. He had associated lightheadedness, dyspnea, diaphoresis along with 1 episode of syncope. He did not use any medications on regular basis. His heart rate was 125 beats/minute and blood pressure 99/53 mmHg. Labs included hemoglobin (Hgb) of 4.5 gm/dL, platelets 75000/mcL, creatinine 1.81 mg/dL and lactic acid 4.4 mmol/L. Patient was subsequently intubated for airway protection due to recurrent episodes of hematemesis. An esophagogastroduodenoscopy (EGD) showed 3 large diverticula in the second portion of duodenum with active bleeding noted from a non-periampullary proximal diverticulum (Figure 1). Hemostasis was achieved with epinephrine injection followed by Hemospray. A follow up arterial angiogram was unremarkable. Patient experienced recurrent bleeding within 48 hours requiring 2 additional EGDs with therapeutic interventions (epinephrine, ablation and endoclips). Repeat angiography was done due to persistent drop in Hgb. This time, an area of irregularity in one of the gastroduodenal artery branches was identified adjacent to the previously placed endoclips. Coil embolization was performed successfully with excellent results. Patient’s condition eventually stabilized without any recurrent bleed. Upon follow up, his Hgb was 10.7 gm/dL 3 weeks after discharge.

DISCUSSION:
The majority of duodenal diverticula are asymptomatic. About 1% result in complications requiring definite endoscopic or surgical intervention. Potentially fatal bleeding represents minimal proportion of these complications and its management can be challenging. Our case demonstrates an extreme example of massive gastrointestinal bleeding that was difficult to control despite multiple endoscopic interventions. Initial angiography was not successful to identify the bleeding. Applying endoclips helped to subsequently localize and control the source of bleeding in the second angiogram. Using this approach can be an invaluable asset in such conditions.
1987 A Rare Cause of Massive Upper Gastrointestinal Bleeding
Authors: Gajjar Bhavesh A. , Aasen Tyler , Goenka Puneet 
Published: October 2019

INTRODUCTION:
Pseudoaneurysm (PA) is a rare, life-threatening complication of pancreatitis. Spontaneous PA rupture can cause massive bleeding, and up to 60% of massive bleeding following pancreatitis is due to rupture of PA. PA rupture may be lethal and in cases of diagnostic delayed mortality can be as high as 60 %. There are no known risk factors for PA rupture. We are presenting a case of gastrointestinal (GI) bleeding due to the ruptured splenic artery pseudoaneurysm. We believe this was a delayed complication of AXIOS stent which is a lumen-apposing metal stent (LAMS) used for cystogastrostomy.

CASE DESCRIPTION/METHODS:
A 30-year-old male with a history of walled off necrosis secondary to alcohol-induced pancreatitis presented with massive hematemesis and lightheadedness. He had undergone cystogastrostomy with LAMS placement three weeks prior. He was taking ibuprofen 800 mg daily. On presentation was in hypovolemic shock. CT scan did not reveal any findings suggestive of bleeding. Esophagogastroduodenoscopy showed bleeding from the LAMS with large clot formation in the stent. The bleeding worsened after attempting to dislodge the clot and did not stop after epinephrine injection. After stabilizing the patient, he underwent CT angiography. It showed a PA arising from the distal splenic artery, directly posterior to the LAMS (Figure 1). The patient was sent for conventional angiography, and multiple coils were placed in the splenic artery near the PA (Figures 2 and 3). He did not have further bleeding. He continued to improve during the hospitalization and was eventually discharged. The LAMS was successfully removed approximately one month after discharge with near resolution of the walled-off necrosis.

DISCUSSION:
Ruptured PA is a life-threatening complication of pancreatitis. Delayed diagnosis has a mortality of 25 to 60 %. Timely diagnosis and treatment can reduce mortality to less than15%. 4 to 10 % of patients with chronic pancreatitis may be at risk of bleeding due to PA. LAMS has been widely used for endoscopic cystogastrostomy. LAMS due to bi-flanged design stays in the place and achieves the better success of draining a pseudocyst. There are few reported cases of delayed bleeding due to ruptured PA due to LAMS. The provider should have a high suspicion of a ruptured PA once other causes of bleeding are ruled out by an EGD. An urgent CT angiography is the diagnostic test of choice. Embolization of bleeding pseudoaneurysm is the first line of therapy even in critical conditions.
1992 Hematochezia? Think Histoplasmosis
Authors: Higley Cory , Cherian Nuval , Steinberg Joshua , Jennings Joseph J. , Lewis James 
Published: October 2019

INTRODUCTION:
Histoplasmosis is the most common mycosis in North America, responsible for more hospitalizations and deaths than any other endemic mycosis in the United States. While it most commonly presents with pulmonary manifestations, we present a case of a 68-year-old female with history of renal transplantation who was transferred to our tertiary-care hospital with hematochezia, abdominal cramping, and emesis.

CASE DESCRIPTION/METHODS:
A 68-year-old female with history of renal transplant on immunosuppressive medications was transferred to our tertiary-care hospital with hematochezia. Prior to arrival at our hospital, she was transfused with 2 units of packed red blood cells for a hemoglobin of 5.3 g/dL. A diagnostic nasogastric lavage was negative. She underwent a colonoscopy which did not reveal active bleeding, however the mucosa throughout the entire colon was abnormal, described as nodular with focal areas of blanching and hemorrhagic appearance. The gross appearance was concerning for lymphoma, specifically posttransplant lymphoproliferative disease given her transplant history. As a result, she was transferred to our facility for further management. Chest CT revealed mesenteric and mediastinal lymphadenopathy as well as scattered calcified and noncalcified pulmonary micronodules. She had no pulmonary symptoms. Additional work up revealed a positive Histoplasma galactomannan urinary antigen. Additional staining of colonic biopsies revealed numerous histiocytes in the lamina propria with small round intracytoplasmic yeast microorganisms (GMS and PAS positive and mucicarmine negative) confirming the diagnosis of disseminated histoplasmosis. Patient was treated initially with a two-week course of amphotericin B before being transitioned to oral itraconazole.

DISCUSSION:
Disseminated histoplasmosis is most common in patients with a history of organ transplant, HIV or immunosuppressive medication regimen. T cell dysfunction accounts for a 10-fold higher risk for dissemination of histoplasmosis with nearly 1 in 2000 acute histoplasmosis infections becoming disseminated. Early diagnosis is the key to effective treatment. A simple urinary test can rule out the diagnosis and should be among one of the first steps in the workup of such patients. We propose clinicians maintain a high index of suspicion and that histoplasmosis be considered in patients with history of immunosuppression who present with acute onset bloody diarrhea with negative work-up for another intra-abdominal pathology.
1993 Diagnosis and Management of Porto-Porto Varices in a Patient With Prior Orthotopic Liver Transplant
Authors: Drosdak Alyssa , Hill Eddie , Ismail Mayada , Al-Natour Mohammed , Post Anthony 
Published: October 2019

INTRODUCTION:
Gastrointestinal variceal bleeding is a frequent complication in patients with liver disease. Small bowel varices represent a less common source of bleeding, and are often challenging to manage due to their location. We describe a case of bleeding small bowel porto-porto varices in a young patient status-post orthotopic liver transplant.

CASE DESCRIPTION/METHODS:
An 18-year-old-female patient presented with melanotic stools and a presyncopal episode. Her medical history was significant for iron deficiency anemia and biliary atresia. Associated surgical history included hepatoportoenterostomy in infancy and orthotopic liver transplantation at age two. Admission labs were significant for hemoglobin (Hgb) of 4.0 g/dL. Hepatic enzymes, INR and platelets were within normal limits. Initial colonoscopy and EGD were revealing for hematin in the cecum and colon. CT enterography showed smaller collateral veins draining into a large superior mesenteric collateral vein. This finding was confirmed by triple phase CT angiography, which also demonstrated chronic occlusion of the portal vein. The collaterals provided bypass of the thrombosed portal vein, and also included jejunal submucosal porto-porto varices. As the patient’s hemoglobin continued to drop despite blood transfusions, recanalization of the portal vein was attempted by Interventional Radiology (IR). The portal vein was stented, resulting in reduced flow through collateral vessels. The patient was taken back to the IR suite three days later as she had recurrent melena and Hgb drop. The stent had thrombosed, and a combination of chemical and mechanical thrombolysis was used to restore flow. Coil embolization of three collateral vessels from the SMV was also performed. A contrasted CT scan of the abdomen three days later revealed a patent stent with significant improvement in jejunal porto-porto varices. At her last clinic appointment two months after discharge, the patient denied further bleeding.

DISCUSSION:
This case illustrates the diagnostic and therapeutic challenges in patients with small bowel varies. This case is noteworthy as it highlights a type of collateralization, porto-porto varices, which have not been well described. Furthermore, this case occurred in a population not frequently studied: patients who previously underwent orthotopic liver transplant for biliary atresia. Recognition and appropriate treatment of associated liver conditions is crucial to increasing survival in this group.
1994 Spontaneous Intramural Intestinal Hematoma: An Increasing Phenomenon?
Authors: Florian Rosemarie , Jackson Christian 
Published: October 2019

INTRODUCTION:
The development of small bowel intramural hematomas is a rare process that is often seen in the young, precipitated by abdominal trauma. Non-traumatic, spontaneous, small bowel intramural hematomas are an even rarer entity, seen in the elderly and is associated with the overuse of anticoagulants.

CASE DESCRIPTION/METHODS:
93 y/o male with past medical history of paroxysmal atrial fibrillation, deep vein thrombosis and pulmonary embolism, on anticoagulation, and diabetes mellitus type 2. He presented to the ED with abdominal pain, constipation, nausea and hematemesis with intermittent melena for 1 week. Anticoagulation was switched to edoxaban from warfarin given his unstable INR levels. Last dose of warfarin was 1 week prior to presentation. Patient denied prior abdominal trauma or NSAID use. On arrival, he had mild tachycardia and normotension. On exam, he had diffuse abdominal pain with mild rebound, no guarding. Labs were significant for coagulopathy INR > 5.5, prothrombin time (PT) > 95s, partial thromboplastin (PTT) time of 121s with stable thrombocytopenia Plt 126 (BILL/L) and hemoglobin Hgb 16.2 (g/dL). CT abdomen pelvis with contrast revealed circumferential wall thickening in the distal duodenum and proximal jejunum with no obstruction. Anticoagulation was held and he received IV fluids, fresh frozen plasma, prothrombin complex concentrate and vitamin K for coagulopathy and started on a protonix gtt. EGD revealed diffuse submucosal hematomas in the jejunum without ulcerations, confirming diagnosis of intestinal intramural hematomas. After medical management symptoms improved and he was discharged without anticoagulation.

DISCUSSION:
Spontaneous small bowel intramural hematomas are not often seen in patients admitted for acute abdominal pain. Although rare, intramural hematomas can have a devastating outcome. In this case, the patient was taking both warfarin and edoxaban, as evidenced by the lab findings. This likely doubled his risk for developing an intramural hematoma. Early imaging resulted in early diagnosis and prompt medical intervention. Prior cases have reported complications of obstruction, acute peritonitis, perforation, and hemorrhage shock. These lesions mostly affect the jejunum in 71.6% and duodenum in 29.8%. Thus, patients who present with non-specific abdominal pain and are on anticoagulant therapy, consider spontaneous intestinal intramural hematoma as a potential etiology. Early intervention may decrease complications and need of surgical intervention.