bluuebunny/crossref_metadata_2025_split huggingface dataset:
1949 Modern Coils and Glue: An Evolving EUS Application in the Management of Gastric Varices
Authors: Houston Jessica , Kumar Manoj , Fahmawi Yazan , Barker Michael , Mizrahi Meir 
Published: October 2019

INTRODUCTION:
Ethylene vinyl alcohol (EVOH) is a liquid embolic agent approved for cerebrovascular lesions. DMSO solvent dissipates into the blood, causing the EVOH copolymer and suspended tantalum to precipitate in situ into a spongy, coherent embolus. Their role in the management of gastric varices is still unknown. We are presenting our experiences with this novel echoendoscope (EUS) guided use of EVOH to achieve gastric variceal obturation (GVO).

CASE DESCRIPTION/METHODS:

Case 1
: 44-year-old male with decompensated cirrhosis presented with melena. EGD showed large gastric varix (GOV-2). EUS- guided coiling and EVOH glue injection was planned. Gastric varices were identified using a linear echoendoscope at 7.5 MHz and 22G FNA needle was then advanced into varix with position confirmed by aspirating blood. Three embolization microcoils (5 mm/mm2, 8 mm/4mm, 7 mm/3mm; proximal end diameter/distal end diameter) were placed into the varix followed by needle flush with a 0.8 ml DMSO (dimethyl sulfoxide). Post DMSO flush, 5 mL EVOH glue was injected with excellent flow reduction on EUS doppler. 0.8 ml of DMSO was again used to flush the needle. Patient tolerated procedure well and had no signs of bleeding prior to discharge.
Case 2
: 39-year-old male with history of alcoholic and HCV cirrhosis and hepatocellular carcinoma, two prior banding procedures for bleeding esophageal varices, gastric varices, presented with signs and symptoms of decompensated cirrhosis, hematemesis and melena. EGD with banding was done for large esophageal varices with stigmata with successful hemostasis. Large gastric varix (GOV-1) was also discovered. Coiling and glue was injected with similar EUS guided technique as above (sixteen embolization microcoils of varying sizes (8 mm/4 mm, 7 mm/3 mm, 5 mm/2 mm); 3 mL EVOH glue injection). Post procedural EUS doppler imaging showed excellent flow reduction.

DISCUSSION:
EVOH is well-known as catheter based embolic therapy for neurovascular lesions. Its application under EUS image guidance for gastric varices has not been reported yet to our knowledge thus making our case as unique. However larger, prospective multicenter trials with EVOH will be required to study rebreeding rates and long-term outcomes in the management of gastric varices.
1950 An Unexpectedly Large Vascular Anomaly Causing Chronic Obscure GI Hemorrhage: A Case Report
Authors: Edwards Jade , Prabakaran Sabrina , Niknam Negar , Brady Patrick 
Published: October 2019

INTRODUCTION:
Approximately 5–10% of patients who present with an acute gastrointestinal (GI) hemorrhage have a primary small bowel source. While small bowel angioectasias are one of the most common causes of small bowel hemorrhage, it is rare to find large vascular anomalies in the small bowel as a cause of chronic GI bleed.

CASE DESCRIPTION/METHODS:
We present a case of a 56-year-old woman referred to our institution for management of obscure GI bleeding, associated with severe iron deficiency anemia. She had intermittent melena and occasional dark red blood mixed with stool. Extensive work up in an outside facility including 2 endoscopies, 2 colonoscopies, and a capsule endoscopy were unrevealing. After referral to our institution; push enteroscopy, colonoscopy and retrograde single balloon enteroscopy were performed and were negative for source of bleeding. Capsule endoscopy revealed a small oozing angioectasia in proximal jejunum. The lesion was treated with heater probe via anterograde single-balloon enteroscopy. Due to persistent melena and anemia, antegrade balloon enteroscopy was repeated and demonstrated an abnormal cluster of vascular-appearing lesions in the proximal jejunum that were marked with two hemostatic clips. CT angiogram was consistent with a large arteriovenous malformation (AVM). Interventional radiology performed glue embolization of the high-flow jejunal arteriovenous malformation. The post procedure course was complicated by ischemic proximal jejunum which was confirmed on repeat enteroscopy. Fortunately, her symptoms completely resolved with conservative management without surgical intervention.

DISCUSSION:
AVMs are abnormal lesions with a direct connection between the arterial and venous blood supply without any true capillary bed connecting them. While extremely rare within the GI tract, they can cause significant amount of bleeding and must be considered in patients with obscure GI bleeding or chronic iron deficiency anemia. Studies have shown that AVMs typically only account for 1–2% of upper GI bleeds. More common sites for AVMs include the cecum and ascending colon, while other sites like the small bowel are much more rare. Diagnostic work up typically begins with upper endoscopy followed by colonoscopy. However, these tests are often unrevealing when dealing with small bowel AVMs. Patient’s typically undergo capsule endoscopy for further evaluation, as seen in our patient. If the source of bleeding is still un-identified, then angiography or bleeding scans may be required.
1956 Never Assume, Always Ask: Beyond Infectious and Inflammatory Proctocolitis
Authors: Pisipati Sailaja , Phoo Wut Yi , Hsieh Ting Hui , Fang Tom , Bronander Kirk 
Published: October 2019

INTRODUCTION:
Chemical colitis can occur as a result of accidental or intentional exposure to various chemicals including alcohol. Ethanol enemas, practiced either to avoid hangovers and upper gastrointestinal (GI) symptoms or as klismaphilia appears to be dangerous practice. We report a rare case of alcohol-induced proctocolitis in association with sexual fetish.

CASE DESCRIPTION/METHODS:
38-year-old female with depression, bipolar disorder, polysubstance abuse, presented with lower abdominal and rectal pain, hematochezia, and tenesmus upon waking up. On questioning, she said that night prior to presentation, she was intoxicated (vodka, methamphetamine), participated in consensual intercourse when her partner “spit” vodka into rectum. She was mildly tachycardic. Examination revealed a distressed, tearful, dehydrated female with lower abdominal tenderness. Labs revealed leukocytosis, metabolic acidosis and hyperchloremia. Urine toxicology was positive for amphetamines, benzodiazepines, opiates, cannabinoids. Blood alcohol level was zero. CT demonstrated diffuse wall thickening of rectum and distal sigmoid colon. She was admitted for hydration, analgesia, systemic antibiotics and was placed nil per oral. Colonoscopy revealed longitudinal ulcers predominantly in the rectum with erythema and erosions extending up to 20 cms above the anus. Biopsies showed mild nonspecific inflammation. Hydrocortisone enemas, stool softeners and oral diet were commenced. Follow-up sigmoidoscopy in six weeks was advised, patient did not attend.

DISCUSSION:
Intentional administration of alcohol enemas has been implicated in sexual practices, suicidal attempts, bowel cleansing, hemorrhoidal pain relief. Symptoms of abdominal pain, diarrhea, hematochezia, tenesmus develop within 24 hours. Endoscopic evaluation reveals edema, friable, hemorrhagic or necrotic mucosa with ulcerations. Histologic features include mild erythema, extensive mucosal sloughing, necrosis. Diagnosis can be challenging if pertinent history is not obtained, given the non-specific nature of clinical, endoscopic and histological findings. Ischemic colitis, perforation and peritonitis, respiratory depression and CO2 narcosis causing noncardiogenic pulmonary edema and death are potential complications. Severity depends on the amount and speed of administration. GI symptoms usually resolve within 7–10 days. Careful history taking, particularly sexual practices, is crucial when evaluating young healthy individuals with lower abdominal pain and colitis of unclear etiology.
1964 Case of a Rare Coagulation Disorder: A Cause of Recurrent Upper GI Bleeding
Authors: Swaminathan Renugadevi , Pandit Sudha , Manas Kenneth J. , Morris James D. 
Published: October 2019

INTRODUCTION:
The most common causes of acute upper gastrointestinal (GI) bleeding are peptic ulcer disease, variceal hemorrhage, Mallory-Weiss tear, and neoplasms. We report a rare case of an acquired hemophilia A diagnosed after recurrent GI bleeding.

CASE DESCRIPTION/METHODS:
A 63 years old male with a history of stroke, dementia, and anemia presented to the ED from clinic for low hemoglobin (Hb). On presentation, patient denied melena, hematemesis or hematochezia. Patient denied NSAIDs, antiplatelet, or anticoagulation therapy. Vital signs were stable. The examination was significant for pallor and right-sided hemiplegia. Admission labs showed Hb 3.9 g/dl and hematocrit 13.7%. Patient received 4 units of pRBC. and was initiated on PPI drip. Upper endoscopy showed active bleeding from duodenal bulb angioectasia, and hemostasis was achieved with 2 endoclips. During the admission, percutaneous endoscopic gastrostomy (PEG) tube was placed for dysphagia secondary to stroke. Subsequently, patient had continuous oozing of blood around the PEG tube insertion site. Aspiration from the PEG tube was negative for blood. Attempt to control the bleeding using external compression with pressure dressing and suture at the access site were unsuccessful. Patient had an episode of melena and required 3 more units of pRBC. Repeat EGD showed actively bleeding duodenal ulcer and non-bleeding gastric angioectasia. Hemostasis was achieved with thermal coagulation and epinephrine. Patient was worked up for coagulation disorder given persistent bleeding days after the PEG tube placement and secondary bleeding sites in the stomach. The lab results showed normal PT, elevated aPTT. and partial correction of the aPTT in the mixing studies. Subsequent labs revealed low Factor VIII activity of 2% and elevated factor VIII inhibitor of 23 Bethesda units/ml, which was consistent with acquired hemophilia A. Patient was initiated on Prednisone and Cyclophosphamide. After a week of initiating the therapy, patient did not have any GI or PEG tube site bleeding and the Hb remained stable.

DISCUSSION:
Acquired hemophilia A is a rare but life-threatening autoimmune condition and the treatment is immunosuppressive therapy to eliminate antibody production against Factor VIII. The risk for bleeding is increased with any invasive procedures including PEG tube placement. All GI bleeding patients in the absence of an obvious cause should have a coagulation work up. It is critical to recognize the underlying cause of GI bleeding for efficient management.
1965 A Case of Gastric Amyloidosis Manifested as Gastrointestinal Bleeding
Authors: Gupta Kamesh , Umar Jalaluddin , Chalhoub Jean , Budhraja Vikram 
Published: October 2019

INTRODUCTION:
Gastrointestinal amyloidosis (GIA) ensues from the deposition of insoluble extracellular protein fragments. GIA is most frequently associated with chronic inflammatory disorders (AA amyloidosis), plasma cell dyscrasias like multiple myeloma (AL amyloidosis), and end-stage renal disease (Beta-2 amyloidosis).

CASE DESCRIPTION/METHODS:
A 60-year-old female with a history of diastolic heart failure, light-chain multiple myeloma complicated with systemic amyloidosis and CKD stage III presented with acute epigastric abdominal pain associated with vomiting and non-bloody diarrhea that started a week after she had chemotherapy with bortezomib and elotuzumab. She was on chronic steroid and PPi therapy. On exam, she was noted to have tachycardia, dry mucous membranes, macroglossia and epigastric tenderness with no rebound. Her labwork showed a drop in hemoglobin from 8 g/dL to 5.9 g/dL in a period of 2 days and a platelet count of 48000/mL. Coagulation profile, liver tests and kidney tests were all normal. In the ED, her stool was positive for occult blood. CECT abdomen showed diffuse small and large bowel wall thickening, including the stomach and duodenum. Gastroscopy showed diffuse discontinuous congestion, friability, and ulceration of the mucosa. Clots overlying ulcers were removed with forceps revealing mild oozing only. The gastric biopsy revealed mucosal cells with extracellular amorphous deposits, staining positive for congo red stain, consistent with amyloid. She was started on palliative chemotherapy given her multi-system involvement of malignancy.

DISCUSSION:
GIA involves the buildup of insoluble proteins, most commonly in the second part of duodenum which impedes the normal organ structure and function. Weight loss and GI bleeding are the most common presentations of GIA. Bleeding is a sequela of mucosal lesions, wall ischemia, or vascular friability. The endoscopic appearance of amyloidosis is nonspecific. The mucosa may have a finely granular appearance, polypoid protrusions, erosions, ulcerations, and thickening of the wall. Tissue biopsy is required to make the diagnosis of GI amyloidosis. Treatment depends on a sufficient suppression of the predisposing inflammatory disorder, or malignancy, along with supportive therapy. The prognosis of patients with AL amyloidosis is worse with GI involvement.
1971 Strongyloides Infection Presenting as a Massive GI Bleeding Without Eosinophilia
Authors: Lagos Samuel , Mehta Amit , Wan David 
Published: October 2019

INTRODUCTION:
Nematode hyperinfection classically presents with eosinophilia. However, immunosuppressed patients on corticosteroid therapy or with chronic HTLV 1-2 infection do not necessarily express the eosinophilic pattern. This case of GI massive bleeding in a patient with T cell lymphoma and HTLV 1-2 infection illustrates this atypical scenario.

CASE DESCRIPTION/METHODS:
A 60 year-old male with a recent diagnosis of C. difficile colitiswas admitted to the ED with syncope and failure to thrive. His past medical history was notable for peripheral T cell lymphoma on azacitidine and CHOP, and chronic HLTV 1-2. The patient reported 6 days of nausea, vomiting, diarrhea, and chest pain. Patient was born in the Dominican Republic and moved to the US more than 10 years ago. On examination he was tachycardic and hypovolemic and responded to fluid resuscitation. The patient was in no acute distress. His labs were notable for hyponatremia, mild anemia without eosinophilia, cholestasis, hypoalbuminemia, increased PT and mild troponinemia. EKG was normal for acute coronary syndrome, and CT chest was significant for new small right and trace left pleural effusions with atelectasis. Abdominal US revealed gallbladder sludge and biliary duct dilatation. MRCP was normal. His course was complicated by melena and hematochezia. Given hemodynamic instability, he was managed with IV vancomycin and piperacillin/tazobactam in addition to vasopressors and blood products. EGD and flexible sigmoidoscopy showed diffuse mucosal oozing in the upper and lower GI tracts with targetoid, punched out duodenal lesions. Biopsy demonstrated worms suggestive of strongyloides on histopathologic evaluation. The patient was started on Ivermectin which was then switched to Praziquantel given concern of inadequate absorption due to ileus.

DISCUSSION:
Strongyloides infections usually present with variable grade of eosinophilia. However, eosinophilia may be suppressed or absent in disseminated disease because of concomitant pyogenic infection or steroid administration as we can see in this patient.3Additionally, patients with HTLV-1 infection express high levels of interferon-gamma production, which decreases the production of interleukin (IL)-4, IL-5, IL-13, and IgE, important molecules in host defense against Strongyloides.4 Strongyloides is typically diagnosed via serology, but was made after EGD was done for GI bleeding. Thus, Strongyloides infection should be on the differential for GI bleeding in an immunocompromised patient.
1972 Proton Pump Inhibitors Causing Severe Chronic GI Blood Loss Resulting in Severe Iron Deficiency Anemia
Authors: Hussain We'am , Musleh Mustafa 
Published: October 2019

INTRODUCTION:
Proton pump inhibitors (PPI) are a commonly used medication for the treatment for gastroesophageal reflux disease (GERD), peptic and NSAIDs induced ulcers. We report a rare case of severe chronic GI bleeding leading to severe iron deficiency anemia, caused by extensive hemorrhagic fundic gland gastric polyps secondary to long term PPI therapy.

CASE DESCRIPTION/METHODS:
A 77-year-old woman with past medical history of GERD controlled with omeprazole 20 mg daily, who was referred to GI due to severe symptomatic iron deficiency anemia. For about a year, her hemoglobin was slowly trending down, when she was referred to GI, her hemoglobin was 8.2 g/dl, with MCV 69 FL. Her iron indices showed iron saturation of 8%, TIBC of 426 mg/dl, and ferritin level of 8. She was started on oral iron therapy, and underwent colonoscopy and esophagogastroduodenoscopy (EGD) which revealed left colon diverticulosis, and innumerable gastric polyps including numerous large hemorrhagic polyps involving the entire stomach but excluding the antrum. Polypectomy of multiple polyps was done, although due to the extensive polyps burden, could not practically remove all polyps in one session. Pathology evaluation confirmed fundic glands polyps, with focal adenomatous changes in one of the large polyps without dysplasia, and there was no evidence of H.Pylori. Patient was advised to stop omeprazole, and was given ranitidine 150 mg BID as needed for reflux symptom. She had a second EGD one month later which still revealed innumerable gastric polyps, further removal of multiple large polyps was done, pathology was consistent with fundic glands polyps. 6 months later on follow up, patient hemoglobin improved to 12.3 mg/dl, with normalization of ferritin level. She had a repeat EGD which revealed remarkable regression of the size and number of the gastric polyps.

DISCUSSION:
We report herein a case of extensive gastric polyposis consistent with stent fundic glands polyps leading to severe chronic blood loss causing severe iron deficiency anemia. Fundic glands polyps in our patient, are attributed to hypergastrenemia secondary to chronic long term PPI administration.Most polyps are sporadic, hypergastrenemia due to ZES or chronic PPI use is associated with increase in prevalence of FGPs. A study showed fourfold increased risk of FGPs in patients on long term PPI therapy (over 5 years). Case reports have showed regression in number and size of FGPs after cessation of PPI therapy, as seen in our patient case.
1974 Seeing Isn’t Always Believing! Recurrent Hematemesis Due to Factitious Disorder
Authors: Lakhoo Krutika , Enayati Pedram 
Published: October 2019

INTRODUCTION:
Gastrointestinal bleeding is a common inpatient diagnosis with a cost >$5 billion in the US. Typically patients undergo endoscopic evaluation, capsule studies, CT imaging with/without embolization and in severe bleeding, surgical management may be pursued. We present a case of recurrent GI bleeding due to factitious disorder.

CASE DESCRIPTION/METHODS:
52-year-old female veterinary tech with a complex surgical history presented to the ER for acute recurrent hematemesis with bright blood seen in ER. In 2017, she developed recurrent upper GI bleeding. Previous EGD showed Dieulafoy lesions that were clipped and she underwent partial gastrectomy. Physical examination showed normal vitals and diffuse mild abdominal tenderness. Labs showed stable normocytic anemia (Hgb 9-10), normal iron stores, LFTs, INR, and platelets. She underwent extensive workup including angiogram, multiple endoscopies, and multiple CTA A/P with no identifiable source of bleeding. Given ongoing visualized bleeding and almost weekly hospitalizations she underwent remnant gastrectomy for definitive management and pathology confirmed Dieulafoy lesions. During the hospitalization, she was found to have 2 blood-filled syringes in her pillowcase. She had multiple concerning signs for a psychiatric disorder: "la belle indifference", no active bleeding on endoscopy, no melena, persistent bleeding despite gastrectomy, stable Hgb, female with medical training, and no further bleeding after sitter placed. Psychiatry team was consulted and discovered she had been ingesting blood drawn from a PICC line to stimulate bleeding. A diagnosis of Munchausen’s disorder was made.

DISCUSSION:
Munchausen’s disorder occurs when patients intentionally produce physical or psychiatric symptoms (usually of dramatic nature), allowing them to assume a sick role and gain medical attention. This is a difficult diagnosis and often results in the excessive use of medical resources. Risk factors include a serious illness/trauma during childhood, loss of a loved one, personality disorder, and being a healthcare worker. The motive is mainly to gain sympathy and attention. Physicians should confront patients with the diagnosis if a good therapeutic relationship has been established and patients benefit from psychotherapy and close medical and psychiatric follow up. Prognosis tends to be poor however, with most patients refusing psychiatric evaluation and leaving AMA. This case adds to literature suggesting factitious disorder with hematemesis is not as rare as expected.
1978 Picking up the Pieces: Surgical and Medical Management of Retained Shattered Glass in the Rectum
Authors: Klein Elliot , Bressler Moshe , Nadler Shmuel , Peysin Konstantin , Lapin Seth 
Published: October 2019

INTRODUCTION:
Retained rectal foreign bodies are an increasingly common presentation requiring emergent surgery. The object can often be retrieved at bedside. However, in the setting of a retained foreign body, especially one complicated by bleeding, perforation, or peritonitis, open surgery or laparoscopic assisted transanal retrieval is often needed. Careful investigation and a high index of suspicion is required as patients are often reluctant to share the etiology of their presentations.

CASE DESCRIPTION/METHODS:
A 55-year-old male presented to the ED with complaints of rectal bleeding. He stated he had placed a glass bottle in his rectum. Upon removal he noticed the top half of the bottle was retained inside his rectum. He developed mild rectal pain and bright red blood per rectum. On exam, there were no peritoneal signs. DRE revealed no perianal lesions, sphincter lacerations, or palpable foreign bodies. Initial labs displayed hemoglobin and hematocrit at 11.7 and 34.1, respectively. CT showed multiple radiopaque foreign bodies in the distal rectosigmoid measuring up to 14 cm in length with presacral edema. Proctoscopy was performed in the OR. Glass which was readily removable via a transanal approach was retrieved, while larger perforating pieces were carefully mobilized proximally and retracted via laparotomy. Sigmoidoscopy confirmed complete removal with multiple deep lacerations and perforations in the rectal wall. On post-op day seven, large volume rectal and mucus fistula bleeding with severe hypotension, tachycardia, change in mental status and a drop in hemoglobin to 5.8 occured. MTP was activated with administration of a total of five units of PRBC and two units of FFP. Colonoscopy was performed in the OR. An ulcer containing a pulsating, protruding, visible vessel was actively bleeding. Two clips were placed over the vessel with no further episodes of bleeding. Three months postoperatively barium enema was performed showing no leaks leading to reversal of colostomy.

DISCUSSION:
A retained rectal foreign body is not commonly the cause of a surgical emergency. Post-op complications, such as rectal bleeding, are rare and are normally handled by a return to the OR to control the source. Colonoscopy after a perforating rectal injury may be considered to evaluate and stop the source of postoperative bleeding, thus avoiding additional surgery and decreasing recovery time. Additionally, DRE should be cautioned when suspecting sharp hazardous material at an undetermined height in the colorectal tract.