bluuebunny/crossref_metadata_2025_split huggingface dataset:
2525 A Case of IgA Vasculitis Diagnosed With Small Bowel Biopsy
Authors: Samies John , Kumar Vikas , Zhu Shaobo , Khara Harshit S. , Confer Bradley 
Published: October 2019

INTRODUCTION:
Immunoglobulin A (IgA) vasculitis is an immune-mediated condition that primarily targets small vessels. Presentation may vary- colicky abdominal pain, palpable purpura, acute arthritis, or nephritis. Adult annual incidence is 0.8-1.8/100,000. In adults, abdominal pain is rarely the presenting symptom. We report a case that presented with abdominal pain and was diagnosed with IgA vasculitis via duodenal biopsy.

CASE DESCRIPTION/METHODS:
A 60 year old male presented with acute onset severe periumbilical pain and watery diarrhea for several days. Pain was associated with vomiting and worsened after meals. Physical examination revealed marked periumbilical and right lower quadrant tenderness. Other review of systems and physical exam findings were unremarkable. Laboratory tests were remarkable for mild leukocytosis with neutrophilic predominance and elevated C-reactive protein. CT scan of the abdomen/pelvis showed significant patchy small bowel thickening with surrounding inflammatory changes. Small bowel enteroscopy showed edematous, purpuric and friable mucosa in the duodenum and proximal jejunum with stigmata of recent bleeding. Biopsies were obtained. Immunostaining for IgA was positive in the lamina propria, suspicious for small bowel IgA vasculitis. Shortly after that, he developed palpable purpura on upper and lower extremities. Punch skin biopsy confirmed IgA vasculitis. He was started on taper of systemic steroids, which lead to the resolution of skin and abdominal vasculitis within a few days. Currently, patient is in remission on rituximab maintenance therapy.

DISCUSSION:
In cases of abdominal involvement, IgA vasculitis has a predilection for small intestine. The classic endoscopic findings are diffuse mucosal reddening with hemorrhagic erosions and hematoma-like protrusions. Treatment is dependent on severity of vasculitis activity. For moderate to severe disease, systemic corticosteroids and analgesics are the mainstay of treatment. The diagnosis of IgA vasculitis is challenging, especially if abdominal pain precedes other manifestations. This case highlights the diagnostic value of early endoscopy in patients suspected of developing IgA vasculitis.
2542 Emerging Use of Hemospray in Lower Gastrointestinal Bleeding: Primary Mucosal Melanoma of the Jejunum
Authors: Alsheikh Mira , El Imad Cheikh Talal , Andrawes Sherif , Weissman Simcha , Deeb Liliane , Kamar Khalil 
Published: October 2019

INTRODUCTION:
Small bowel (SB) primary melanomas (PM) are extremely rare; around 30 cases are reported to date. Diagnosis is challenging due to difficult endoscopic access and dealing with its complications such as bleeding is even more difficult. We describe in this report a case of jejunal primary melanoma presenting with lower gastrointestinal (GI) bleeding controlled with Hemospray.

CASE DESCRIPTION/METHODS:
A 70-year-old man with coronary artery disease on aspirin presented with symptomatic anemia. He endorsed recurrent melena associated with weight loss. Vital signs were stable. Physical exam remarkable for melena on rectal exam. Computed tomography scan of the abdomen revealed a jejunal mass. The patient underwent a push enteroscopy, which showed a large ulcerated necrotic mass in the mid-jejunum that was actively bleeding. The entire mass was oozing from multiple foci with a large surface area. It was invading the jejunal wall with larger vessels exposed. Hemospray was used to achieve hemostasis. Pathology revealed malignant melanoma; a thorough skin and eye exam was negative for PM. The patient denied any history of excision of pigmented skin lesions. The final diagnosis was primary melanoma of the jejunum.

DISCUSSION:
Malignant melanomas are mostly cutaneous. Only 3-4% originate in mucosal membranes as primaries. The diagnosis is challenging due to nonspecific manifestations and difficult pathologic access. Radiological studies are the first diagnostic approach. Balloon enteroscopy allows histopathological diagnosis and management of complications such as bleeding. In our case, the jejunal tumor was ulcerated with an extensive surface area and multiple foci of actively bleeding vessels. Due to the abundant lymphovascular supply of the intestinal mucosa, SB melanoma is a highly vascularized tumor. Hemospray was the preferred initial modality in this particular scenario and was successfully used for hemostasis. It is an inorganic powder that provides hemostasis by acting as mechanical tamponade and increasing the local concentration of clotting factors. It is easy to use with an excellent safety profile, does not require precise targeting, and is efficacious in large surfaces. Mucosal tissues do not absorb it; thus, it has no risk of systemic toxicity. It is FDA approved for hemostasis of non-variceal GI bleeding. It is contraindicated in varices and fistulas. It was also used in cancer-related bleeding with promising results. It can be applied repeatedly as a bridge to other definitive modalities.
2547 Atraumatic Paraduodenal Hematoma in a Patient Presenting With Gastric Outlet Obstruction
Authors: Sannapaneni Shilpa , Assaf Andrew , Feldman Mark 
Published: October 2019

INTRODUCTION:
Paraduodenal hematomas are hematomas occurring alongside, near, and/or around the duodenum, the latter of which is characterized by hemorrhage into the duodenal wall. They have been reported in the setting of abdominal trauma, coagulopathy/anticoagulants, malignancy, chemotherapy, pancreatic disease, alcoholism, and endoscopic procedures.

CASE DESCRIPTION/METHODS:
A 56-year-old Caucasian male presented with epigastric pain that started 10 days prior to presentation. He described the pain as sharp, up to 10/10 in intensity, non-radiating, waxing and waning, and associated with nausea and multiple episodes of coffee ground emesis. He denied any abdominal trauma and was on no anticoagulation. He drank 2-3 glasses of alcohol every night. On presentation, he was afebrile with normal vital signs. He had a soft abdomen, normal bowel sounds and mild tenderness to palpation in the epigastric region. Laboratory studies were significant for a Hgb of 11.7 g/dL and a WBC count of 13.4 × 109/L. A CT scan of the abdomen with IV contrast revealed an 8 × 8 cm paraduodenal mass. Abdominal magnetic resonance imaging with and without contrast revealed a paraduodenal hematoma approximately 7 × 10 × 8.2 cm in size. The patient was kept NPO and a nasogastric tube was placed. Upper endoscopy revealed intrinsic traversable moderate stenosis at the 2nd part of the duodenum. Repeat abdominal CT scan with and without IV contrast was negative for any aneurysm with no interval change in the paraduodenal hematoma. Total parenteral nutrition was started on the second day of hospitalization and was discontinued on the sixth day. The patient's diet was slowly advanced until he was able to tolerate a full liquid diet. On the day of discharge, the patient did not have abdominal distention, abdominal pain or nausea. The patient was followed two weeks later; he was advanced to a regular diet and had complete resolution of his symptoms.

DISCUSSION:
Duodenal hematoma was first described by MacLauchan in 1838. Up to 80% of cases are secondary to high impact abdominal trauma. The esophagus, duodenum, jejunum have all been reported to have cases of intramural hematomas. Duodenal hematomas have a higher incidence secondary to the fixed retroperitoneal position; a location that is anterior to the spine makes it highly susceptible to blunt abdominal trauma. Patients can present with abdominal pain, signs of small bowel obstruction, hematemesis, anemia and rarely pancreatitis. Treatment is usually conservative.
2554 A Hefty Hematoma: A Rare Case of Pancreaticobiliary Obstruction After Gastrectomy With Roux-en-Y
Authors: Lech Diana , Wander Praneet , Ashamalla Michael , Pizzuti Jessica , Cheung Mary 
Published: October 2019

INTRODUCTION:
Pancreaticobiliary obstruction is an uncommon complication of total gastrectomy with Roux-en-Y reconstruction. We present a case of a patient with a closed loop obstruction due to a hematoma at the location of jejunojejunal anastomosis. The patient underwent EGD with clot evacuation resulting in decompression of the pancreaticobiliary limb.

CASE DESCRIPTION/METHODS:
A 57-year-old male, with hypertension, who had recently immigrated from China presented for evaluation of persistent heartburn. He underwent an upper endoscopy, which showed erythematous gastric mucosa and pathology was positive for superficial invasive adenocarcinoma. He was referred to surgery and underwent laparoscopic esophagogastroduodenoscopy, robotic assisted total gastrectomy and Roux-en-Y reconstruction with jejunostomy tube placement. On postoperative day one, there was bright red blood on aspiration from his nasogastric tube and J-tube. Laboratory tests were notable for downtrending hemoglobin and he required 2 units of packed cells. Due to concern for active bleeding, the patient underwent an upper endoscopy in the operating room, which demonstrated no active bleeding and presence of a blood clot at the JJ anastomosis. Epinephrine was injected at the site of the clot. Post procedure, he had increasing total bilirubin which peaked at 5.9. A computed tomography was done on postoperative day 3, demonstrating marked dilation of the pancreaticobiliary limb, which was suspicious for a clot within the small bowel at the level of the JJ anastomosis, concerning for a closed loop obstruction. He then underwent a repeat endoscopy using a duodenoscope. A 9 cm clot was visualized at the JJ anastomosis causing pancreaticobiliary obstruction. The clot was removed with cold soft snare, grasping forceps and roth net with resultant free flow of bile at the site of JJ anastomosis. Total bilirubin subsequently downtrended and returned to normal. The patient's recovery was uneventful, and he was discharge 16 days after clot evacuation.

DISCUSSION:
The most common early complications of total gastrectomy with Roux-en-Y reconstruction include SBO and anastomotic leak. Our case highlights a rare complication of pancreaticobiliary limb obstruction due to hematoma at the JJ anastomosis. Early EGD allowed for clot evacuation and limb decompression without need for re-operation.
2556 Duodenal Candidiasis Presenting as Mass-Like Lesion: A Rare Presentation
Authors: Alakkam Anas , Masood Umair , John Savio 
Published: October 2019

INTRODUCTION:
Candida is a normal inhabitant in the GI tract. It is typical for candidiasis to appear in the esophagus and oropharynx in immunocompromised patients. However, candidiasis of the stomach or duodenum is rare. We report a case of a gastric outlet and biliary obstruction due to a duodenal mass-like lesion in the setting of duodenal candidiasis.

CASE DESCRIPTION/METHODS:
Patient is a 66 year old female with past medical history of diabetes mellitus type 2, hypertension and osteoarthritis who presented to the hospital with progressive non-bloody vomiting, poor oral intake and constipation for two months. She endorsed abdominal pain and yellowing of the eyes and skin. Her vitals on admission were normal. Physical exam was pertinent for diffuse abdominal tenderness and scleral icterus. Her laboratory findings were significant for AST of 137 U/L, ALT of 130 U/L, alkaline phosphatase of 205 U/L, total bilirubin of 8.9 mg/dL and direct bilirubin of 5.3 mg/dL. Abdominal CT scan showed duodenal thickening with possible mass-like lesion causing gastric outlet obstruction. MRI of the abdomen and MRCP only showed duodenal wall thickening. She had a subsequent EGD that showed mild gastric erythema and a mass like lesion in the duodenum hindering the visualization of the papilla. Biopsy results were significant for active chronic duodenitis with presence of Candida albicans. Gastric biopsy was positive for H. pylori infection. The patient was treated with a 21 day course of Fluconazole followed by bismuth based quadruple therapy. Follow-up EGD showed resolution of the duodenal lesion. At two months follow up after treatment, the patient had no symptoms and liver enzymes were normal.

DISCUSSION:
Candida is part of the normal flora of the GI tract and commonly causes infection in the mouth and esophagus. Stomach and duodenal infections are less common due to their relatively acidic environment creating a harsh environment for the fungal species to grow and cause disease. However, immunocompromised patients and patients on acid suppressive therapy are vulnerable to opportunistic candidal infection. The long standing history of diabetes may have predisposed patient to the infection. In conclusion, our case highlights a rare presentation of a duodenal candidal infection; mass-like lesion causing gastric outlet and biliary obstruction. This case should serve as a reminder to clinicians to keep candidiasis in the differentials for duodenal infections especially in diabetic patients.
2564 Rare Malignant Peritoneum Mesothelioma Masquerading With Respiratory Manifestation
Authors: Patel Ravish , Vekaria Pratikkumar , Vaishnani Devin , Mao Johnnie , Raiyani Chandrika , Vaishnani Marvin , Raiyani Tejas 
Published: October 2019

INTRODUCTION:
Mesothelioma is a rare and aggressive cancer that affects the linings of the pleura, peritoneum and pericardium. Pleural involvement is however most common. Malignant Peritoneal mesothelioma (MPM) is a cancer developing in the lining of the peritoneum, which is extremely rare. Most MPM cases are caused by asbestos exposure. Common symptoms of MPM include abdominal distension, abdominal pain, swelling or tenderness and constipation or diarrhea, with most common being abdominal swelling. MPM is difficult to diagnose due to its vague, nonspecific symptoms.

CASE DESCRIPTION/METHODS:
67-yo-Male presented to the ER with complaint of Shortness of Breath for 6 weeks and dry cough. He was treated as an outpatient with bronchodilator, steroid and 2 rounds of antibiotics with no relief. He also had poor appetite, unexpected 10 lb weight loss and generalized weakness. CT Chest was pertinent for abdominal findings with bilateral anterolateral mesenteric nodularity along with ascites. CT abdomen & pelvis subsequently asserted it with likely malignant diagnosis. Surgical biopsy confirmed mesothelioma of the peritoneum. Patient denied any exposure to asbestos, but had worked in construction his entire adult life. Oncology offered palliative chemotherapy, which he refused. Follow-up CT Abdomen 1 month later showed progressive MPM. With rapidly worsening disease, no chemotherapy and overall poor prognosis, patient accepted comfort care. Unfortunately, he succumbed to his fatal diagnosis within 2 months on hospice care.

DISCUSSION:
Ours is a rare case of MPM where patient presented with atypical respiratory symptoms. Generally, abdominal symptoms are common to present. Early on, he was treated as cough variant asthma. But without improvement, further evaluation was carried out leading to incidental unexpected abdominal findings on CT Chest. Further workup with concluding biopsy confirmed MPM. Due to rarity and short life expectancy, MPM does not have set staging system. Early and timely diagnosis aids rearranging goals of care in such instances. In terminal illnesses, quality of life with timely discussion of comfort care is crucial. With red flag symptoms, like rapid weight loss in our case despite atypical presentation, should warrant careful evaluation as it could change goals and treatment plans substantially. However, it can offset the balance for high value care at times. We hope that future medical advances will bridge this disparity positively for rare cases also.
2565 Clostridioides difficile Enteritis Refractory to Multiple Fecal Microbiota Transplantions
Authors: Sharma Bashar , Antoine Marsha , Shah Mili , Hasan Muhammad , Rawlins Sekou 
Published: October 2019

INTRODUCTION:
Clostridioides difficile (CDI) is a spore-forming, toxin-producing, gram positive bacteria that can colonize the colon when the normal flora is disrupted causing colitis. However, it can rarely colonize the small intestines causing enteritis, especially in patients with recent antibiotic use, on immunosuppression or have surgically altered intestinal anatomies.

CASE DESCRIPTION/METHODS:
A 77-year-old female with a history of fulminant CDI colitis requiring subtotal colectomy with end ileostomy presented with abdominal pain and increase in ileostomy output two months after surgery. Her ileostomy drainage tested positive for CDI by PCR and she was started on oral vancomycin for CDI enteritis with resolution of her symptoms. Over the next year, she had multiple recurrences of her CDI that failed vancomycin, fidaxomicin and IV immunoglobulin (IVIG). She eventually had fecal microbiota transplantation (FMT) with stool infused into the proximal jejunum. Her symptoms improved initially, however recurred and her ileostomy drainage tested positive for CDI again. She had a total of four FMT due to recurrence. After her fourth FMT, her symptoms recurred, however; she tested negative for CDI this time. Infectious diarrhea as well as celiac disease were negative and her symptoms did not improve with antidiarrheal agents. She developed significant anxiety and requested to be placed on vancomycin understanding the risks of long-term use of antibiotics. She was started on a prophylactic daily dose of oral vancomycin 125 mg which helped to improve her symptoms.

DISCUSSION:
CDI enteritis is rare; yet, its incidence is rising. Diagnosis is made both clinically and biochemically by testing for CDI toxin by PCR. In the literature, there are no prospective studies on the treatment of CDI enteritis except for a few case reports. Oral metronidazole has been used, with oral vancomycin used for refractory cases. In our case, the patient failed vancomycin, fidaxomicin, IVIG and three FMT with recurrence of the symptoms after the fourth one. Prophylactic oral vancomycin was started on the patient's request and she noticed improvement in her symptoms. Prophylactic vancomycin has been effective in preventing recurrence of CDI in patients with a history of CDI being treated with oral antibiotics. Our case is unusual given the ongoing symptoms in a PCR negative CDI state. Further research is needed in patients with refractory CDI enteritis with analysis of their bowel flora to better understand this disease and how to treat it
2574 15 Years Out, a Small Bowel Transplant That Defeated the Odds
Authors: Khan Ummi , Soliman Isaac , Nathan Swami 
Published: October 2019

INTRODUCTION:
Small bowel transplant has been shown to have good short-term patient survival rates, however long-term rates are often dismal. We present one of the longest documented survivals of a small bowel transplant.

CASE DESCRIPTION/METHODS:
A 69-year-old female underwent multiple surgical interventions due to recurrent small bowel obstruction during her 3rd and 4th decades of life. Unfortunately, this resulted in a short gut syndrome. At the age of 54, she underwent an isolated small bowel transplant. She had a prolonged post-transplant hospitalization requiring 11-month stay. Despite being compliant with mycophenolate and tacrolimus, she had multiple admissions for sepsis and volume depletion from her ileostomy losses. Due to nephrotoxicity form immunosuppressive drugs, she developed ESRD requiring HD in the last 3 years. Despite the challenges, she has continued to live independently.

DISCUSSION:
Isolated small intestine transplantation is a rare procedure in adult patients. This continues to be the last measure for intestinal failure in patients who cannot tolerate or receive total parental nutrition. Some of the common causes of intestinal failure in adults include bowel ischemia, volvulus, trauma, and Crohn's disease. Over the last two decades, the success rate of small bowel transplantation has improved due to advancements in immunosuppression, refined surgical techniques, and better post-transplantation care. However, despite this glimmer of hope, both the procedure and post-transplanted state are associated with high morbidity and mortality rates. Post-transplant complications include opportunistic infections due to immunosuppressive agents, graft rejection and surgical complications including anastomotic leaks. Graft rejection appears to be the most common and at times difficult to manage complication, though this too has improved. Today, patient survival at one year is close to 85%, 5 years at 61% but at 15-years survival is unfortunately at 35%. Our patient has no signs of graft rejection after 15 years post-transplant and her liver synthetic function remains normal.
2578 Meckel's Diverticulum: A Diverticulum Like No Other
Authors: Alsheikh Mira , Haddad Fady , Mulrooney Stephen 
Published: October 2019

INTRODUCTION:
Meckel's diverticulum (MD) is a relatively uncommon cause of gastrointestinal (GI) bleeding in adults. “Often looked for and seldom found,” MD is challenging to diagnose despite the various imaging modalities available. Herein, we present the case of a young man who presented with lower GI hemorrhage and negative endoscopy, bleeding scan, and angiography. Meckel's diverticulum was later diagnosed via scintigraphy scan. We review the noninvasive diagnostic imaging for Meckel's diverticulum, mainly technetium-99m (Tc 99m) pertechnetate scan, and bleeding scan.

CASE DESCRIPTION/METHODS:
A 26-year-old man presented with multiple episodes of melena. He had acute onset anemia. Workup, including upper endoscopy, colonoscopy, and push enteroscopy were not able to identify the site of bleeding even after repeat procedures. A computed tomography scan with intravenous contrast and mesenteric angiography were also unrevealing. A Technetium 99m bleeding scan was read as negative. Persistent bleeding necessitated recurrent transfusions. Capsule endoscopy was deployed. A Meckel's scan (Tc 99m Pertechnetate scan) revealed an abnormal focus of uptake in the right lower abdomen suggesting the diagnosis of Meckel's diverticulum. The patient underwent laparoscopic resection of the diverticulum and was discharged home (Figures 1 and 2). A retrospective review of the bleeding scan revealed isolated uptake in the location of the Meckel's Diverticulum. Review of the capsule endoscopy revealed a diverticulum in the small bowel in the right lower quadrant without active bleeding (Figure 3).

DISCUSSION:
Bleeding Meckel's diverticulum is easier to diagnose than MD presenting with other symptoms, but still an outstanding challenge. High suspicion for MD should be sought in the evaluation of a young patient presenting with GI bleeding; the gold standard for diagnosis is the technetium-99m pertechnetate scan or so-called Meckel's scan. Bleeding scan is another noninvasive imaging modality that helps to detect a bleeding MD. Although both scans use Tc 99m, the mechanism is different. Meckel's scan uses Tc 99m, which is secreted by parietal cells in the mucus, thus detecting gastric cells within MD. On the other hand, the bleeding scan works via identifying Tc 99m that is bound to hemoglobin, therefore identifying a bleeding MD. Both scans are noninvasive and safe. The use of either one should be tailored according to the clinical presentation.