bluuebunny/crossref_metadata_2025_split huggingface dataset:
3091 Squamous Papilloma of the Esophagus
Authors: Olson Kristin , Sunkara Tagore , Becker Bradley , Gaduputi Vinaya , Andres Matthew 
Published: October 2019

INTRODUCTION:
Squamous esophageal papillomas are rare epithelial lesions typically discovered incidentally during esophagoduodenoscopy (EGD). The occurrence in patients undergoing EGD is less than 0.45 percent and the prevalence in the general population inferred from autopsy is less than 0.04 percent. Most patients are asymptomatic unless the lesion is large. The most common symptom is dysphagia. A majority of these lesions are found in the distal one third of the esophagus. They have not been demonstrated to progress to esophageal carcinoma.

CASE DESCRIPTION/METHODS:
Our patient was a 53 year old male with history of alcohol abuse who presented with new-onset seizure/syncope, six painless maroon stools, and coffee-ground emesis. The patient admitted to frequent diclofenac use. He was found to be anemic with a hemoglobin of 7.9 G/dL and had an elevated INR of 1.2. He was transfused two units of packed red blood cells and was started on a pantoprazole drip. Initial endoscopy revealed an island of tissue growth in the mid-esophagus and a bleeding duodenal ulcer that was injected with epinephrine, cauterized with gold probe, and clipped. Biopsy of the esophageal lesion was deferred to outpatient follow-up given the severity of the patient's presenting condition. Following the procedure, he was continued on the pantoprazole drip with transition to oral pantoprazole 40 mg daily. He had no further signs of gastrointestinal bleeding. Two weeks later, an EGD was performed. Biopsies were taken of the stomach mucosa and mid-esophageal mass. Gastric biopsy demonstrated mild chronic gastritis without dysplastic changes or helicobacter pylori. Esophageal biopsy demonstrated findings consistent with squamous papilloma.

DISCUSSION:
Squamous papilloma of the esophagus is a rare but benign lesion. Its macroscopic appearance is similar to other, less benign growths (verrucous squamous cell carcinoma, granulation tissue, or papillary leukoplakia). The etiology is unclear. Chronic mucosal irritation from GERD or esophagitis is the prevailing theory of pathogenesis, but HPV – strongly associated with cervical, anal, and oropharyngeal cancers (depending on viral serotype) – has been detected in some lesions. Thus, the gold standard for evaluation is biopsy. There are various proposed therapies for squamous papillomas including resection, cautery and radiofrequency ablation. Future research is needed in regard to treatment and surveillance for these lesions.
3100 Acute Esophageal Necrosis (Gurvits Syndrome) in a 78-Year-Old Male Filipino Patient
Authors: Menchavez Ma Charisse P. , Batoctoy Karen S. 
Published: October 2019

INTRODUCTION:
Acute Esophageal Necrosis (AEN), also known as Gurvits Syndrome and commonly referred to as Black Esophagus, is a rare life-threatening clinical entity with an estimated prevalence of 1 to 200 in 100,000 and a mortality rate of approximately 30%. Only 88 patients over a span of 40 years have been reported. It is associated with geriatric males, diabetes mellitus, GERD, CKD, hypertension, vascular disease, alcohol abuse, malnourishment, ingestion of caustic agents and some medications. These factors predispose a patient to AEN through hemodynamic compromise, low-flow states, tissue hypoperfusion, corrosive injury and diminished mucosal defenses. Upper GI bleeding is the presenting complaint in around 90% of cases. It is diagnosed on endoscopy where characteristically, a diffuse, circumferential, necrotic esophageal mucosa is seen. The treatment for AEN aims to address the underlying medical illness, maintain and restore hemodynamic stability with intravenous fluid resuscitation and blood transfusions, attain complete esophageal rest, gastric acid suppression and antimicrobials.

CASE DESCRIPTION/METHODS:
A 78-year-old Filipino man developed hematemesis on a background of T2DM, hypertension, NSAID use and excessive alcohol use. He had no GI signs or symptoms prior to this episode. Four hours later he became drowsy and confused and was noted to be in hyperosmolar hyperglycemic state. An endoscopy revealed a distinctly diffuse circumferential necrosis of the esophagus with abrupt demarcation at the gastroesophageal junction. The gastric mucosa and biopsies were unremarkable. CT showed a distended aperistaltic esophagus with circumferential thickening with no evidence of perforation. Post endoscopy he was treated in ICU where he was maintained on parenteral nutrition, meropenem, nystatin, pantoprazole and insulin. Repeat endoscopy 7 days later showed pink mucosa after appropriate glycemic control, bowel rest and hemodynamic stabilization. He was discharged 3 days later.

DISCUSSION:
This is the first known report of a Filipino diagnosed with AEN. He presented with hematemesis, many of the risk factors associated with AEN, and his endoscopic findings were classic for AEN. However, he was only diagnosed sometime after endoscopy. This case highlights that AEN may be underdiagnosed and that clinicians should be mindful of it as populations develop more co-morbidities and risk factors that predispose them to developing it. This case also highlights the reversibility of this life-threatening condition.
3101 Barrett's Esophagus With Metastatic Neuroendocrine Tumor
Authors: Burgos Melanie , Sotiriadis John 
Published: October 2019

INTRODUCTION:
Neuroendocrine tumors are a rare group of cancers that can occur in many different organs. Due to their rarity and variable presentation, they are not well understood. In contrast, Barrett's esophagus is a well-known condition frequently associated with the development of esophageal adenocarcinoma. A review of literature has shown only 8 cases demonstrating an association between neuroendocrine tumors and Barrett's esophagus.

CASE DESCRIPTION/METHODS:
A 73-year-old male presented to the hospital status post fall due to altered mental status. Relevant past medical history included GERD, Barrett's esophagus, and gastric adenocarcinoma which was treated with surgery and chemoradiation 6 years prior. Imaging of the head revealed metastatic lesions. Further investigation with a CT chest, abdomen, and pelvis showed metastatic lesions in the bilateral lung lobes and the left trochanter. Biopsies of the esophagus and stomach on esophagogastroduodenoscopy (EGD) showed Barrett's esophagus with no presence of gastric metaplasia. A biopsy of the trochanter was also performed. Pathology results were positive for synaptophysin, chromogranin, CK7, and CK20, at both sites of biopsy for the esophagus and trochanter. Ultimately, the patient was placed on hospice.

DISCUSSION:
Neuroendocrine carcinomas of the esophagus are rare, accounting for 0.4-5.9% of all esophageal carcinomas. The rarity of neuroendocrine tumors and their ability to manifest in many different organs often makes diagnosis difficult. As with this patient, the origin of metastatic disease was initially unclear due to the multiple sites involved. Synaptophysin and chromogranin are specific to neuroendocrine tumors which were found in both the esophagus and trochanter. CK7 and CK20 are markers usually found in gastrointestinal mucosa, suggesting that the esophagus was the primary site of cancer. Furthermore, biopsies of the esophagus and stomach were positive for Barrett's esophagus and negative for metaplasia of the stomach, indicating that these metastatic lesions were not from a recurrence of the patient's prior gastric cancer. Further research is needed to determine if these findings are coincidental or if there is a true association between Barrett's esophagus and neuroendocrine tumors.
3113 The Hidden Culprit: A Case of an Accidental Foreign Body Ingestion
Authors: Wankhade Charudatta , Jacob Bobby , Karim Syed , Jiyani Rucha , Rizvon Kaleem 
Published: October 2019

INTRODUCTION:
Foreign body in the esophagus is a common emergency faced by a gastroenterologist. A thorough history and clinical examination followed by appropriate investigations and interventions is very essential. We present a case of a 41 year old male who accidentally swallowed a bottle cap and was symptomatic in spite of negative imaging studies.

CASE DESCRIPTION/METHODS:
41 year old African American male presented with epigastric pain after he accidentally ingested a plastic cap of a small water bottle 3 days ago. Pain was non radiating, intermittent, associated with an episode of non-bloody vomiting. He was unable to eat solid food after the ingestion of the bottle cap. He visited the two different hospital prior to this visit and was discharged after negative imaging studies. Review of systems was negative for any other systemic symptoms. Medical history was significant for asthma but he did not have any significant surgical, family or social history. On physical exam, he was afebrile, blood pressure and heart rate were 128/80 and 86 per minute respectively. He was speaking in full sentences but was irritable. Rest of the physical exam was unremarkable. After initial x ray's and CT scan were negative for foreign body ingestion, the patient was scheduled for upper endoscopy. Endoscopic intervention revealed a plastic bottle cap at 35-38 cm from incisors. It was successfully removed with a raptor forcep. A cratered linear esophageal ulcer was noted at 35-38 cm from esophagus. Patient tolerated the procedure well without any complications. He was able to consume mechanical soft diet a day after the procedure.

DISCUSSION:
The initial approach towards patients presenting with esophageal foreign body demands urgent clinical assessment and appropriate radiological investigation. Asymptomatic patients with an acute presentation and lack of respiratory impairment can be seen on an outpatient or inpatient basis, depending on the clinical scenario. Most foreign bodies in the esophagus pass spontaneously but about 3-10% may require some type of intervention. In the event of non-resolution of symptoms and negative radiography, intervention should be sought without delay. Our patient could have benefited from endoscopic intervention on his initial visit to the emergency room. Food, plastic, and wood are not radio-opaque and as a result are not seen on routine x-rays or can be missed on CT scan. If suspicion of a foreign body remains high after negative imaging studies, then diagnostic endoscopy may be indicated.
3117 “A Gut Feeling”: Autonomic Instability and Dysbiosis in Connective Tissue Disease
Authors: Steimle Cassandra , Ali Farhan , Kelts Andrew , Jeng Jennifer , Golikov Edwin , Kochik Michael , Raborn Eric 
Published: October 2019

INTRODUCTION:
Ehlers-Danlos Syndrome (EDS) is a connective tissue disease in which mutations in certain genes result in a disruption of normal collagen. There are several subtypes of the disease. Among the various subtypes which exist, hypermobility is the most common. Many of these patients can have co-existing gastrointestinal symptoms, which are often times overlooked by practitioners.

CASE DESCRIPTION/METHODS:
A 23 year old female presented with chest tightness, daily palpitations, and diarrhea which had been persistent for three days. Her past medical history was notable for spinal stenosis and lactose intolerance. She denied any associated abdominal pain, fever, or chills. Her family history was non contributory. One month later, she continued to have diarrhea and heartburn. She endorsed symptoms of mucorrhea with associated bright red blood per rectum, lower abdominal pain, and fecal urgency. A thorough physical examination revealed hyper flexible joints and greater than normal mobility of her fingers. After genetic testing, she was later diagnosed with Ehlers-Danlos Type 3.

DISCUSSION:
Up to 57% of patients with EDS have coexisting functional bowel disorders.1 Chronic gastrointestinal discomfort was reported in 86% of patients with Ehlers-Danlos – hyper mobile subtype.2 Gastrointestinal complications can include gastro esophageal reflux disease, hiatal hernia, gastritis, gastric emptying, irritable bowel syndrome (found in 62% of patients), rectal evacuatory dysfunction, and delayed colonic transit.1,2,4 Symptoms are thought to occur as a result of bidirectional signaling between gut bacteria and the brain. Enterochromaffin cells are not only accessible by enteric microbiota but also have contact with afferent and efferent nerve terminals acting as “transducers” between the gut and brain,8 able to secrete various compounds, including serotonin. One study showed that pretreatment of animals with probiotic formulation consisting of Lactobacillus helveticus R0052 and Bifidobacterium longum R0175 attenuated hypothalamic pituitary axis and autonomic nervous system activities, which were assessed through the measurement of plasma cortisol and catecholamines.10 In our patient, she was treated with a course of Rifaximin for IBS-D and was placed on a bowel regimen including a probiotic. At a four-week follow up, her symptoms had improved.
3119 Pseudomelanosis of Stomach and Duodenum
Authors: Pasha Syed Bilal , Yezaz Ghouri , Tahan Veysel , Samiullah Sami 
Published: October 2019

INTRODUCTION:
Pigmentation of the lower gastrointestinal tract called melanosis coli is a commonly encountered endoscopic finding. A similar pattern of pigmentation called pseudomelanosis is sometimes encountered during upper GI endoscopies. Duodenum is the most commonly reported site for pseudomelanosis, but there have been limited number of reported cases of gastric pseudomelanosis.

CASE DESCRIPTION/METHODS:
We present a case of 71 year old male with history of iron deficiency anemia, coronary artery disease, congestive heart failure, chronic kidney disease, hypertension, gout and hyperlipidemia who presented for GI endoscopy to evaluate his anemia. His medications included torsemide, hydralazine, ferrous sulfate, clopidogrel, pantoprazole, febuxostat, atorvastatin, amlodipine, isosorbide mononitrate, bisoprolol, irbesartan, citalopram, doxazosin and oxybutynin. Esophagogastroduodenoscopy (EGD) revealed a 3 mm dark spot in the antrum which was biopsied (Figure 1). Similar pigmentation was seen in the duodenum as well (Figure 2). Pathology revealed benign gastric mucosa with histological pattern of pseudomelanosis. Rest of the gastric mucosa was benign with non-specific chronic inflammation. Additional endoscopic findings observed were a linear pattern of mild erythema in the gastric antrum which was consistent with endoscopic appearance of gastric antral vascular ectasia. No active bleeding or oozing was observed. Rest of the EGD, as well as colonoscopy was unremarkable except for multiple small colon polyps.

DISCUSSION:
The exact etiopathogenesis of this rare entity remains unclear and various mechanisms have been proposed for this pigmentation pattern. Iron supplementation or upper GI bleeding leading to abnormal iron accumulation in macrophages of lamina propria has been proposed as a possible mechanism. Results of electron probe X-ray identified the role of sulfur containing compounds in causing accumulation of this pigment. Conditions associated with pseudomelanosis are CKD, hypertension, gastric hemorrhage and diabetes. Medications such hydralazine, thiazide, furosemide, Iron sulfate, methyldopa and propranolol have been shown to be associated with it. Sulfur containing drugs (such as hydralazine, furosemide and hydrochlorothiazide) are worth mentioning, since sulfur is shown to promote pigment deposition. The clinical significance, treatment and follow up of this rare condition is still unknown. Furthermore, no malignant transformation or long term complications have been reported so far.
3131 Rectal Dieulafoy's Lesion: A Rare Cause of Massive Lower GI Bleed
Authors: Singh Vikram , Mehra Shilpa 
Published: October 2019

INTRODUCTION:
Dieulafoy's lesions can be a life-threatening source of gastrointestinal bleeding. While most commonly seen in the stomach, they have been described throughout the GI tract, including the rectum. These lesions consist of a persistent caliber, submucosal artery that can be difficult to identify on endoscopic evaluation. Rectal Dieulafoy's lesions are a rare source of lower GI bleeding that can present with large volume hematochezia requiring prompt management. Two cases of bleeding secondary to a rectal Dieulafoy's lesion are reviewed.

CASE DESCRIPTION/METHODS:
Case 1: A 94-year-old man with multiple cardiompulmonary comorbidities presented initially for sepsis secondary to osteomyelitis and developed hematochezia during admission. Hgb went from 10.0 g/dL to 7.1 g/dL, but he remained hemodynamically stable and bleeding self-resolved. Colonoscopy was deferred due to patient preference. The patient was readmitted to the hospital 8 days later with continued hematochezia and found to have Hgb 6.3 g/dL. Colonoscopy showed a visible Dieulafoy's lesion that was injected with 2 mL 1:10,000 epinephrine and then treated with 2 hemostatic clips. After intervention, bleeding resolved. Case 2: A 91-year-old man with a history of dementia and COPD was admitted for two days of hematochezia. On admission, he was transiently hypotensive with a SBP in the 50s and a Hgb of 9.4 g/dL with a baseline of 13-14 g/dL. Hgb eventually reached a nadir of 7.4 g/dL. Flexible sigmoidoscopy showed a visible Dieulafoy's lesion. Three hemostatic clips were placed in setting of active oozing with control of bleeding.

DISCUSSION:
Dieulafoy's lesions were first described in 1884 and are now more commonly described given advances in endoscopy. These lesions account for only 1-2% of GI bleeds, however this number may be underrepresented due to the difficulty of diagnosis. The rectum is involved in only about 2% of cases of Dieulafoy's lesions. The etiology of these lesions is unclear, but likely have some relationship to age, co-morbidities, and NSAID use. Endoscopy is the main method of diagnosis, though EUS, VCE, or angiography are also useful. Hemostasis is usually achieved through thermal therapy, injection with epinephrine, or banding/hemoclip with dual modality being preferred. The cases above represent two examples of a rectal Dieulafoy's lesion, a rare etiology of lower GI bleeding. Management of these bleeds requires prompt evaluation with endoscopy and can be successfully treated via multiple modalities.
3141 Large Gastric Hyperplastic Polyp as a Rare Cause of Iron Deficiency Anemia
Authors: Hafiz Nazar , Pandit Sudha , Maruvada Smita , Rashid Shazia , Alexander Jonathan , Jordan Paul , Manas Kenneth J. , Morris James D. 
Published: October 2019

INTRODUCTION:
Gastric polyps are encountered in approximately 6% of endoscopic procedures. Most of the patients are asymptomatic, some of them can present with complications. We present a rare case of a large hyperplastic polyp resulting in iron deficiency anemia.

CASE DESCRIPTION/METHODS:
A 57 year-old man with past medical history of diabetes mellitus came in with complaints of 1 week history of dizziness, dyspnea on exertion and fatigue. Associated symptoms included persistent nausea and few episodes of non-bilious, non-bloody emesis. Patient denied melena or hematochezia. He endorsed weight loss of 8 lbs in 4 months. Vitals were grossly stable. Labs significant for Hb 6.7, Hct 23.8, and MCV 62. Patient was subsequently transfused with blood. Iron panel revealed severe iron deficiency with serum Iron 10, TIBC 443, Ferritin 4.6, Transferrin saturation 10. Colonoscopy was unremarkable however EGD revealed a large ulcerated polypoid mass, measuring about 10 to 15 cm in antrum concerning for early carcinoma. Pathology returned positive for hyperplastic polyp with no signs of dysplasia. Based on the large size of polyp, partial gastrectomy was done. On follow up, Hb increased and pt reported clinical improvement.

DISCUSSION:
Hyperplastic polyps constitute 75% of all the gastric polyps encountered. Hyperplastic polyps result from hyperplasia of epithelium secondary to chronic gastritis. Usually they range from 0.5 to 2 cm. About 1.4% of these polyps can reach a size large enough to cause iron deficiency anemia secondary to chronic bleeding. The risk of malignancy increases with size >1 cm and require surgical resection. Yun et al reported a rare case of 1.5 cm hyperplastic polyp which was a cause of iron deficiency anemia. We describe a case of a large 10-15 cm hyperplastic polyp causing GI bleeding subsequently resulting in iron deficiency anemia. We recommend that physicians should be aware of this rare complication as polypectomy will benefit therapeutically in preventing future complications such as chronic bleeding.
3146 A Curious Case of Hematochezia in a Young Adult
Authors: Lim Chong Teik , Law Ngai Moh 
Published: October 2019

INTRODUCTION:
Meckel's diverticulum is a common congenital abnormality of the small intestine secondary to the vitello-intestinal duct. It commonly presents as hematochezia and abdominal pain in young children particularly those less than 2 years old.

CASE DESCRIPTION/METHODS:
A 26 years old lady presented to Emergency Department with history of hematochezia and abdominal pain for 2 days. The abdominal pain was mainly paraumbilical and colicky in nature and it was present intermittently for the past 6 months. One day prior to this visit, she was treated for acute gastroenteritis by a General Practitioner in view of presence of vomiting and diarrhea. However, symptoms were not improving and she subsequently developed hematochezia. She denies any fever and family history of gastrointestinal disease such as inflammatory bowel disease or malignancy. She denies any recent travelling and there is no sick contact recently. Physical examination was unremarkable and per rectal examination reveals blood mixed with stool with no mass or hemorrhoids seen. She has leukocytosis on blood investigation and abdominal radiograph performed in emergency department was unremarkable. She was subsequently admitted for treatment of dysentery and was started on intravenous ceftriaxone and metronidazole. However, patient's abdominal pain became severe requiring opioid for analgesia and an inpatient Computer Topography scan of her abdomen was obtained. Figures 1 and 2 shows the appearance of bowel within bowel appearance in the right lower quadrant in keeping with ileocolic intussusception. An urgent surgical consult was done and patient was agreeable for operation for bowel resection. Intra-operatively, a Meckel's diverticulum was noted to be the cause of the intussusception. The segment of ileum in the intussusception was noted to be ischemia with gangrene but no perforation noted. The intussuscepted bowel was resected and an end to end ileocolic anastomosis was performed. Post operatively patient recovered well and tolerated orally without any complications. She was discharged subsequently.

DISCUSSION:
This case illustrated that Meckel's diverticulum could be a differential diagnosis for young adults presenting with hematochezia. It is commonly misdiagnosed preoperatively in view of the rarity of these cases in the adult population.