bluuebunny/crossref_metadata_2025_split huggingface dataset:
1513 Efficacy of the Traction Device “S-O Clip” Assisted ESD for the Colonic Tumor Involving a Diverticulum
Authors: Sakamoto Naoto , Fukushima Hirofumi , Murakami Takashi , Ueyama Hiroya , Nagahara Akihito 
Published: October 2019

INTRODUCTION:
Background: Endoscopic submucosal dissection (ESD) allows en bloc resection of large gastrointestinal neoplasms regardless of the size. However, technical difficulties associated with ESD in the colorectum make it less widely applied in the treatment of tumors in this region. To address this difficulty, we designed a traction device, called S-O clip and reported previously (Endoscopy2008, Gastrointest Endosc 2009). ESD with this device was effective for complete resection of large tumors (LSTs) (Surgical Endoscopy2014). Although the lesions of unusual sites such as within the appendix and diverticulum are very difficultto remove by ESD and sometime surgical treatment is required, We reported the first case of aLSTs involving a diverticulum successfully treated by ESD with this device (Gastrointest Endosc 2016). Aim: To evaluate the efficacy and safety of S-O clip assisted ESD for the tumor of the colon involving a diverticulum.

CASE DESCRIPTION/METHODS:
Results: 4 cases are LSTs involving a diverticulum in the ascending colon. One case is in the sigmoid colon. All 5 cases were removed safely and successfully en bloc without any complications. Procedure time s were 67, 145, 25, 68 and 64 minutes, with resected specimens measuring 20, 32, 20, 18 and 30 mm, respectively.

DISCUSSION:
Conclusion: This limited case series demonstrate that S-O clip-assisted ESD is safe and effective for en bloc resection of the colonic lesion involving a diverticulum.
1514 Intestinal Tuberculosis Presenting as GI Bleed and Cecal Mass
Authors: Bommena Shoma , Mann Sarabdeep 
Published: October 2019

INTRODUCTION:
Abdominal tuberculosis (TB) is rare and comprises only 5% of all cases of TB. Lower GI bleeding occurs in 5-15% of patients with intestinal TB, with the ileocecal region is the most common site of hemorrhage. We present a case of disseminated TB with intestinal involvement, presenting as a GI hemorrhage and cecal mass.

CASE DESCRIPTION/METHODS:
A 72-year-old female of Vietnamese origin with PMH of dementia and chronic hepatitis C presented to our hospital with a chief complaint of increased somnolence and melena. She was febrile, hypotensive, and tachycardic. Labs showed a hemoglobin of 6.2 and hematocrit of 20.3. She was admitted to the ICU for presumed sepsis due to a UTI, and was initiated on broad spectrum antibiotics. She was transfused packed red blood cells, and treated with IV pantoprazole and IV octreotide. Ultimately she underwent an EGD which was unremarkable. Subsequent workup with a chest CT revealed innumerable non-calcified bilateral lung nodules concerning for granulomatous disease. She underwent a bronchoscopy, and BAL was positive for AFB on cultures. Anti-TB therapy with rifampin, isoniazid, pyrazinamide and ethambutol was initiated. Due to ongoing encephalopathy an MRI of the brain was performed and showed multiple enhancing nodules suggestive of disseminated or metastatic disease. Ultimately a CT abdomen pelvis was performed showing a possible cecal and ascending colon mass with ileal thickening in the R pelvis. Subsequently a colonoscopy was performed which revealed an ulcerated non-obstructing mass at the ileocecal valve, with oozing and stigmata of recent bleeding. Biopsies showed granuloma formation with necrosis, with acid-fast bacilli confirmed on AFB stain.

DISCUSSION:
Intestinal TB is rare in Western countries and has a higher incidence in migrant populations. Its nonspecific features make establishing a diagnosis difficult. It should be considered in the differential diagnosis of GI hemorrhage in the appropriate clinical setting. As the presentation of colonic TB often mimics that of a neoplasm, colonoscopy with tissue biopsy remains the main stay of diagnosis.
1516 A Rare Cause of Diarrhea in the U.S.: Schistosomiasis Colitis Case Report and Literature Review
Authors: El Zein Mohamad , Ismail Hibah , Heif Muhannad , Kobeissy Abdallah , Sodeman Thomas , Nawras Ali 
Published: October 2019

INTRODUCTION:
Schistosomiasis is one of the neglected tropical diseases and is endemic in more than 70 countries. Herein, we present a case of schistosomiasis colitis in the USA.

CASE DESCRIPTION/METHODS:
A 21-year-old man born in Libya, resident in USA for more than 9 years, was referred to the Gastroenterology consultation for chronic diarrhea (8 bowel movements per day of liquid feces), intractable diffuse abdominal pain, associated with subjective fevers, chills, nausea, vomiting (nonbloody), and decreased oral intake. Laboratory workup was negative for leukocytosis; stool cultures were negative. Computed Tomography (CT) abdomen and pelvis showed diffuse colitis with bowel wall thickening. Patient was treated with ciprofloxacin and metronidazole. Given no improvement in symptoms, Colonoscopy was performed showing diffusely congested and hyperemic mucosa. Random colonic biopsies were positive for parasitic infection associated with non-necrotizing granulomas most consistent with schistosomiasis. This was followed by a positive serology test for Schistosoma. He was started on praziquantel (40 mg/kg) with improvement in diarrhea frequency prior to discharge to follow up in clinic.

DISCUSSION:
Colonic schistosomiasis is common in endemic areas (Africa, South America and Asia) and the endoscopic findings can be confounded with inflammatory bowel disease with just a few reports published in these countries and very rare in the USA. The most common presentation is a form of symptomatic chronic active colitis with diarrhea and abdominal pain. The diagnostic gold standard is the histology. Even though new cases have not occurred recently in USA, we should remain aware of schistosomiasis colitis for patients who came from foreign epidemic areas.
1520 Colonic Webs—A Case Report Abstract
Authors: Singh Sohrab , Nustas Rosemary , Body Cameron B. , Shahnavaz Nikrad 
Published: October 2019

INTRODUCTION:
Intestinal webs in adults are rare anomalies of the gastrointestinal tract associated with Non-Steroid Anti-inflammatory drug use often causing small bowel obstruction.
1,2
The presence of a colonic web found incidentally on a follow-up colonoscopy in an asymptomatic adult patient makes our case unique.

CASE DESCRIPTION/METHODS:
A 58-year old African American female with chronic NSAID (meloxicam) use for Ankylosing Spondylitis underwent elective superior hypophyseal artery aneurysm coil embolization without complications. After a drop in Hb and episode of melena, EGD and colonoscopy on 9/31/2018 revealed a superficial non-bleeding distal rectal ulcer, two duodenal ulcers and a pinpoint opening in the ascending colon, one fold distal to the cecum representing a Colonic Web (diaphragm) likely due to NSAID use. Lumen was narrow with no evidence of obstruction. Focused physical exam and imaging were benign. Patient was asked to stop NSAID and discharged on Proton Pump Inhibitor. Follow-up colonoscopy to assess ulcer healing on 12/18/2018 still showed the diaphragm but it was smaller and lumen was patent. No intervention was done again since patient was asymptomatic. Post procedure, she was discharged in stable condition and advised to continue avoiding NSAID, stay on stool softener and look for symptoms of obstruction.

Discussion:
Webs in the colon are a very rare entity. The investigation of choice remains capsule endoscopy or contrast study where non-passage of contrast distal to dilated segment in case of an obstructing colonic web indicates the level of obstruction. Intraoperative endoscopy and balloon dilatation help to relieve obstruction in symptomatic patients.
3
No intervention is suggested in asymptomatic patients. Use of NSAID is the likely cause of development of web-like strictures in the small bowel.
1,2
This case can be useful in the differential diagnosis of one of the rare causes of colonic obstruction.
1522 Energy Therapy—An Alternative Treatment of Anal Fissures
Authors: Malik Fahad , Kim Marina , Reyes Jonathan M. , Patel Bhavin , Gonzalez Manuel O. , Weissman Simcha , Aziz Muhammad , Wickremesinghe Prasanna 
Published: October 2019

INTRODUCTION:
Energy Therapy has been a well known non-surgical, minimally invasive treatment option for symptomatic grades I and II internal hemorrhoids. This treatment has not yet been studied in anal fissures refractory to medical therapy. Anal fissures, like hemorrhoids, can severely disrupt the quality of life for patients. Currently, only a few non-surgical treatments are available for anal fissures which involve conservative and supportive measures that include: increasing dietary fiber intake, stool softeners, sitz baths, topical analgesics or vasodilators. The gold standard for chronic anal fissures (CAF) refractory to medical therapy is treatment with internal sphincterotomy. Unfortunately with this treatment there is a chance of relapse and a risk of anal incontinence. We propose the use of hemorrhoid energy therapy (HET) with bipolar cautery as a safer, less invasive and effective therapy for recurrent anal fissures refractory to conservative management.

CASE DESCRIPTION/METHODS:
53 year old obese heterosexual man presented with bright red blood per rectum for two months managed outpatient for chronic constipation. Rectal examination revealed a large clot with anal tenderness and few internal hemorrhoids. Colonoscopy revealed 3 internal non-bleeding hemorrhoids and slow oozing bleeding anterior anorectal fissure. The anal fissure exhibited characteristics of chronicity with base exposing to the internal anal sphincter, hypertrophic anal papilla and sentinel pile. HET therapy with bipolar cautery was applied to the bleeding anal fissure. The tissue consisting of anal fissure in bowel wall was compressed in a parallel fashion and bipolar radiofrequency energy was delivered until the temperature reached 55 C or 131 F (5-20 seconds) for approximately 1.5 to 2 seconds.

DISCUSSION:
The delivery of energy to a targeted region with temperatures between 50 to 55 C along with compression of the tissue can help obtain homeostasis for bleeding or CAF along with change of histology to mild scarring with fibrosis and occlusion of blood supply which would result in healing of the fissure. This intervention using bipolar cautery which could be an alternative treatment as a safer, less invasive and effective therapy for recurrent anal fissures refractory to conservative management prior to considering surgery. Our patient was followed up 2 years after the procedure with no recurrences of anal fissures or rectal bleeding, and reported improved quality of life with no complications from the procedure.
1527 Ulcerative Colitis With Concomitant Serrated Polyposis Syndrome
Authors: Smith Zachary , Yezaz Ghouri , Ibdah Jamal A. , Tahan Veysel 
Published: October 2019

INTRODUCTION:
Ulcerative colitis (UC) is associated with increased risk of colon cancer. Current knowledge of UC with concomitant serrated polyposis syndrome (SPS) is limited and clinical guidelines regarding management is lacking. Sessile serrated adenomas and traditional serrated adenomas are precursors of at least 20% of sporadic colorectal carcinomas. Patients with SPS have higher risk of developing dysplastic lesions. We describe an interesting case of concurrent UC with SPS and a brief review of literature surrounding this association.

CASE DESCRIPTION/METHODS:
A 45-year old female with no significant past medical history presented to clinic for a 2-month history of change in bowel habits with bloating and occasional hematochezia. She denied a family history of colon cancer or inflammatory bowel diseases (IBD). Colonoscopy revealed three flat polyps measuring 2 mm, 7 mm and 8 mm in size at the cecal base, and two flat polyps each 11 mm in size in the ascending colon. All these polyps were removed and found to be of sessile serrated type on histopathology thereby meeting the WHO criteria for SPS. Patient was also found to have a 20 cm segment of inflammation in the rectum, biopsies showed diffuse chronic active proctitis with severe activity, meeting the criteria for ulcerative proctitis. Patient was started on mesalamine 1000 mg rectal suppository daily with plan for a repeat colonoscopy in 6 months to assess response. Laboratory analysis at time of colonoscopy showed C reactive protein <0.40 mg/dL, WBC count 6.12 × 10(9)/L and Hgb 12.5 g/dL.

DISCUSSION:
Frequency of occurrence of SPS among IBD patients seems to parallel that of general population. But the risk of colon cancer in this setting is unclear since IBD itself can give rise to colonic dysplasia. It has been suggested that a serrated pathway of carcinogenesis in inflammatory bowel disease is characterized by silencing of MGMT by gene promoter methylation, KRAS mutations, and potentially molecular alterations that are yet to be characterized and suspected to eventually lead to adenocarcinoma. Further studies are needed to define optimal management of these patients. This case highlights the complexity of managing this concurrent syndrome in patients with IBD.
1531 Failed Fecal Microbiota Transplantation for Fulminant C. difficile Colitis With Toxic Megacolon
Authors: Dong Michael Q. , Wentworth Brian , Hays R. Ann 
Published: October 2019

INTRODUCTION:
Fulminant disease develops in 3-8% of patients with Clostridioides difficile infection (CDI) and may progress to toxic megacolon (TMC), the latter of which is typically managed surgically but has high mortality. Although fecal microbiota transplantation (FMT) is a well-established therapy for recurrent CDI, its utilization in cases of TMC is sparsely documented. Here we describe our experience with a patient who elected FMT over surgery and their clinical response.

CASE DESCRIPTION/METHODS:
A 74-year-old African-American woman with a recent perforated duodenal ulcer with surgical repair was transferred to our medical ICU (MICU) with septic shock from an initial CDI. She was previously treated with PO vancomycin, which was switched to fidaxomicin in the setting of continued diarrhea. On admission, she was afebrile with hypotension, tachycardia, and tachypnea. Labs showed leukocytosis, thrombocytopenia and an AKI. Physical exam revealed an acutely ill appearing woman with a diffusely tender, distended and tympanic abdomen. Fidaxomicin was stopped and PO/PR vancomycin and IV metronidazole were initiated. On day 3 of admission, the patient clinically deteriorated and abdominal x-ray demonstrated increased bowel distention. TMC was diagnosed and surgery was consulted. Colectomy was offered but she declined the procedure. FMT was discussed as an alternative, off-label therapy and she agreed to proceed with placement via colonoscopy. The elevated risk of perforation was deemed acceptable by the patient. Colonoscopy revealed pseudomembranes, deep ulcers, and friable mucosa. Donor stool was deployed at the hepatic flexure and the scope was carefully withdrawn. Over the 48 hours post-procedure, the patient had hemodynamic improvement and decreased pressor requirement. Her stool output decreased and abdominal exam improved. By 72 hours, however, the patient's condition again worsened and she elected palliative care and died shortly thereafter.

DISCUSSION:
While colectomy is standard treatment for fulminant CDI with TMC, FMT may represent a non-surgical alternative in selected cases. We describe transient, but profound, clinical improvement in patient parameters for 48 hours following FMT. The mechanism of benefit may be multifactorial, including repopulation of normal colonic flora and mechanical colonic decompression. Although our patient died, her case provides a framework for clinicians to consider this therapy and the expected response.
1533 Cytomegalovirus as the Forme Fruste of Colorectal Cancer in a Young Female
Authors: Thomas Michelle , Pinto Jonathan , Tan Zimri , Culpepper-Morgan Joan 
Published: October 2019

INTRODUCTION:
Cytomegalovirus (CMV) infection is often seen in the GI tract among patients who are immunocompromised and most commonly affects the large bowel. Studies have shown CMV infection presenting as a colorectal cancer (CRC) like mass. We present a case of CMV presenting as the forme fruste of CRC.

CASE DESCRIPTION/METHODS:
A 31 year old Hispanic woman presented with a one week history of worsening abdominal pain, generalized weakness, hematochezia, and a 30 lb weight loss. She was a nonsmoker who had presented similarly 6 months prior to another institution and was diagnosed with CMV colitis by flexible sigmoidoscopy and biopsy of a rectal ulcer. Pathology revealed focal atypical epithelial proliferation, indefinite for dysplasia, and CMV immunostain was positive. The patient was treated with valganciclovir with improvement in symptoms, but later worsened. She denied change in bowel habits, history of anogenital warts, or HPV vaccination, but admits to a remote history of Chlamydia which was treated. History was also positive for chronic inactive HBV infection diagnosed 6 years prior to presentation. Significant labs were Hb 4.6 g/dL, MCV 65.9, Plt 466 K/uL, AST 43 U/L, ALP 111 U/L, HIV nonreactive, AFP 3.0 ng/ml, HBsAg reactive, HBV viral load of 613 IU/mL, HBcAb total reactive, HCV Ab nonreactive and CEA 44.6. CT abd/pelvis showed an inflammatory, ulcerated, rectal mass with wall thickening compatible with neoplasm (Figure 1). Large hypodensities were seen in both hepatic lobes consistent with metastases (Figure 2). Sigmoidoscopy showed an ulcerated partially obstructing mass in the rectum which was circumferential and friable and located at the anal verge and was approximately 10 cm in length. Biopsy of the mass showed scant adenocarcinoma admixed with ulcer and granulation tissue. Liver biopsy confirmed metastatic adenocarcinoma, colon primary.

DISCUSSION:
Potential previous exposure to oncogenic viruses such as HBV and HPV may have predisposed our patient to develop CRC at age 31. She had no other risk factors such as HIV infection, radiation exposure, or previous chemotherapy. Her underlying malignancy may have rendered her in an immunocompromised state that would have allowed CMV reactivation. Another possibility is exposure to multiple viruses caused immunocompromise allowing both CMV reactivation and CRC formation. CMV pseudo tumors are known to mimic CRC. Alarm symptoms such as weight loss and hematochezia in this patient warranted close follow up to complete resolution or alternative diagnosis.
1535 A Rare Case of Rectosigmoid Mucosal Schwann Cell Hamartoma
Authors: Abbas Syed Hassan , Shahid Tamoor , Hertan Hilary 
Published: October 2019

INTRODUCTION:
Colorectal polyps of mesenchymal origin are rare. Mucosal Schwann cell hamartomas have a pure proliferation of Schwann cells in the lamina propria and show immunoreactivity to S-100 protein. To our knowledge, only 11 cases have been reported in the literature since it was first described in 2009.

CASE DESCRIPTION/METHODS:
We present a case of a 50-year-old African-American female who presented to us for routine screening colonoscopy. Her past medical history was only significant for a prolactinoma for which she was on cabergoline. The patient had no personal or family history of neural lesions or inherited syndromes such as NF1, Cowden syndrome or MEN 2B. The colonoscopy revealed a 2 mm polyp in the cecum and a 3 mm sized rectosigmoid polyp which were resected and sent to pathology. The cecal polyp showed a tubular adenoma. The pathology report for the rectosigmoid polyp was consistent with spindle-shaped lesional cells with immunohistochemical staining strongly positive for S-100. They did not have immunoreactivity for epithelial membrane antigen (EMA). Hence, supporting the diagnosis for Schwann cell hamartoma. The patient was made aware of pathology findings and reassured.

DISCUSSION:
Mucosal Schwann Cell Hamartoma is a rare and benign lesion that forms in the colon. It usually arises in older adults. The specific risk factors of Mucosal Schwann Cell Hamartoma are unknown. Most patients are asymptomatic however rectal schwannoma may cause symptoms such as obstruction, bleeding, and tenesmus. They are often found incidentally in the distal colon during a colonoscopy. These tumors are poorly circumscribed, with short fascicles of uniform spindle cells replacing the colonic lamina propria, especially the superficial lamina propria, and separating and entrapping the crypts. These tumors involve the mucosa but never the submucosa. Although the histological differential diagnosis of a mucosal Schwann-cell hamartoma can include a gastrointestinal stromal tumor (GIST), neurofibroma, mucosal neuroma, ganglioneuroma, or mucosal schwannoma, a mucosal Schwann-cell hamartoma is composed of single Schwann cells without other cells, such as axons or fibroblasts, and is uniformly stained for S-100. These cells do not have immunoreactivity for c-Kit, CD34, glial fibrillary acidic protein, epithelial membrane antigen (EMA), smooth muscle actin, or neurofilament protein (NFP). Due to the benign nature of Mucosal Schwann Cell Hamartoma, they do not generally require any treatment.
1541 Colorectal Lymphoma: A Wolf in Sheep's Clothing
Authors: John Jason J. , John Elizabeth S. , Linder Jeffrey 
Published: October 2019

INTRODUCTION:
Although extranodal lymphomas are most commonly found in the gastrointestinal (GI) tract, colorectal lymphomas are a rare diagnosis accounting for only 0.2% of large intestinal malignancies and 4% of malignancies in the entire GI tract. We report a case of a female patient with vague abdominal symptoms, ultimately diagnosed with diffuse large B-cell lymphoma (DLBCL) of the colon.

CASE DESCRIPTION/METHODS:
A 55 year old African American female with HIV (CD4 164) was admitted for acute shortness of breath and 4 months of intermittent diffuse abdominal pain. She denied any diarrhea, changes in bowel habits, hematochezia, melena, or weight loss. Imaging revealed a pneumonia and nonspecific mesenteric lymphadenopathy (LAD), but no bowel abnormalities. Her abdominal pain initially improved with treatment of the pneumonia, but she was readmitted to the hospital one month later with recurrence of the abdominal pain and worsening shortness of breath. Vitals included BP 136/94, HR 125, RR 25, SpO2 90%, T 98.5. Exam showed bibasilar crackles and accessory muscle use with respirations. She had diffuse abdominal tenderness without obvious hepatosplenomegaly or LAD. Laboratory workup showed WBC 5.2 (normal differential), Hb 11.0, Platelets 361, normal CMP, BNP 300, LDH 9,845. CT revealed new bilateral pleural effusions, nonspecific mesenteric LAD, and mild transverse colon thickening (Figure 1). Colonoscopy revealed a non-obstructive 4 cm mass in the transverse colon. Biopsies revealed high-grade DLBCL. Thoracentesis confirmed the diagnosis. Before treatment could be initiated, the patient expired from tumor lysis syndrome and subsequent cardiac arrest.

DISCUSSION:
Colorectal lymphoma is extremely rare. Early recognition is crucial as stage I and II disease can be treated with surgery and chemotherapy, and if not treated, the mortality rate is 58%. Though DLBCL can occur in 5-10% of patients with HIV, the incidence of GI involvement in this population is still as low as 3%. As with our patient, diagnosis is often delayed due to nonspecific and non-localizing symptoms and signs. Imaging can be helpful, but can have a wide variety of characteristics–bulky masses, diffuse infiltration, multi-site involvement, and lymphadenopathy. Definitive diagnosis relies on histologic analysis. Later diagnosis also limits treatment. Management of stage I and II include chemotherapy and surgery while stage III and IV often require clinical trials. This case presentation highlights the importance of early diagnosis.