bluuebunny/crossref_metadata_2025_split huggingface dataset:
3197 Pyogenic Liver Abscess in B-Thalassemia: A Case Report
Authors: Nnaoma Christopher , Ruberwa Joseph , Chika-Nwosuh Ogechukwu Z. , Pal Chitanya , Quintilliani Safiyya B. 
Published: October 2019

INTRODUCTION:
Pyogenic liver abscess typically develops via systemic seeding of an infection or from biliary disease through direct spread or portal circulation. Invasive liver abscess though may occur in Beta-thalassemia major patients are a rarity in Beta-thalassemia minor.

CASE DESCRIPTION/METHODS:
36-year-old woman with a history of B-thalassemia minor presents to the ED with complaints of acute onset severe, non-radiating right upper quadrant pain. She endorses fevers, chills and night sweats but denied anorexia, nausea, vomiting, diarrhea or urinary symptoms. Never been transfused. Physical exam was pertinent for a temperature of 102.8 F, tachycardia of 138 bpm, and an upper quadrant abdominal tenderness with some guarding. Labs was notable for leukocytosis with neutrophil predominant, anemia with Hb of 5.3 g/dl. Elevated ESR and CRP. Lipase and amylase were normal. CT abdomen showed 10.3 cm thick-walled, complex fluid collection in the right hepatic lobe and splenic abscesses consistent with a pyogenic abscess. Blood cultures were negative. She was started on empiric antibiotic with vancomycin and piperacillin/ tazobactam and was subsequently taken to interventional radiology for drainage of the abscess, with a J-P drain left insitu. The patient received 2 units of packed red blood cells. Fluid culture from drain was positive for Klebsiella pneumoniae which was sensitive to Levaquin. The patient's condition improved while on antibiotics with subsequent removal of the J-P drain. She was successfully discharged on oral Flagyl and Levaquin for 14 days.

DISCUSSION:
Typically, thalassemia minor carriers are clinically asymptomatic with very little to no complications. Infections however, are a major complication, and constitute the second most common cause of mortality and a main cause of morbidity in patients with thalassemia. The major culprit bacterial infections in thalassemia patients are Klebsiella sppand Yersinia enterocolitica. K. pneumoniae is also associated with a community-acquired primary invasive liver abscess syndrome. Liver abscess occur more commonly in beta- thalassemia major as these group of patient have predisposing factors such as underlying hepatobiliary dysfunction and recurrent transfusions. This condition is rare in beta- thalassemia minor. Abscess rupture is a rare complication, while metastatic infection to other sites can occur. Diagnosis is usually made with CT scan of the abdomen while treatment is should be started with empiric broad-spectrum and drainage of the abscess.
3203 Atypical Presentation of Viral Gastroenteritis in a Three-Year-Old Child Due to a UNC80 Mutation
Authors: Stenehjem Kristen , Schweigert Jessica , Kumar Parag 
Published: October 2019

INTRODUCTION:
We report on a three-year-old child with a rare genetic phenomenon, a UNC80 mutation, who had an unusual presentation of viral gastroenteritis. The UNC80 gene encodes for an important voltage-independent channel in neurons and a mutation in this protein can lead to severe hypotonia. The hypotonia manifests as delayed gastric emptying, impaired respiratory clearance, and/or delayed muscle coordination, which can predispose to infection susceptibility. UNC80 gene mutations have also been shown to cause global developmental delays, failure to thrive, and phenotypic dysmorphisms.

CASE DESCRIPTION/METHODS:
In our patient, we believe that his genetic defect precipitated a complicated hospital course. The patient's delayed gastric emptying caused difficulty in recovering from viral gastroenteritis while a concurrent pneumonia diagnosis required assistance in clearing respiratory contents.

DISCUSSION:
The UNC80 mutation is under-studied and more studies are necessary to understand the clinical implications of its phenotypes.
3206 Intestinal Motility: Not Part of Trihexyphenidyl's Job Description
Authors: Diaz Carolina , Fernández Carlos , Alegre-Boschetti Sergio M. , De Jesús Henry , Rodriguez Frances , Martinez-Souss Jaime , Martin-Ortiz Jose 
Published: October 2019

INTRODUCTION:
Paralytic ileus presents similarly to mechanical obstruction; however, there is absence of a culprit anatomic lesion. It is commonly due to surgical intervention, peritonitis, trauma, medications, electrolyte disturbances, or intestinal ischemia.

CASE DESCRIPTION/METHODS:
This is the case of an 86-year- old male with past medical history of Parkinson's Disease and hypertension who was admitted at IM ward due to complicated UTI and bacteremia. During hospitalization, the patient developed abdominal distention and referred not having a bowel movement in 5 days. Physical exam was remarkable for a distended, tympanic, and non-tender abdomen. Labs displayed improving leukocytosis, normocytic-normochromic anemia, and absence of electrolyte disturbances. KUB was ordered, which revealed a very dilated stomach with gaseous distention in the stomach and small intestine as well as moderate amount of stool in the colon. As a result, Miralax, a sodium phosphate enema, and a nasogastric tube with intermittent suction were recommended. However, no bowel movements were reported as a result. Therefore, mineral oil was recommended the following day. Given lack of significant improvement, half a gallon of polyethylene glycol (golytely) was added to therapy. Two large bowel movements were achieved as a result. However, the patient's abdomen continued distended and tympanic for which CT abdomen with contrast was done. CT results showed no evidence of mechanical obstruction. Given lack of improvement despite interventions, trihexyphenidyl, which patient had recently started for Parkinson's Disease, was discontinued. Patient was not on opioid or other constipation inducing medications. Five bowel movements were reported in the 24-hours that followed removal of medication. The following day KUB displayed improvement and physical exam was remarkable for positive bowel sounds in all 4 quadrants and a non- tender, non-distended abdomen.

DISCUSSION:
Rapid resolution of symptoms suggests trihexyphenidyl as culprit. It is important to note that although anti-cholinergics are known to cause or precipitate paralytic ileus, few cases have been reported as a result of trihexyphenidyl use. Trihexyphenidyl is prescribed with frequency for the treatment of Parkinson's Disease, being aware of its side effects may lead to prompt diagnosis and better outcomes.
3214 Acute Extensive Jejunal Ulceration Following Single Balloon Enteroscopy
Authors: Maklad Muthena , Makar Ranjit , Lankarani Daisy S. , Aziz Hamza , Fayad Joseph 
Published: October 2019

INTRODUCTION:
Small bowel ulceration can be difficult to diagnose and maybe confused with perforation or intestinal obstruction. The differential considerations for small bowel ulceration include inflammatory causes: PUD, isolated terminal ileal ulcers, drug induced, Crohn's disease. Vascular disorders: vasculitis, Behcet's, vascular dysplasia, microangiopathic ischemic ulcers, veno-occulsive. Other causes: ischemia, neoplasia and more. We are reporting a case of diffuse jejunal ulceration after episode of hypotension diagnosed by capsule endoscopy (CE).

CASE DESCRIPTION/METHODS:
75 yo male veteran with IBS-C, CAD, CHF, A fib on ApixabanPatient admitted for acute CHF exacerbation. Hgb was decreased to 8.1 g/dl (baseline 13 g/dl). Patient denied hematemesis, hematochezia, melena Due to patient cardiac issues, we used CE to evaluate for possible GI bleed. CE findings noted for AVM in early jejunum, distal jejunal polyp, bleeding ileal AVM. He was transferred to another facility for single balloon enteroscopy (SBE) with ablation of 4 areas of AVM's. A tattoo was placed to the most distal area of the jejunum reached. The jejunal polyp wasn't seen on SBE. Post procedure he developed hypotension, and started on pressor for blood pressure (BP) support. The patient was transferred back to our facility after 2 weeks. We were asked to evaluate if the jejunal polyp was missed on SBE. A repeat CE showed: multiple areas of severe, large circumferential ulceration throughout the jejunum. Jejunal polyp was noted distal to the tattoo, bleeding AVM in the ileum again. Anticoagulation was held and started iron supplement.

DISCUSSION:
Patients needing pressor support for BP control are at risk for CV events such as intestinal ischemia. Given the acute changes in the small bowel seen on the CE, likely due to either the hypotensive episode or use of vasoactive drugs to support the patient's BP. In our literature search, we didn't find any reports on acute extensive jejunal ulceration following a hypotensive episode or after use of vasoactive drugs. This entity may be under reported due to patients' hemodynamic instability preventing endoscopic eval. In general, unless targeted the small bowel is not routinely evaluated. We propose using CE, which requires minimal prep and no anesthesia, to help reveal the diagnosis of ileal ischemia in patients with pressor support or hypotension that aren't responding to supportive measures in order to alter the clinical intervention. This can be done as a future prospective study in ICU patients.
3218 Duodenal Adenocarcinoma Masquerading as Gastroenteritis: A Case Report
Authors: Marcuard Maurice , Samuel Gbeminiyi , Khalid Hamza 
Published: October 2019

INTRODUCTION:
Small bowel cancers are rare only compromising 5% of gastrointestinal cancers and among those, 40% are small bowel adenocarcinomas.1 Duodenal adenocarcinomas in the 4th portion of the duodenum are even less frequent and are a diagnostic challenge as they typically at an advanced stage when they present.1,2 There are several risk factors associated with it including celiac disease, inflammatory bowel disease and smoking amongst others.1 Given the rarity we present a case of a young patient without any major risk factors that was thought to have gastroenteritis but was found to have something more sinister.

CASE DESCRIPTION/METHODS:
We present a 49 year old African American male with a medical history of hypertension who presented to the hospital with intermittent nausea, vomiting, and crampy abdominal pain over the last 4 months. He was seen in the emergency department (ED) early on, and was diagnosed with gastroenteritis and treated symptomatically. At this point his abdominal pain has worsened and recurrence of nausea and vomiting. He noted a 25 pound weight loss over this time. He denied blood in vomit or stools and any tobacco or alcohol use. He never had an endoscopy or colonoscopy. Physical exam showed decreased bowl sounds and tenderness in epigastrium, otherwise was unrevealing. In the ED the patient was evaluated during which a CT abdomen showed a severe bowel obstruction and bowel thickening suspected at the level of the third/fourth portion of the duodenum (Figure 1). With this a nasogastric tube was placed to decompress. On endoscopy there was a large circumferential fungating mass in the fourth portion of the duodenum causing a complete obstruction (Figure 2). Biopsies were taken which confirmed adenocarcinoma (Figure 3). He was returned to the floor and later underwent a resection of the 4th portion of his duodenum and first part of the jejunum.

DISCUSSION:
As seen here making a diagnosis can be a very challenging and might not always be correct the first time. We cannot perform endoscopies on all patients who arrive with nausea and vomiting, but with recurrent symptoms an endoscopy would be helpful in identifying these malignancies. In this case, even on endoscopy the lesion could have been missed since his malignancy was in the 4th portion which is rare and beyond the extent of the normal exam.2 In the end this case is a reminder to always keep the differential wide and be diligent to look further even when the patient does not fit perfectly with the description in the book.
3219 Intussusception Not Just a Pediatric Problem
Authors: Ali Sara , Capatina-Rata Ana M. 
Published: October 2019

INTRODUCTION:
Intussusception is usually considered a pediatric condition, but it may also be present in adults, where it is more often associated with an underlying pathology. In adults, intussusception is found in only 1% of patients with bowel obstructions. Most cases have distinct lead points, this in comparison to the pediatric cases is contrasting where more 90% of the cases are idiopathic. Malignancy is the most common cause of pathologic lead point.

CASE DESCRIPTION/METHODS:
20 year old male with known history of Crohn's previously on Vedolizomab, presents with nausea, vomiting with melena. He was initially rehydrated intravenously along with IV steroids. On presentation his vitals indicated that he was slightly hypotensive and tachycardiac. Abdominal exam demonstrated a diffusely tender abdomen with no signs of guarding or rigidity. CT Abdomen revealed mucosal enhancement and wall thickening of the terminal ileum and cecum indicating Crohn's flare up along with Jejunu-jejunal intussusception in the left upper quadrant persistent on both arterial and delayed phases. Surgery was consulted however no surgical intervention was planned as no tumor, obstruction or lead point was identified. A small bowel follow through with gastrografin was planned which revealed resolution of the intussusception. The patient subsequently got better with appropriate management of his Crohn's flare. He was discharged with recommendations to follow up with his Gastroenterologist for Vedolizomab infusions.

DISCUSSION:
Adult onset intussusception presents with recurrent abdominal pain and due to the rarity of the condition the diagnosis is often missed or delayed. Abdominal CT is the most useful test in diagnosing intussusception. While most cases of adult onset intussusception require a surgical approach it is important for clinicians to be aware that it is not true for all cases. Transient intussusception has been observed occasionally on small bowel barium studies in patients with Crohn's and adult celiac disease. If no lead point is identified or in cases of transient small-bowel intussusceptions in the setting of celiac sprue or Crohn's disease surgery is not needed. Non surgical reduction in cases when no necrosis is identified has several advantages including avoidance of surgery, limiting the extent of bowel resection and decrease the risk of complications such as short gut syndrome. When dealing with adult onset intussusception it is important to consider the aforementioned factors.
3222 A Rare Presentation of a Sizable Asymptomatic Abdominal Aortic Aneurysm
Authors: Baseer Yaseen 
Published: October 2019

INTRODUCTION:
An abdominal aortic aneurysm (AAA) occurs as plaque builds up in vessels due to long-standing atherosclerosis. AAA takes years to develop and has few if any noticeable symptoms during this time. The larger an aneurysm becomes, the more likely symptoms develop including abdominal pain, back pin, dizziness and nausea. Significant risk factors for the development of AAA include smoking, hypertension, old age and family history. Aneurysms are more likely to burst and rupture as its size increases. Symptoms generally develop when an AAA becomes larger than 3 cm and elective repair should be considered for aneurysms measuring greater than 5.5 cm in size. Here, we present a case of an asymptomatic patient presenting to the hospital with an incidental AAA measuring 14 × 11 cm.

CASE DESCRIPTION/METHODS:
A 100-year-old female with a history of dementia, emphysema secondary to 25 pack year smoking, and anemia presented to the hospital with right leg pain after a recent mechanical fall. She denied any complaints at the time of admission including chest pain, shortness of breath, dizziness, nausea, abdominal pain and back pain. CT of the pelvis revealed acute right subcapital femoral neck fracture as well as a large infrarenal AAA measuring 14 × 11 cm with high risk for rupture. Cardiology was consulted for preoperative risk assessment for hemiarthroplasty versus percutaneous pinning of the right femoral neck. Patient was deemed too high of a risk for hemiarthroplasty and decision was made by medical team to pursue percutaneous pinning although patient remained high risk for surgery due to large AAA. While patient was in the operative room immediately prior to surgery, the patient developed hypotension and hypoxia. After discussion with family and medical team, patient opted for palliative care.

DISCUSSION:
The case highlights an extreme clinical presentation of a massive AAA that was found incidentally on imaging after a recent mechanical fall. Current guidelines recommend that an AAA should be surgically evaluation when its size exceeds 5.5 cm due to the life threatening risk of rupture. This patient's unusual presentation of a large AAA despite not presenting with any of the classical symptoms is concerning because of the risk associated with spontaneous rupture and death. More research is needed for the evaluation and screening of AAA's to prevent potential catastrophic complications.
3225 A Rare Case of Ruptured Jejunal Diverticulitis
Authors: Gurala Dhineshreddy , Idiculla Pretty Sara , Philipose Jobin , Krzyzak Michael , Mukherjee Indraneil 
Published: October 2019

INTRODUCTION:
Small intestinal diverticula are very rare, and the incidence ranges from 0.06 to 1.3%. Among these, duodenal diverticula are more frequent in 79% of patients followed by 18% in jejunum or ileum and 3% in all segments together. A jejunal diverticulum is usually asymptomatic, but only 10% develop complications. We report a unique case of a 70-year old female who presented with confusion, likely due to sepsis from perforated jejunal diverticulitis, that was successfully managed with initial resuscitation and definitive surgery.

CASE DESCRIPTION/METHODS:
A 76-year old female presented to the emergency room with confusion and epigastric pain for two days prior to presentation. Vital signs were stable. Physical examination was positive for mild epigastric tenderness. Laboratory results were normal except for leukocytosis of 15000, with left shift. Plain radiograph of the abdomen was negative for obstruction or perforation. Computed Tomography (CT) of the abdomen with oral and intravenous contrast showed the loop of thickened and edematous mid-jejunum and intraperitoneal free air consistent with perforated small bowel diverticulitis with abscess formation (Figure 1). She was initially resuscitated with intravenous fluids and was started on intravenous antibiotics. She underwent diagnostic laparoscopy with small bowel resection, primary anastomosis, drainage of the diverticular abscess. Pathology of resected jejunum was positive for diverticular disease with perforation. She did well postoperatively, tolerated diet, and discharged to home without any complications.

DISCUSSION:
Jejunal diverticula are usually multiple localized in proximal jejunum, develops as a result of herniation of mucosa, submucosa, serosa through muscular layer of bowel at the point of where vasa recta enter the muscular propria. Jejunal diverticulosis usually asymptomatic, only 10% develop complications. Perforation of jejunal diverticula is a severe complication that occurs in 2-6% of cases. A plain radiograph is the initial testing, but CT or Magnetic Resonance Imaging (MRI) is a gold standard for diagnosis. Acute uncomplicated jejunal diverticulitis is managed with intravenous fluids, bowel rest, and antibiotics. Acute Complicated diverticulitis needs surgical intervention such as laparotomy with segmental small bowel resection with primary anastomosis. Jejunal diverticulitis requires a high degree of clinical suspicion given the low incidence of the condition and increase in mortality after surgery up to 24%.
3233 Massive Gastric Distention… Aaand It's Gone!
Authors: Mulat Baruh , Boroda Konstantin , Hertan Hilary 
Published: October 2019

INTRODUCTION:
Gastric outlet obstruction is usually a sequelae of malignancy or PUD. When these causes are ruled out, other etiologies like gastroparesis should be considered.

CASE DESCRIPTION/METHODS:
A 72 year old female nursing home resident with a history of schizophrenia, depression, dementia (on Mirtazapine, Trazodone, and Donepezil), hypothyroidism, and longstanding type 2 diabetes with a Hemoglobin A1c of 6.1% was admitted with abdominal pain, emesis, and increased agitation. CT of the abdomen and pelvis revealed marked fluid filled distention of the stomach and proximal duodenum with no clear gastric outlet obstruction (Figure 1). Nasogastric tube placement was not tolerated by the patient. She was then made NPO and gradually advanced to a clear liquid diet. EGD performed six days later revealed a normal duodenum with mild stomach distention and no evidence of gastric outlet obstruction (Figures 2 and 3). Her symptoms then resolved and she was discharged.

DISCUSSION:
Our patient presented with non-obstructive, massive gastric distention, which improved rapidly with dietary restriction. Gastroparesis was thought to be the primary diagnosis due to her risk factors of diabetes and psychotropic medication use. The cause of gastroparesis is most commonly idiopathic, but it is also linked to diabetes, certain medications, postsurgical injuries, hypothyroidism, and post viral syndromes. In diabetes oxidative stress and long-standing disease leading to autonomic dysfunction are postulated mechanisms for gastroparesis. A recent review demonstrated the following prevalence of gastroparesis over a 10 year time period: 5.2% in Type 1 Diabetes, 1.0% in Type 2 Diabetes, and 0.2% in controls. Additionally, antidepressants and antipsychotic medications (eg, anticholinergic, dopamine agonists, tricyclic antidepressants) have been suggested as possible triggers for gastroparesis. Commonly prescribed medications including calcium channel blockers, narcotics, glucagon-like peptide-1 agonists and amylin analogues have similar effects. Our case is interesting as it demonstrates how gastric distention can develop to a massive extent in the setting of offending drugs, despite well controlled diabetes. Patients with longstanding diabetes taking multiple psychiatric medications are at a particularly high risk of developing gastroparesis.