bluuebunny/crossref_metadata_2025_split huggingface dataset:
1475 Plasmablastic Lymphoma Presenting as Ileocolic Intussusception
Authors: Selby Alexandra 
Published: October 2019

INTRODUCTION:
Plasmablastic lymphoma (PBL) is an exceedingly rare yet aggressive subtype of diffuse large B cell lymphoma that is most often identified in HIV-infected individuals. PBL is detected with the highest incidence in the oral cavity, with only 12% of cases being documented in the gastrointestinal tract. Even rarer are cases of PBL manifesting as intussusception, a phenomenon observed almost exclusively in children. To the author's knowledge, only two case reports of plasmablastic lymphoma presenting as intussusception (ileoileal and colonic) have been documented in the American literature since 2015. Herein the first case of PBL manifesting as ileocolonic intussusception in an immunocompromised adult is presented.

CASE DESCRIPTION/METHODS:
A 49-year-old man with a past medical history significant for AIDS (CD4+ 128) on intermittent HAART therapy presented with a 1-week history of sharp, bilateral lower quadrant pain and worsening abdominal distension. Admission labs revealed a mild transaminitis (AST 104 U/L, ALT 61 U/L) and lactic acidosis (2.8 mmol/L) but were otherwise unremarkable. His abdominal exam was notable for bilateral lower quadrant tenderness and marked abdominal distention. CT abdomen/pelvis with IV contrast demonstrated moderate-to-severe ascites as well as marked thickening of the terminal ileum, cecum and ascending colon with hyperemia and surrounding infiltration of fat concerning for short segment ileocolic intussusception. The patient was evaluated by general surgery and later deemed not to be a surgical candidate after several days of appearing non-obstructed. The patient subsequently underwent diagnostic and therapeutic paracentesis, with cytology consistent with plasmablastic neoplasm. Colonoscopy revealed a large, hard, partially obstructing mass in the ascending colon, with biopsy results most consistent with plasmablastic lymphoma. HHV-8 and EBV were negative on pathology. The patient was initiated on EPOCH chemotherapy by hematology/oncology and continues on therapy at the time of publication.

DISCUSSION:
The aforementioned case demonstrates the first known case report of PBL presenting as ileocolonic intussusception in recent review of the American literature. Taken in conjunction with other case reports documenting the association of PBL with intussusception, this case underscores that practitioners must be cognizant to include PBL in the differential diagnosis of intussusception in the immunocompromised adult so as to help expedite appropriate initiation of chemotherapy.
1477 A Rare Case of Successful Endoscopic Decompression of Ileal-Pouch Volvulus
Authors: Cavaliere Kimberly , Trindade Arvind , Kuntzen Christain 
Published: October 2019

INTRODUCTION:
Ileal-pouch anal anastomosis is a common surgery to restore bowel continence after total proctocolectomy. Obstruction is the most common late complication and occurs in up to 25% of cases. However, Ileal-pouch volvulus is an exceedingly rare complication of this procedure with only 16 published cases. All but one were treated with emergent surgical intervention. We present the second case of successful endoscopic decompression and the first reported in a patient with familial adenomatous polyposis (FAP).

CASE DESCRIPTION/METHODS:
A 33-year-old female with FAP status-post total proctocolectomy with ileoanal anastomosis and J-pouch formation complicated by history of ventral hernia repair and pouchitis presented with one week of severe left sided abdominal pain and emesis. On the day of presentation she noted new onset of abdominal distension causing her to present to the emergency room. The patients work up was notable for urosepsis, leukocytosis, AKI, hyperkalemia and a metabolic acidosis. A CT showed dilated small bowel loops swirled around a transition point in the left lower quadrant. A barium enema confirmed the diagnosis with barium that did not pass the distal rectum but was not therapeutic. Flexible sigmoidoscopy was then performed and showed twisted bowel with stenosis at 20 cm proximal to the anus. The endoscope was gently advanced with minimal CO2 insufflation and the stenosis re-opened, revealing dark gray, edematous mucosa with black spots. Proximally and distally, the mucosa appeared healthy. A colonic decompression tube was inserted to prevent future volvulus. The patient underwent exploratory laparotomy seven days later. No volvulus or bowel ischemia was found at that time and the pouch appeared viable. Extensive lysis of adhesions in the right upper quadrant and reduction of an internal hernia were performed. A small segment of small bowel was resected due to serosal injury. The patient then completed a course of antibiotics and was discharged home.

DISCUSSION:
This is a unique case of an extremely rare complication of an Ileal-pouch anal anastomosis. Additional abdominal surgeries, pouchitis and sepsis have been described as risk factors for pouch complications, all of which occurred in our patient and may have contributed to this rare presentation. Endoscopic decompression, if done expeditiously, may prevent loss of the pouch and need for surgical repair. This demonstrates the need for high clinical suspicion and awareness of this rare complication.
1478 Small Cell Carcinoma of the Cecum: A Rare Entity
Authors: Gladys-Oryhon Jordan , Umar Shifa , Cole Rita , Farah Katie 
Published: October 2019

INTRODUCTION:
Small-cell carcinoma of the colon (SmCC) is a very rare disease and is difficult to achieve long-term survival due to its aggressive behavior. Distant metastases are often found at the time of diagnosis of tumor. High recurrence rates contribute to poor survival with a median survival of 10.5 months. The World Health Organisation (WHO) in 2010 classified SmCC as a subgroup of neuroendocrine carcinoma (NEC) which accounts for approximately 0.6 percent of all colorectal cancers. Peak incidence of these tumours is in the sixth and seventh decades of life. The limited information on colorectal small cell carcinoma in the literature shows that these tumors have similar demographic features to colorectal adenocarcinomas with the exception of being more common in females. Of note, cecal small cell carcinoma is even more rare.

CASE DESCRIPTION/METHODS:
A 51-year-old female with no significant past medical history presented with a 2 year history of iron deficiency anemia and PICA. She had experienced 3 weeks of RUQ pain, abdominal distension, and fatigue. Colonoscopy revealed a 15 cm infiltrative mass in the cecum. Pathology showed invasive poorly differentiated grade 3 small cell carcinoma of the colon (Figure 1). Immunostains + CAM, synaptophysin, MAP-2, and CDX2. CTscan showed diffuse liver metastasis. PET scan showed diffuse brain metastasis. Chemotherapy with cisplatin and etoposide was instituted. Her course was complicated by confusion, lethargy, pulmonary embolus, recurrent ascites, and sepsis. She passed away 8 months after diagnosis.

DISCUSSION:
The available literature consists mainly of series of case reports or small case series that provide guidance for optimal therapy to prolong survival. Prognosis is very poor and is secondary to the tumor's aggressive biology, the presence of metastatic disease at the time of diagnosis, and poor response to chemo/radiotherapy. Seventy percent of patients present with metastases at the time of diagnosis. The reported 6 months, 3 year and 5 year survival rates of 58%, 13%, and 6%, respectively, with a median survival of 10.4 months. There is no agreed standard treatment approach for colorectal SmCC at the present time. Combination of surgery, chemotherapy and radiotherapy is the standard at this time but overall prognosis is poor. It is of utmost importance to perform colonoscopic evaluation if patients have any alarm features such as iron deficiency anemia, unexplained abdominal pain, and altered bowel habits so that diagnosis can be made earlier.
1482 Chalk Eating: A Culturally-Accepted Form of Pica in Georgia?
Authors: Uy Pearl Princess , Crisona Frank , Sridhar Subbaramiah 
Published: October 2019

INTRODUCTION:
Pica is the persistent intake of nonnutritive and nonfood substances seen commonly in children, pregnant women, institutionalized persons, patients with developmental disabilities and iron deficiency. Kaolin ingestion in the form of chalk, white dirt or white clay, is a lesser known form of pica but a common occurrence in Central Georgia. We present a case of a young black female from Georgia who presented with a partial bowel obstruction from eating chalk.

CASE DESCRIPTION/METHODS:
A 35-year-old black female from Augusta Georgia with iron deficiency anemia and depression presented with worsening abdominal pain, distention and constipation with the last bowel movement 2 weeks prior to presentation. She ate 5 lbs of chalk with each meal for the previous 10 years, like her mother. Her cravings for chalk increased with worsening anemia. Physical exam was pertinent for abdominal distention and tenderness. Laboratory tests revealed iron deficiency anemia but normal calcium and vitamin D level. The abdominal x-ray showed radiopaque material opacifying the lumen of the colon with nonobstructive bowel gas pattern. Flexible sigmoidoscopy was performed for mechanical disimpaction using endoscopic accessories was unsuccessful. Gastrograffin enema was then performed twice with resulting bowel movements. The patient received intravenous iron therapy and was evaluated by psychiatry. She was discharged home on iron supplements and laxatives.

DISCUSSION:
Kaolin is a soft white clay and an important ingredient in making porcelain, paper and rubber. It is not absorbed systemically but acts locally in the intestines where it adsorbs toxins and is used as an anti-diarrheal agent. The prevalence of kaolin ingestion especially among black female residents in Central Georgia represents a cultural-bound syndrome shared by family members or friends such as in our patient. Although our patient had iron deficiency anemia which could be associated with pica, the cultural practice of eating chalk is widely accepted in their community and believed that ingesting chalk helps with nausea, indigestion, and even constipation! Complications from this form of pica include anemia, malnutrition, constipation, intestinal obstruction, and even colon perforation. Management include medical, endoscopic or surgical removal of these substances and most importantly cognitive behavioral treatment. It is important to have a high index of suspicion for pica when multiple opacities are noted in the colon especially among residents of Georgia.
1485 Rectal Foreign Body: A Novel Minimally Invasive Extraction Technique With Blakemore Tube
Authors: Ali Ijlal Akbar , Hayat Maham , Kanagala Rajesh 
Published: October 2019

INTRODUCTION:
Rectal foreign bodies often pose a challenging diagnostic and management. They are usually classified as sharp or blunt and sexual or non-sexual. A few novel techniques described in literature to aid with extraction include Foley catheter, Blakemore tube, obstetrical forceps and vacuum extractor. We describe such a case of rectal foreign body extraction with Blakemore tube and flexible sigmoidoscopy, which saved the patient from an open surgical approach.

CASE DESCRIPTION/METHODS:
A middle-aged male presented to the Emergency room with complaint of inability to pass a rectal foreign body (cucumber) he had inserted into his rectum. He reported doing this on a regular basis and would usually remove them by bearing down. He did endorse any vomiting or abdominal pain and had been passing gas. A CT scan noted an elongated 23.5 × 4.9 × 4.7 cm foreign body in the rectosigmoid area with no bowel wall thickening or perforation with distal tip was 8.8 cm from the anal verge. Initial attempts at manual extraction by surgeon with exam under anesthesia were unsuccessful. An adult upper endoscope was inserted and used to guide a Blakemore tube under direct visualization beyond the proximal edge of the foreign body. The gastric balloon was inflated to 60 cc with saline and endoscope was withdrawn. Traction was applied by pulling the Blakemore and distal edge of cucumber was manually grasped and removed by the surgeon. Endoscopic re-inspection of the rectosigmoid colon confirmed no deep mucosal injury.

DISCUSSION:
This case demonstrates a few important principals which one should be cognizant of when managing large rectal foreign bodies. The most important factor in successful extraction is patient relaxation. Objects located more proximally in the rectum or the distal sigmoid colon may need a combined approach between gastroenterology and general surgery. A combined approach is also safer and minimally invasive, and able to save patient from an unneeded laparotomy. It is also important to re-evaluate the bowel mucosa for inadvertent injuries and perforations after successful removal of foreign body.
1486 Rectal Melanoma Occurring in a Properly CRC Screened Patient
Authors: Wojtkowski Antoni , Pandit Sarbagya , Karadsheh Zeid , Atia George , Chalise Shyam 
Published: October 2019

INTRODUCTION:
Rectal melanoma is a very rare, highly aggressive malignancy. Anal melanoma is the 3rd most common melanoma after the cutaneous and ocular varieties. It is the most common site of primary GI melanoma. Cutaneous melanoma metastasizes to the GI tract only 2% of the time, and only 2% of these metastases are to the rectum.

CASE DESCRIPTION/METHODS:
A 68-year-old male with a past medical history of HTN presented for evaluation of changed bowel movements. His stool diameter had decreased, and he noticed bright red blood mixed with his stool. He sometimes experienced fecal urgency, with no output. Rectal bleeding occurred just before or with bowel movements. He recently changed his diet, because of constipation. He recently lost 10 lbs. unintentionally. He did not use NSAIDs aside from aspirin 81 mg qd. He had a colonoscopy 5 years ago, with a 2 mm polyp removed (no abnormality seen on pathology). He had no family history of colon cancer. He was a retired chiropractor. A colonoscopy was performed, which found a suspicious lesion in the rectum (biopsied). Pathology showed pigmented melanoma. EUS staged the rectal mass as uT2uN1. Immunostains of the biopsy were performed: CK20-, CDX2-, p63-, S100 focally positive, HMB45 diffuse and strongly positive. No evidence of cutaneous melanoma was found. He was referred for surgical and oncology evaluation and treatment. He successfully underwent laparoscopic abdominal perineal resection with end colostomy. 9/10 sampled lymph nodes during surgery were positive for melanoma. He was started on nivolumab/ipilimumab dual therapy. He proceeded to undergo chemotherapy as outpatient (currently on chemotherapy cycle 2).

DISCUSSION:
Anorectal melanoma is a rare disease, accounting for ∼ 0.05% of all colorectal malignancies, and 1% of all anal cancers. Risk factors for anorectal mucosal melanoma are not currently known, although there is an increased risk associated with HIV infection. Survival is poor, depending on staging (Stage I – 24 month median survival; 5-year survival 26.7%, Stage II – median survival 17 months; 5-year survival 9.8%, Stage III – median survival 8 months; 5-year survival 0%). Adjuvant therapy consists of radiotherapy, however adjuvant immunotherapy with nivolumab has an established role in treating lymph node involvement. Anti-CTLA4 monoclonal antibody ipilimumab has been shown to significantly prolong survival in cutaneous melanoma, however more investigation is necessary to clarify role of ipilimumab in patients with mucosal melanoma.
1488 Melanoma Immune Checkpoint Inhibitors-Induced Colitis, Stay Vigilant!
Authors: Khalaf Suha Abu , Albarrak Abdulmajeed , Yousef Mohamad , Tahan Veysel , Ibdah Jamal A. 
Published: October 2019

INTRODUCTION:
Immunotherapy can induce multiple immune-related adverse events; one of them is colitis. We are presenting a case of colitis in a 37-year-old male who presented with a passage of loose bloody stool, abdominal pain with tenesmus. Colonoscopy with colon biopsies confirmed the diagnosis. Interestingly, the patient developed severe adverse reaction with colitis within five days following his first immunotherapy cycle.

CASE DESCRIPTION/METHODS:
A 37-year-old man presented with irregular, loose and bloody bowel movements that were associated with generalized abdominal pain for a week. The patient was newly diagnosed with metastatic melanoma to the left axially lymph nodes (T0, N3c, M0) that was positive for BRAF mutation. Treatment with nivolumab and ipilimumab were initiated five days before the time of his presentation. Lab workup showed elevated white cell count and liver transaminases fitting hepatocellular injury pattern. Stool testing for bacterial enteropathogens and Clostridium difficile were negative. CT scan of the abdomen showed mild wall thickness associated with inflammatory changes in the transverse and descending colon. The patient was started on empiric antibiotics with ciprofloxacin and metronidazole upon admission awaiting pending cultures, in addition to empiric prednisone as well. He then underwent colonoscopy the following day, which showed diffuse erythema and ulcers in the entire colon and rectum. The terminal ileum was unremarkable. Colonic biopsies were obtained and showed acute inflammation with severe ulceration and granulation tissue. Based on these findings, the diagnosis of immunotherapy-induced colitis grade 4 was established. The patient had a total of two months of prednisone treatment. His immunotherapy was switched to BRAF/MEK inhibitors.

DISCUSSION:
Since the time of approval of the immune checkpoint inhibitors for the treatment of advanced melanoma, impressive improvement in survival rates and extension of their use to other malignant fields have been observed, but on the other hand, autoimmune-related side effects have arisen. Studies have reported that the median time to onset of diarrhea is 5-8 weeks after the start of a combination therapy that includes Ipilimumab. Our patient was undergoing treatment with both nivolumab and ipilimumab, and the symptoms started acutely 5 days after the first treatment session. The patient was found to have colitis grade 4 based on the Common Terminology Criteria for Adverse Events (CTCAE) V.4.
1490 Ursodeoxycholic Acid for the Management of Recurrent Clostridioides difficile Infection
Authors: Perreault Gabriel , Baylor Jessica , Radin Arielle , Javitt Norman , Chen Lea Ann 
Published: October 2019

INTRODUCTION:
Fecal microbiota transplant (FMT) is an effective treatment for recurrent Clostridioides difficile infection (rCDI), but its precise mechanism remains unknown (1-2). Recent studies suggest that the restoration of gut bacteria, which carry necessary enzymes to convert primary bile acids (PBAs) to secondary bile acids (SBAs), may play a key role in rCDI risk (3, Figure 1). For example, in vitro studies have demonstrated that PBAs stimulate C. difficile spore germination and that deoxycholic acid, a SBA, inhibits toxin-producing C. difficile (4). As normal fecal bile acid pools consist predominantly of SBAs, we hypothesize that a contributor of rCDI risk is the decrease in SBAs from enteric bacteria loss following antibiotic use (5-8). We present the first case enrolled in our clinical trial using ursodeoxycholic acid (UDCA), a SBA, as an adjunct treatment to prevent future rCDI.

CASE DESCRIPTION/METHODS:
An otherwise healthy 46-year-old man presented with S. aureusbacteremia secondary to septic knee arthritis. While on an extended course of cefazolin, he developed profuse, watery diarrhea and stool C. difficile toxin PCR was positive. He was then treated with intravenous metronidazole for one week and oral vancomycin for two weeks, with resolution of symptoms. Six weeks later, CDI recurred and was successfully treated with oral vancomycin for two weeks, in conjunction with concurrent UDCA 300 mg twice daily for eight weeks. Stool samples were collected at two-week intervals and fecal bile acid compositions were assessed via liquid chromatography - mass spectrometry. Fecal bile acid analyses demonstrated a shift towards protective SBAs by the end of the 8-week course of ursodiol (Figure 2). This profile of increased SBAs remained consistent despite subsequent retreatment with cefazolin at 5 months for recurrent septic arthritis. The patient has been without rCDI now for almost 2 years.

DISCUSSION:
The findings in this case are consistent with our hypothesis that increasing SBAs through adjunct treatment with UDCA can be effective in breaking the rCDI cycle. While some CDI patients have adequate enteric bacteria to produce SBAs after antibiotic treatment, others may have a delayed normalization of their gut microbiome, and may therefore require “bridge therapy” with supplementary SBAs (e.g., UDCA) until their endogenous microbial community is restored. Treatment and analysis of additional patients with rCDI in this clinical trial are in progress.
1496 Visceral Involvement as the Initial Presentation of Kaposi Sarcoma Carries a Worse Prognosis
Authors: Ashamalla Michael , Wander Praneet , Pizzuti Jessica , Lech Diana , Rishi Arvind , Vitkovski Taisia , Greenberg Ronald 
Published: October 2019

INTRODUCTION:
AIDS-related Kaposi sarcoma (KS) is a vascular tumor associated with infection by the human herpesvirus-8 (HHV-8) that most commonly affects mucocutaneous sites. In its disseminated form, it can also involve lymph nodes and visceral organs, in particular the respiratory and gastrointestinal tract. Visceral involvement as the initial manifestation of KS is extremely rare and carries a worse prognosis. We present a case of a 54-year-old Male with disseminated KS with rectal involvement presenting with cough and chills.

CASE DESCRIPTION/METHODS:
54-year-old Male with a past medical history significant for HIV, not adherent with HAART therapy, who presented to the Emergency Department (ED) with a chief complaint of cough and subjective chills of three days duration. He later endorsed recent sick contacts, bloody diarrhea, and a 40 lb weight loss over the last year. In the ED, he was hypotensive and tachycardic and found to have a CD4 13 with a viral load of 3 million copies/ml. A CT Chest showed evidence of bilateral pleural effusions for which he was started on broad spectrum antibiotics. He underwent bronchoscopy with BAL which showed small nodules suspicious for KS versus Lymphoma. His hospital course was complicated by microcytic anemia (Hb 6.1 on admission) with a positive fecal occult test requiring multiple blood transfusions. Gastroenterology was consulted and the patient underwent colonoscopy which showed evidence of a large, non obstructing, fungating mass in the distal rectum. The mass had a purple hue, was noncircumferential, and was confluent with multiple scattered oozing purple sessile nodules. Biopsies were taken with cold forceps for histology. The rectal biopsy was positive for Human Herpes Virus 8 (HHV-8) and he was diagnosed with disseminated KS. He was subsequently transferred to the National Institutes of Health Clinical Center in Maryland after failed initial treatment for further management and care.

DISCUSSION:
Visceral involvement as the initial presentation of KS is rare and carries a worse prognosis. While gastrointestinal KS lesions are usually asymptomatic, they may also cause a wide array of symptoms including nausea and vomiting, weight loss, upper or lower gastrointestinal bleeding, and abdominal pain. Because visceral involvement is rare as the initial presentation, the possibility of disseminated KS in an immunocompromised patient is often over looked and thus, a high index of suspicion is required.