bluuebunny/crossref_metadata_2025_split huggingface dataset:
3069 CMV Colitis Presenting as Chronic Non-Remitting Diarrhea and Anemia
Authors: Bsrat Makda , Kassim Gassan , Rastogi Neelesh , Rogers Steven 
Published: October 2019

INTRODUCTION:
Cytomegalovirus (CMV) is a common infection in immunocompromised patients including solid organ transplant patients. CMV infection of the GI tract can present in various ways. We present a case of chronic diarrhea of one-year duration associated with anemia.

CASE DESCRIPTION/METHODS:
A 56 year old female with a past medical history of hypertension, end stage renal disease with renal transplant in 2004 (maintained on cyclosporine, mycophenolate mofetil and prednisone) presented to the emergency room with generalized weakness of 4-days duration. The patient further endorsed significant weight loss and gradually progressive watery diarrhea that initially was postprandial and had been present for about one year. The symptoms persisted despite treatment with anti-diarrheal agents. The patient was also found to have anemia that began around a similar time as the diarrhea, and required multiple admissions for blood transfusions. She denied melena, hematochezia, fevers or chills. During prior admissions, fecal occult blood tests were negative and stool studies were unrevealing. On admission, the patient was found to have hemoglobin (Hgb) of 5.4 g/dL, acute kidney injury and metabolic acidosis. Fecal occult blood test was positive. Colonoscopy revealed diffuse pan colonic erythematous inflamed mucosa with rectal sparing and no evidence of punched-out ulcers (see Figures 1 and 2). Qualitative CMV polymerase chain reaction study was positive. Hematoxylin and Eosin stained biopsies were inconclusive for inclusion bodies. Immunohistochemical staining for CMV was positive for scattered reactive cells. CMV colitis was diagnosed. Patient was treated with oral valganciclovir leading to complete symptom resolution, improvement of anemia and weight gain.

DISCUSSION:
CMV colitis in immunocompromised patients typically presents with diarrhea associated with abdominal pain, fever, leukopenia and frank hematochezia. This case represents an unusual disease manifestation with an atypical timeline of disease duration, lack of aforementioned symptoms and non-characteristic endoscopic findings, making the diagnosis challenging. Furthermore, delayed CMV infection in organ transplant patients is quite unusual, as most typically, CMV infection presents shortly after initiation of immunosuppressive therapy.
3072 A Unique Cause of Ischemic Colitis: Docetaxel Chemotherapy
Authors: Syed Azfar , Francis Jonathan P. 
Published: October 2019

INTRODUCTION:
Ischemic Colitis (IC) is the most common form of intestinal ischemic disorders. This disease process typically affects older adults and is the result of non-occlusive hypoperfusion, which can be precipitated by a multitude of risk factors. Patients usually present with lower abdominal pain and hematochezia. A colonoscopy with biopsies is the gold standard for diagnosis. Increasingly, medications have been associated with contributing to this disease process. Here, we report a unique case of IC attributed to Docetaxel, a taxane class chemotherapeutic agent.

CASE DESCRIPTION/METHODS:
A 76-year-old Caucasian female with a history of multi-focal intraductal carcinoma (Stage IIA), hypertension, and diverticulosis presented to the emergency room (ER) with complaints of lower back and abdominal pain. She had begun therapy with Docetaxel and Cyclophosphamide 8 days prior to presentation. In the ER, she was afebrile, neutropenic (ANC 400), and hypotensive requiring supportive care including antibiotics, fluids and a very brief course of norepinephrine. She was subsequently admitted to the intensive care unit where her neutropenia was noted to have resolved and antibiotics were discontinued in setting of negative cultures. On hospital day 3, she complained of continued abdominal pain and hematochezia with CT imaging that demonstrated bowel wall thickening and mild inflammatory changes in the sigmoid/descending colon. Subsequently, a colonoscopy was performed and showed circumferential, violaceous mucosa consistent with IC. Antibiotics were restarted and the patient was treated supportively with complete resolution of symptoms. Following hospital discharge, she was evaluated by her oncologist who discontinued her Docetaxel and initiated therapy with Paclitaxel. No recurrence of her symptoms have been noted and repeat cross sectional imaging demonstrated resolution of colonic thickening in the previously noted watershed distribution.

DISCUSSION:
IC is a rare but serious complication that has been described in patients receiving Docetaxel. Among the 6 reported cases, symptoms occur within 10 days of Docetaxel administration. Patients present with abdominal pain and hematochezia in the setting of neutropenia with or without fever. This type of IC is often severe, with spontaneous perforation, bowel necrosis, and a reported mortality rate of 40-50%. Although underreported, Docetaxel use is a risk factor for developing IC, one deserving of more clinical awareness.
3073 Eosinophilic Gastroenteritis and Eosinophilic Proctocolitis With a Large Rectal Sessile Serrated Adenoma: A Rare Association
Authors: Nagaraj Savitha V. , Aamar Ali , Reddy Madhavi 
Published: October 2019

INTRODUCTION:
Eosinophilic Gastrointestinal Disorders (EGID) are a group of rare disorders characterized by eosinophilic infiltration of the gastrointestinal tract. Eosinophilic gastroenteritis (EGE), eosinophilic colitis (EC) and eosinophilic proctitis (EP) are different types of EGID. We report a case of rare association of EGID and a large sessile serrated adenoma in a middle-aged Hispanic female.

CASE DESCRIPTION/METHODS:
A 49-year-old Hispanic female presented with epigastric discomfort, nausea and hematochezia. The symptoms were insidious in onset and evolved over the span of 3 years. Upper GI Endoscopy showed mild diffuse erythematous mucosa in the antrum and body of the stomach. Colonoscopy showed a few superficial ulcers in the terminal ileum, two polyps in the transverse colon and a large laterally spreading polypoid lesion in the rectum with adjacent multiple small polypoid lesions (Figures 1 and 2). Histological assessment of the gastric biopsy specimen revealed chronic active gastritis, numerous H. pylori, in addition to very high number of eosinophils in the lamina propria. Biopsies of ileum, colon and the rectum also revealed very high number of eosinophils in the lamina propria. Stool for ova and parasite examinations were negative and no peripheral eosinophilia was noted. Patient did not have any food or environmental allergies. Other disorders that could contribute to eosinophil infiltration of the GI tract were ruled out. Hematochezia was likely due to eosinophilic proctitis and rectal polypoid lesion. Although exact eosinophilic count in the biopsy specimen of the stomach, small bowel and the colon was not reported, the clinical presentation and histology was likely consistent with EGID. Patient was treated for H. Pylori infection. Endoscopic submucosal dissection of the rectal polypoid lesion was performed (Figure 3). Pathology revealed sessile serrated adenoma.

DISCUSSION:
Eosinophilic gastrointestinal disorders are a group of rare gastrointestinal diseases with non-specific symptoms and clinical presentation. Diagnosis of EGE, EC and EP involves evaluating for presence of gastrointestinal symptoms, histopathology finding of eosinophilic infiltration of the GI tract and ruling out secondary causes of eosinophilia. Endoscopic examination may reveal patchy erythema, loss of vascularity and lymphonodular hyperplasia mostly localized to the rectum. The authors report this rare case of possible association of EGID and sessile serrated adenoma.
3076 Post Colonoscopy Diverticulitis in a 50-Year-Old Woman Undergoing Surveillance Colonoscopy
Authors: Mahoro Giselle , Copland Andrew , Frye Jeanetta 
Published: October 2019

INTRODUCTION:
Colonoscopy is used as a diagnostic and therapeutic tool to treat a wide range of gastrointestinal disorders. Acute diverticulitis after colonoscopy is a rare but potentially serious complication. The incidence of acute diverticulitis after colonoscopy is reported to be 0.084%. Since this is a rare entity, there is limited data regarding the risk, prevention and management of acute diverticulitis after colonoscopy.

CASE DESCRIPTION/METHODS:
A 50 year old woman with a history of adenomatous polyp with villous component detected 4 years prior presented for surveillance colonoscopy. She did not have any abdominal pain. Her labs from a year prior showed WBC 6.86 k/uL. Colonoscopy was notable for pan-colonic diverticulitis (Figure 1), most prominent in sigmoid colon. There was a 2 mm sessile polyp in recto-sigmoid colon that was removed with cold biopsy forceps. The procedure was otherwise uncomplicated. She presented to the emergency department (ED) 3 days later with left lower quadrant pain (LLQ) and fever up to 101 Fahrenheit. The pain started 2 days after she underwent colonoscopy. She did not have nausea, vomiting or rectal bleeding. In the ED, she was afebrile with moderate LLQ tenderness without rebound or guarding. Labs showed WBC 15.41 k/uL (72.5% segmented neutrophils), BUN 11 mg/dL, Cr 1.0 mg/dL. CT of the abdomen and pelvis had findings concerning for acute sigmoid colon diverticulitis without abscess (Figure 2). The patient was discharged from the ED on moxifloxacin and metronidazole.

DISCUSSION:
The American Society for Gastrointestinal Endoscopy (ASGE) lists diverticulitis as a miscellaneous complication, however, there is limited data regarding the risk of developing diverticulitis after colonoscopy. In a retrospective cohort of 236, 377 patients who underwent colonoscopy, 68 patients (0.029%) developed post-colonoscopy diverticulitis. The mean time to develop diverticulitis after colonoscopy was 12 ± 8 days. 34 patients (50%) had a history of diverticulitis prior to colonoscopy and 30 patients (44%) required hospitalization. Prospective studies are now needed to evaluate the risk, mechanism and prevention of colonoscopy induced diverticulitis. If significant diverticula are noted on colonoscopy, post-colonoscopy diverticulitis should be discussed as a potential complication, and it should be considered in a patient who presents with fever and abdominal pain after undergoing colonoscopy.
3077 Inverted Appendix Caused by Inversion-Ligation Appendectomy: An Unusual Case of Cecal Mass
Authors: Moosvi Zain , Sowa Piotr , Samarasena Jason , Albers Gregory 
Published: October 2019

INTRODUCTION:
Polypoid lesions involving the cecum and more specifically the appendiceal orifice (AO) can be a diagnostic dilemma. The thin walled cecum poses risk of perforation, therefore resection should be avoided for benign lesions. Invasive adenocarcinoma or adenocarcinoma is situ arising from the appendiceal lumen or AO are rare with less than 250 reports. Other lesions include appendiceal endometriosis, juvenile polyps, adenomatous polyps, and appendiceal inversion.

CASE DESCRIPTION/METHODS:
A 68-year-old female with a past medical history of fibroids s/p hysterectomy and prophylactic appendectomy over 30 years ago presents for first time screening colonoscopy. She denies history of rectal bleeding, constipation, weight loss or family history of colon cancer. An elongated tubular lesion was identified in the cecum (Figures 1 and 2). During inspection, the lesion appeared to arise from the AO. Due to risk of perforation, the polypoid lesion was not removed and multiple biopsies were obtained. The patient had 4 additional polyps, ranging from 4-10 mm, that were removed during the procedure. Pathology report of the cecal mass showed normal colonic mucosa with mild inflammation.

DISCUSSION:
Inversion of appendiceal base is an expected occurrence after inversion-ligation appendectomy. This surgical procedure has been performed historically as an incidental appendectomy, which avoids the transection of the appendiceal lumen and decreasing risk of bacterial peritonitis. The majority of these cases result in atrophy of the appendiceal stump causing scar tissue formation in the AO. However, few autopsy reports show a retained polypoid appendiceal stump that occasionally increases in size. A few reports have described appendiceal inversion resembling a neoplastic polyp during routine colonoscopy. Many of these patients have undergone inversion-ligation appendectomy. The risk of perforation and major bleeding is dramatically increased if endoscopic resection is attempted. We recommend a conservative approach with biopsy to assess for dysplasia or malignancy. If endoscopic resection is attempted, complications can be minimized with the utilization of endoloop or endoscopic clips.
3080 Intestinal Endometriosis: A Case of Mistaken Identity
Authors: Shrimanker Isha , Thein Kyaw , Goel Siddharth , Singh Pratiksha , Charan Mohan , Nookala Vinod 
Published: October 2019

INTRODUCTION:
Intestinal involvement is seen in 3-30% of the cases of endometriosis with the rectum and sigmoid colon being frequently affected (75-90%) followed by distal ileum (2–16%) and appendix (3–18%). In addition to the classic triad of pelvic disease, the presentation may vary from being asymptomatic to rectal bleeding, bowel obstruction and rarely perforation. In the majority of the cases, the mucosa is spared with involvement limited to serosa and muscularis propria. The median age of diagnosis is 34-40 years, but reports of diagnosis in the peri- and post-menopausal women are known to exist in literature.

CASE DESCRIPTION/METHODS:
A 55-year-old Caucasian female presented with intermittent bleeding per rectum and abdominal pain for a period of two months with a history of irritable bowel syndrome and anemia. She denied any weight loss or loss of appetite. The examination was unremarkable except for pallor and tenderness in the lower quadrant and laboratory investigations revealed microcytic anemia. Colonoscopy was significant for a 1.5 cm mass in the sigmoid colon. Biopsy of the mass showed endometrial foci and stroma with signs of transmural involvement but was negative for signs of malignancy. The patient was managed with hormonal suppression therapy leading to resolution of abdominal symptoms.

DISCUSSION:
Intestinal endometriosis mimics a broad spectrum of diseases; inflammatory bowel disease neoplasms, colitis, diverticular disease, and infection. The clinical picture along with its overlapping clinical, endoscopic and radiological findings add to the diagnostic conundrum. It is essential to differentiate it from colon adenocarcinoma, the third most common type of cancer in women, to avoid unwarranted diagnostic and therapeutic interventions. The literature regarding standardized workup and treatment is limited and continues to be a topic of research.
3082 Overdosing From Down Under: An Atypical Route of Methamphetamine Use Resulting in Bowel Ischemia
Authors: Narasimha Shruthi , Rios de Choudens Fabiola 
Published: October 2019

INTRODUCTION:
Methamphetamines are sympathomimetic medications that cause a surge in catecholamines, which leads to a significant abuse potential. The National Survey on Drug Use and Health reported in 2017 that 5.4% of the population, which at that time made up over 14.7 million people have used methamphetamines at least once in their lives. The usual routes of administration include oral, nasal or intravenous. However, novel anal routes are being seen in current literature and clinicians should be aware so they can notice the severe and potentially life threatening side effects.

CASE DESCRIPTION/METHODS:
The case involves a 29-year-old male with history of benzodiazepine and methamphetamine use who came to the hospital with complaints of rectal pain and hematochezia. He reported continued daily intravenous drug use but also divulged that he had been inserting methamphetamines rectally for the past 5 days. He reported that recently, the bag burst and caused him significant hemorroidal irritation and bleeding. Most of the drugs passed rectally per the patient and the bleeding was improving by the time of admission. Vitals were stable and labs were significant for mild leukocytosis, mild normocytic anemia, and a urine drug test showed elevated amphetamines and benzodiazepines. Due to the continued hematochezia, gastroenterology was consulted and a flexible sigmoidoscopy showed distal ischemic changes in the rectum and an anal ulcer that showed chronic inflammation on biopsy. Through the hospital course, his symptoms improved and he was eventually discharged after extensive education and two weeks of rectal mesalamine.

DISCUSSION:
This case highlights two important points. The first deals with the unusual route of administration, which is helpful to know so that providers can address proper removal of the source. Methamphetamines have rapid gastrointestinal absorption, so it would be important to evacuate the rectal area to prevent further intoxication. The second key aspect of this case deals with the resulting side effect of bowel ischemia. A handful of case reports describe this adverse effect and patients range from having fatal to self-limited outcomes. However, these cases do not all address the route of drug ingestion but direct anal exposure would likely increase the risk of bowel ischemia due to the local vasocontrictive mechanism. Thus, it is vital to initially ask how patients administered the methamphetamines and evaluate the patient's clinical course for bowel injury secondary to ischemia.
3088 Zenker's Full Thickness Diverticulotomy Combined With Botox Injection
Authors: Dawood Enad , Sharma Bashar , Deskmukh Ameya , Nieto Jose 
Published: October 2019

INTRODUCTION:
We present a case of an 88 year old gentleman with a history of dysphagia and a recent episode of aspiration pneumonia. A routine swallow evaluation showed a defect in the cricopharyngeal region. A follow up esophagram revealed a large Zenker's diverticulum. We present a case of full thickness endoscopic Zenkers diverticulotom followed by Botox injection post diverticulotomy and resolution of symptoms on one month follow up.

CASE DESCRIPTION/METHODS:
The endoscope was introduced into the esophagus, a wire was passed, then a nasogastric tube was passed into the stomach via the wire, this was used to identify the esophageal lumen. Using a hybrid I knife The diverticulotomy was started. Complete dissection and myotomy of the diverticulum was completed. 10 cc of 100 units of botox were then injected to the proximal esophageal muscle and a diverticular ricopharyngeal muscle. In order to assess for perforation, a upper esophagram was preformed that showed no evidence of leak and the patient was discharged. 30 day follow up showed a completely resolved Zenkers diverticulum and an asymptomatic patient from dysphagia and no evidence of recurrent aspiration pneumonia.

DISCUSSION:
Zenker's diverticulum can be repaired with a variety of surgical and procedural options. However, endoscopic intervention has been shown to reduce operative time and to simplify management in postoperative care. We introduce a novel approach using Botox injections following Zenker's full thickness diverticulotomy to correct a diverticular pouch and relax the surrounding musculature. The video case report showcases the practicality and effectiveness of the procedure.
Watch the video: http://bit.ly/2M2fgMv
3097 Reduction of a Hiatal Hernia Using Osteopathic Treatment
Authors: Peck Meredith T. , Volokitin Mikhail , Sonpal Niket 
Published: October 2019

INTRODUCTION:
Hiatal hernia describes superior herniation of abdominal contents through the diaphragm. This type of herniation occurs when the esophageal hiatus weakens and the positively pressurized abdominal cavity forces contents into the negatively pressurized thoracic cavity. Risk factors include conditions that either increase intra-abdominal pressure (e.g., obesity) or weaken the hiatus and associated structures (e.g., fibromuscular degeneration associated with normal aging). Multiple types and classifications of hiatal hernias encumber assessments of disease prevalence; however, hiatal hernias are broadly classified as either sliding or paraesophageal. While many sliding hernias are asymptomatic, patients may experience reflux-like symptoms due to weakening of the lower esophageal sphincter. Paraesophageal hernias are more serious and can lead to volvulus, bleeding, and respiratory compromise. Surgical repair of the hernia is indicated in symptomatic patients refractory to conservative management and to manage complications; however, surgical intervention is a risk factor for more serious complications such as stenosis and perforation.

CASE DESCRIPTION/METHODS:
Here we present a case of a 71-year-old female with reflux symptoms diagnosed with a 3 cm hiatal hernia on esaphagogastroduodenoscopy (EGD). After four osteopathic manipulative treatments (OMT), follow-up EGD showed no evidence of hernia or gastritis and the patient reported complete relief of symptoms.

DISCUSSION:
To our knowledge, this is the first case confirmed by EGD to show a complete reduction of a 3 cm hiatal hernia with OMT being the sole treatment modality. This case demonstrates that hiatal hernias can be managed using OMT, without the use of medications or the need for surgical intervention.
3109 A Rare Cause of Dysphagia—Epiphrenic Diverticulum
Authors: Lopez Michell , Then Eric O. , Gayam Vijay , Ofosu Andrew , Culliford Andrea , Gaduputi Vinaya 
Published: October 2019

INTRODUCTION:
An epiphrenic diverticulum is a rare, benign disorder of the distal esophagus characterized by protrusion of the esophageal mucosa through the musclular layer, proximal to the gastroesophageal junction. They are false diverticula mainly associated with motility disorders. The most frequent symptoms experienced by patients are dysphagia, regurgitation, and aspiration, but most cases are usually asymptomatic. We present a rare case of epiphrenic diverticulum in a 71-year-old male.

CASE DESCRIPTION/METHODS:
The patient is a 71 year-old man with a medical history of cerebrovascular accident (with residual left sided weakness, and chronic encephalopathy), and hypertension who presented to our emergency department after family members noticed he was unable to tolerate oral intake and had multiple episodes of vomiting over the past two days. Notable imaging in the emergency department included a computed tomography (CT) of the chest which showed irregular wall thickening in the distal esophagus suggestive of a neoplasm. Laboratory workup including a complete blood count and comprehensive metabolic panel were within normal limits. Upon admission the gastroenterology service was consulted who recommended the patient undergo esophagogastroduodenoscopy (EGD) to rule out malignancy. Given the risks associated with EGD the patients family refused the procedure. They did however agree to a barium swallow to better evaluate the esophagus. This was done and showed an epiphrenic diverticulum in the distal esophagus (Figure 1). After this was discovered the patients family refused any intervention including EGD or surgery. During his admission the patient was able to tolerate a pureed diet and his medications were crushed which were also tolerated appropriately. He was then discharged home with follow up appointments scheduled.

DISCUSSION:
Esophageal diverticula are uncommon acquired disorders of the esophagus that have an estimated incidence of 1 in 500,000 people per year. As opposed to Zenkers diverticula which occur in the proximal esophagus, epiphrenic diverticula are rarer and occur in the distal esophagus. To put its rarity into context the estimated ratio of epiphrenic divertila to zenkers diverticula is 1:5. Although most cases are asymptomatic, some cases may present with dysphagia, regurgitation of undigested food, heartburn and aspiration pneumonia. Surgical resection is the treatment of choice, but endoscopic procedures such as per-oral endoscopic myotomy are challenging that concensus.