bluuebunny/crossref_metadata_2025_split huggingface dataset:
1557 Not Your Average Colon Cancer: Diffuse Large B-Cell Lymphoma in a Terminal Ileum Mass and Colon Polyp
Authors: Gordon Benjamin , Wan David 
Published: October 2019

INTRODUCTION:
Although the GI tract is a common site of extranodal non-Hodgkin lymphoma, primary ileocolonic lymphoma is rare among GI malignancies. Here, we report the case of a man presenting with abdominal pain diagnosed with diffuse large B-cell lymphoma (DLBCL) in his terminal ileum and sigmoid colon on colonoscopy.

CASE DESCRIPTION/METHODS:
A 72 year-old male with type 2 diabetes mellitus and recurrent UTIs presented with several weeks of abdominal pain and rectal bleeding. A colonoscopy 7 years prior showed diverticulosis. He had a 10 pack-year smoking history (quit 35 years prior). Family history was notable for a father with prostate cancer. Exam showed abdominal tenderness in the right lower quadrant. Laboratory work-up was only notable for ESR 25 and CRP 1.1. CT abdomen/pelvis demonstrated wall thickening in the cecum/ascending colon with surrounding inflammatory change and reactive adenopathy. Colonoscopy showed an ulcerated 2.0 × 1.8 cm mass in the terminal ileum, involving one-third of the lumen circumference (Figure 1). A 1.0 cm semi-pedunculated polyp was found in the sigmoid colon (Figure 2). Pathology of the ileal mass was consistent with DLBCL, non-germinal center B cell origin; pathology of the sigmoid polyp was tubular adenoma with large atypical lymphoid submucosal cells, suggestive of lymphatic involvement.

DISCUSSION:
The ileocolonic area is the least common site of primary GI lymphoma, accounting for only 0.3-0.5% of malignancies found there. Most patients present with abdominal pain, lower GI bleeding, or weight loss. GI lymphoma is more common in men, age 60-70s. Other risk factors are immunosuppression, chronic viral illness, H. Pylori, IBD, and Celiac disease. CT is the mainstay in diagnostic imaging. However, radiographic and endoscopic appearance cannot differentiate GI lymphoma from other malignancy; biopsy is the only way to confirm diagnosis. DLBCL is the most common subtype, with mantle cell and follicular lymphoma less prevalent. There is no standard treatment, although surgery is generally performed given risk of spontaneous perforation. Chemotherapy is often offered alone or adjuvantly as disease usually extends beyond local fields. Though our case has some typical features of GI lymphoma, ileocolonic involvement is very uncommon, and occurrence in multiple areas is rare, found in less than 10% of primary GI lymphomas. Thus, this case is unique, as the patient had an ileal mass as the primary site of DLBCL with a polyp in the sigmoid, suggesting lymphatic spread.
1560 Sessile Serrated Polyposis Syndrome (SPS) and Sessile Serrated Polyps (SSPs): Features, Variations in Detection Rate, and the Associated Risk of Both Synchronous and Metachronous Neoplasia
Authors: Alansari Tarek H. , Alansari Ahmed , Khan Gulam 
Published: October 2019

INTRODUCTION:
Colorectal cancer (CRC) is the second most common cancer worldwide, accounting for 8% of all cancer related deaths. Sessile serrated polyposis syndrome (SPS) is a genetically inherited disease. The actual prevalence is unknown but is estimated to be 1 in 2000 to 3000

CASE DESCRIPTION/METHODS:
63 year old female with no family history of colon cancer, presented for a diagnostic colonoscopy after a positive fecal occult blood test (FOBT). FOBT was done for screening purposes. Patient had a negative FOBT X 3 a year ago. Colonoscopy showed 10 polyps. All polyps were resected with different techniques based on size, features and location. All polyps came back as sessile serrated polyps. 6 polyps showed features of cytologic dysplasia. 5 were proximal to the Sigmoid colon (1 was >20 mm in size and 3 were >10 mm in size).

DISCUSSION:
Based on a growing body of data, sessile serrated polyps (SSPs) have a higher prevalence than previously thought. Whether sporadic or part of the sessile serrated polyposis syndrome (SPS), SSPs are associated with increased risk of synchronous and metachronous neoplasia. A recent study looked at the synchronous burden of large (≥ 20  mm) SSPs in patients without SPS. The study found that 67/146 patients (45.9 %) had SPS, 53/146 (36.3 %) had a solitary SSP, and 26/146 (17.8 %) were categorized as oligo-SSP. Dysplasia in large SSPs was frequent in all groups (41.1 % overall). SPS was recognized by referring endoscopists in only 9.0 % of cases. Patients meeting the World Health Organization criteria who elect long-term endoscopic surveillance should receive annual colonoscopy after the diagnosis is established. Surgery is indicated when CRC is diagnosed or the number of polyps makes endoscopic control unfeasible. White-light endoscopy is considered the gold standard for detection and removal of colorectal lesions to prevent CRC development. However, detection of small adenomas (<5 mm) and SSPs is difficult as conventional endoscopy relies on the experience of the endoscopist. As a result, the reported adenoma detection miss rate for the general population is relatively high (27%). This underscores the necessity of improving endoscopic detection strategies. In a randomized controlled trial, 86 patients with SPS underwent tandem high-definition (HD) colonoscopies from February 2015 through July 2016 at 7 centers in Spain. It was found that panchromoendoscopy increases detection of polyps (mostly of small serrated lesions) and should be considered in patients with SPS.
1567 A Case of Gastrointestinal Amyloid Causing Colocolic Intussusception in an Adult
Authors: Laszkowska Monika , Garcia-Carrasquillo Reuben 
Published: October 2019

INTRODUCTION:
Intussusception is very rare in the adult population. It is typically associated with a pathologic lead point, most commonly a malignant lesion. To our knowledge, colocolic intussusception due to gastrointestinal amyloidosis has not been reported.

CASE DESCRIPTION/METHODS:
This is a case of a 57-year-old man with kappa light-chain (AL) amyloidosis with biopsy-proven myocardial involvement who was initially admitted for congestive heart failure exacerbation and was being managed with ionotrope-assisted diuresis. Five days into his hospitalization, he developed sudden onset abdominal cramping, nausea, non-bloody vomiting, and melena. Physical exam revealed no abdominal tenderness and maroon stool in the rectal vault. Laboratory testing was notable for a hemoglobin decline from 10.2 g/dL to 7.7 g/dL over the course of one day. A CT of the abdomen and pelvis showed a 6 cm segment of distal transverse colon with irregular mural thickening and an apple core lesion, initially concerning for malignancy. A colonoscopy was done, and a protruding, large mass with dusky mucosa was identified in the transverse colon concerning for intussusception. Re-review of CT imaging did suggest a region consistent with intussusception. The patient underwent a laparoscopic extended right colectomy to remove a hemorrhagic transverse colon mass. Pathology of the excised segment showed two foci of hemorrhagic infarction, including a large polypoid lesion, associated with severe perivascular amyloidosis.

DISCUSSION:
AL amyloidosis rarely involves the gastrointestinal tract, and intussusception secondary to amyloidosis is extremely rare. It has been described as a possible complication in the small bowel, but to our knowledge this is the first report of amyloid causing colocolic intussusception.
1602 Mantle Cell Lymphoma Presenting as Intussuscepting Colon Mass
Authors: Smith Brandon , Reilly Kyle , Baker Elena , Deeken Amy H. , Dan Adrian 
Published: October 2019

INTRODUCTION:
Mantle Cell Lymphoma (MCL) is a non-Hodgkin lymphoma accounting for 2.5% of lymphoid neoplasms in the United States. Primary gastrointestinal (GI) lymphomas account for 1-4% of all GI malignancies, with few reports of primary mantle cell lymphoma presenting as a single colonic mass and none to our knowledge with colon-colonic intussusception as the presenting finding. Accurate and timely diagnosis is imperative because MCL has rapid progression and early chemotherapeutic intervention results in improved patient outcomes.

CASE DESCRIPTION/METHODS:
A 61-year-old male presented with 1 month history of nonspecific right sided abdominal pain. Computed Tomography (CT) of the abdomen identified an intussuscepting mass of the proximal ascending colon and an additional 8mm hepatic lesion. Colonoscopy identified a large mass in the corresponding area of colon identified on CT. Histology and immunohistochemistry of biopsied specimen diagnosed MCL. Planned surgical intervention was deferred and the patient was referred for oncologic evaluation and treatment.

DISCUSSION:
We report the first case to our knowledge of MCL presenting as colon-colonic intussusception and discuss the work-up of this rare lymphoma that clinicians may be required to diagnose and manage. This report serves as a reminder to maintain a broad differential inclusive of uncommon diseases and unanticipated pathology. Practicing with a thorough understanding of medical principles and clinical acumen is essential for optimal patient care and, as demonstrated in this case, preventing a potentially unnecessary surgical intervention thus delaying appropriate chemotherapy.
1603 Abdominal Pain in a Patient With Marfan Syndrome
Authors: Itani Wafic , Tageldin Omar , Mansoor Muhammad Sohail , Parsa Nour , Alexandre Cassidy 
Published: October 2019

INTRODUCTION:
Marfan syndrome is an inherited systemic disease affecting the aorta and multiple organ systems. Aortic dissection is the leading cause of mortality in Marfan syndrome. We describe a case of person well known to have Marfan syndrome, who had abdominal pain and diarrhea and eventually turned out to have type B aortic dissection.

CASE DESCRIPTION/METHODS:
This is a 33-year-old female known to have Marfan syndrome presenting with one week of dark diarrhea and nausea. Patient also had prior to presentation one day of crampy, sharp lower back and abdominal pain. CT scan abdomen and pelvis with IV and oral contrast done showed mild bowel wall thickening involving the ascending colon. Patient underwent EGD and colonoscopy were unremarkable. After the colonoscopy, she developed extreme abdominal pain in her lower quadrants radiating to the back. CT angiogram chest abdomen pelvis showed intact vasculature, but showed interval development of a moderate amount of new proteinaceous fluid seen within the pelvis, the hepatic and the splenic flexure. Patient underwent emergent open laparotomy for a concern of colonic perforation post colonoscopy. Patient was found to have partial bowel obstruction with a band of adhesion that came across the transverse colon. She underwent lysis of adhesions. Her abdominal persisted after the surgery, but was manageable with pain medications, so she was discharged home. Two days later, she presented with severe chest pain radiating to the back. Due to the high level of suspicion, she underwent CT angiogram chest abdomen pelvis showing aortic dissection arising just distal to the origin of the left subclavian artery and extending inferiorly along the abdominal aorta to the level of the right common iliac artery. Patient underwent emergent endovascular repair of the descending aortic dissection. Patient did well post operatively and was discharged home.

DISCUSSION:
Aortic dissection is a well known complication of Marfan syndrome, but only 10% of aortic dissections occur distal to the left subclavian. New abdominal pain in patients with Marfan should raise suspicion for aortic dissection, especially when the pain radiates to the back. Free fluid in the abdomen post colonoscopy should not be only seen as colonic perforation, but also a sign of vascular complication in patients with Marfan. Even when CT scan was negative a few days ago, repeating CT scans in the appropriate clinical setting can be life-saving.
1608 Double Trouble: A Rare Case of Recurrent Ischemic Colitis Due to Pseudoephedrine
Authors: Shehata Alexandre , Mallipudi Rajiv , Khan Qamar , Itidiare Michael , Alquran Lance , Matin Sirawar , Nathan Swami 
Published: October 2019

INTRODUCTION:
There are 10 reported cases of ischemic colitis due to pseudoephedrine. We present the first case of recurrent ischemic colitis due to pseudoephedrine.

CASE DESCRIPTION/METHODS:
A 64-year-old female with past medical history of hypertension, seasonal allergies presented to the ED with two days of worsening severe left lower quadrant pain and hematochezia. Her medications included rosuvastatin, HCTZ, and fexofenadine hydrochloride/pseudoephedrine hydrochloride (Allegra-D). On admission she was afebrile and normotensive. Physical exam showed mild tenderness in the left lower quadrant, no rebound tenderness, rigidity or peritoneal signs. Hemoglobin was 14.9 g/dL with leukocytosis at 15,100/µl. A CMP, hepatic panel, and pancreatic enzymes were unremarkable. A CT scan revealed diffuse edema with surrounding infiltration of fat in the bowel in the region of the splenic flexure and proximal descending colon, consistent with ischemic colitis. Patient was made NPO and started on IV fluids and antibiotics. Her bleeding subsided. It was suspected that the pseudoephedrine in the Allegra-D may have induced vasoconstriction of the bowel. Allegra-D was discontinued and she improved with conservative care and discharged four days later. She was advised to avoid vasoconstrictors such as pseudoephedrine and switched from Allegra-D to Allegra. Unfortunately, seven years later the patient presented again with similar complaints of abdominal pain and hematochezia. She reported taking Claritin-D (loratadine and pseudoephedrine) for allergies. A CT angiogram displayed normal vasculature. A colonoscopy showed ulcers in the sigmoid area with denuded mucosa with sharp margins. Biopsy revealed colonic inflammation, regenerative changes of the crypt with mucin depletion, and the presence of a fibrin thrombus. These findings were consistent with ischemic colitis. The patient had a score of 11 on the Naranjo Scale suggesting that the ischemic colitis was caused by an adverse drug reaction. She was switched from Claritin-D to regular Claritin and symptoms resolved without hospitalization.

DISCUSSION:
It is unprecedented for a patient to have unintentional pseudoephedrine induced ischemic colitis on two separate occasions. The minute nuances in branding can mislead patients into thinking that a medication does not contain certain agents – in this case pseudoephedrine – and lead to adverse health outcomes. It is our duty to carefully reconcile these medications, and educate patients in order to prevent such adverse events.
1630 Rectal Duplication in a Middle-Aged Adult Presenting With Constipation and Abdominal Mass After Hysterectomy
Authors: Sirimongkolkasem Jarongkorn , Tantiphlachiva Kasaya , Sanpavat Anapat , Patcharatrakul Tanisa , Gonlachanvit Sutep 
Published: October 2019

INTRODUCTION:
Alimentary tract duplications are rare congenital malformation that usually presented since childhood.

CASE DESCRIPTION/METHODS:
A 43–year-old female presented with constipation and progressive enlargement of abdominal mass for 4 years. Her constipation symptoms started after she underwent hysterectomy for myoma uteri. She had straining and fecal soiling that was refractory to laxatives. Physical examination revealed a 25-cm non-tender hard mass at mid-lower abdomen. Digital rectal examination showed anal wink, normal sphincter tone, and empty rectum. Paradoxical anal sphincter contraction was presented while pushing. Other physical findings were unremarkable. CT abdomen showed marked dilatation of rectosigmoid colon with feces content with an abrupt change of caliber at upper rectum. Small bowel was not dilated. Barium enema study was shown in Figure 1. Colonoscopy showed a 1.5-cm opening of a large blind pouch at 10 cm above anal verge. Anorectal manometry revealed dyssynergic defecation type II with rectal hyposensitivity with delayed balloon expulsion time. The patient underwent a complete transabdominal resection of the duplication with temporary loop sigmoid colostomy. Gross findings showed a large uniloculated cyst (Figure 2). Pathological findings showed a cystic lesion lined by complete colonic wall (Figure 3).

DISCUSSION:
Rectal duplications are rare congenital anomalies (1/200,000 live births) and seventy percent of them are diagnosed before the age of two. They can be classified as type I (cystic) and type II (tubular) with or without communication to rectum or perineum. The wall of the duplications is typically lined with complete rectal wall. Surgical removal is indicated as it prevents septic and carcinogenic complications [1]. Our patient’s symptoms interestingly occurred late in adulthood after surgery. Removal of uterus and myoma uteri might change the angle of the duplication’s opening. Also, the presence of dyssynergic defecation might contribute and cause gradual accumulation of fecal content inside. Three months post-operative anorectal manometry still showed dyssynergia but improved rectal sensitivity. At present, our patient has bowel movement every 1-2 days per colostomy with minimal usage of laxative and is currently undergoing biofeedback training before colostomy closure.
1638 Post-Colonoscopy Diverticulitis: A Rare Complication
Authors: Mohan Neena , Goldstein Jack 
Published: October 2019

INTRODUCTION:
Post-colonoscopy diverticulitis is a rare but potentially significant complication. We report a case of colonoscopy-induced diverticulitis in a patient with no prior history of diverticulitis.

CASE DESCRIPTION/METHODS:
A 59-year-old female with a past medical history of hypertension, hypothyroidism and gastroesophageal reflux disease presented for a screening colonoscopy. Colonoscopy findings included a few small and large-mouthed diverticula in the sigmoid colon, a 4mm sessile polyp in the sigmoid colon removed with cold biopsy forceps, and non-bleeding grade I internal hemorrhoids. Pathology of the polyp returned as tubular adenoma. Two days post-procedure, she reported worsening lower abdominal pain as well as nausea and was recommended to go to the emergency room. On arrival, she was afebrile and hemodynamically stable. She was noted to have tenderness to palpation along her lower abdomen, greatest in the left lower quadrant. She denied fevers, chills or rectal bleeding. Labs were significant for a white blood cell count of 11.63 × 103/μL (reference range 4.5-11 × 103/μL). CT abdomen/pelvis with IV contrast showed inflamed diverticulum within the sigmoid colon with surrounding inflammatory changes, consistent with uncomplicated sigmoid diverticulitis. She was discharged home with a 10 day course of ciprofloxacin and metronidazole, and was doing well at her follow up visit.

DISCUSSION:
Although colonoscopy-induced diverticulitis is a rare finding, it is important to consider it as a complication in patients with symptoms after colonoscopy. Potential causes of post-colonoscopy diverticulitis include barotrauma, multiple attempts for intubation, and direct pressure of the scope. Another possible cause is reactivation of silent diverticulitis, with air insufflation unsealing micro-perforations in diverticula. Prior history of diverticulitis is associated with incomplete colonoscopy and can be a risk factor for developing diverticulitis; this is likely due to deformed colonic architecture from prior severe inflammation. Our patient had no prior history of diverticulitis, and presented with diverticulitis two days after her first colonoscopy. More research needs to be done on the risk of post-colonoscopy diverticulitis in those without a prior history of diverticulitis, as the prevalence of this complication is likely higher than reported.
1646 Primary Colorectal Diffuse Large B-Cell Lymphoma: A Rare Presentation of a Rare Colonic Neoplasm
Authors: Mellor Thomas , Fawley Ryan 
Published: October 2019

INTRODUCTION:
Diffuse Large B Cell Lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma accounting for 25% of cases. Of those, only one third are found to have a primary extranodal source. While this is known to arise from the stomach, a colorectal primary site is exceedingly unique. We present the case of primary colonic DLBCL diagnosed in a patient admitted for hematochezia.

CASE DESCRIPTION/METHODS:
An 85-year-old female with coronary artery disease on aspirin and diverticulosis presented to the emergency room with acute hematochezia and left lower quadrant (LLQ) abdominal pain. She was hemodynamically stable with reproducible LLQ tenderness and rectal exam confirming bright red blood. Labs were pertinent for leukocytosis and hemoglobin of 12.1 g/dL down from a baseline of 14.4 g/dL. Contrasted abdominal CT revealed a 4.1 cm soft tissue mass in the ascending colon with extravasation of contrast consistent with active bleeding. Due to concern for a malignant bleeding etiology, interventional radiology performed CT angiography, but were unable to identify an active arterial source. The patient continued with hematochezia and was taken for urgent colonoscopy. Within the ascending colon, a 5cm non-obstructing, fibrous mass with central ulceration was identified and biopsied. Colorectal surgery was consulted; due to concern for recurrent bleeding a right hemicolectomy was performed the following day. Final pathologic diagnosis revealed primary colonic DLBCL with local lymph node involvement. PET/CT showed complete resection of disease and, through multidisciplinary shared decision making, further treatment or surveillance was not pursued. At follow up the patient is doing well without recurrent symptoms.

DISCUSSION:
Primary colorectal DLBCL accounts for less than 0.3% of all cancers involving the large intestine. While data is limited, the majority of patients are male between the 5th and 7th decades of life. Symptoms are nonspecific with few cases discovered due to overt bleeding. Endoscopic appearance is variable including mucosal nodularity, ulceration or a mass with or without ulceration, which can mimic adenocarcinoma. Due to the abundance of lymphoid tissue, most lesions involve the cecum and ileocecal valve. Diagnosis of primary colonic DLBCL can include local lymph node involvement, but distant nodal disease must be excluded. The mainstay of treatment is surgical resection with adjuvant chemotherapy, however, due to patient age and preference a conservative strategy was pursued.