Isolated Colonic Amyloidosis: An Uncommon Cause of Chronic Diarrhea

Rajshekhar Chakraborty; Shahinur Chowdhury; Shiva Kumar Mukkamalla; Leelavathi Kasturi; Henry Safier

Isolated Colonic Amyloidosis: An Uncommon Cause of Chronic Diarrhea

American Journal of Gastroenterology

Abstract

Results: Out of 4,015 colonoscopic encounters, 352 patients satisfi ed the inclusion criteria for the study. Th ere were 47.1% African Americans, 45.7% Hispanics, 5.5% Caucasians, and 1.7% others. Th e mean age for the cohort was 63.3 years (SD 10.2). Th ere were no signifi cant diff erences in the demographics among the three groups. Group A, B, and C included 210, 94, and 48 patients, respectively. Th e bowel preparation was rated as poor in 46.6% of A, 52.1% of B, and 50% of C (p=0.6). ADR was 24.3% in A, 20.2% in B, and 27.1% in C (p=0.6). AADR was 12.9% in A, 11.7% in B, and 18.8% in C (p=0.4). Th ere was no statistically signifi cant diff erence in ADR and AADR among the groups on accounting for bowel preparation. Conclusion: Th e level of control of diabetes may have no impact on the quality of bowel preparation, adenoma detection rate, and advanced adenoma detection rate. Larger studies are warranted to validate these fi ndings.

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Purpose: Sodium polystyrene sulfonate (SPS) is a cation exchange resin administered an osmotic laxa- tive (e.g., sorbitol), orally or as a retention enema, to treat hyperkalemia. SPS-sorbitol use has been implicated in colonic necrosis of the gastrointestinal tract. We present a rare case of ischemic colitis with pseudomembranes following single use of oral rectal SPS-sorbitol administration for treatment of acute hyperkalemia in a patient with chronic kidney disease. Am J Gastroenterol 2013; 108:S187-S463; doi:10.1038/ajg.2013.267

Subsquamous Esophageal Adenocarcinoma after Radiofrequency Ablation of Barrett’s Esophagus with High Grade Dysplasia Subhash Chandra, MD,’ Danielle Marino, MD,? Vivek Kaul, MD, FACG'. 1. University of Rochester, Division of Gastroenterology and Hepatology, Rochester, NY; 2. Internal Medicine, Greater Baltimore Medical Center, Towson, MD.

[642] Figure 1: Subsquamous adenocarcinoma under low power. Discussion: To the best of our knowledge, only three definitive cases of subsquamous adenocarci- noma post-RFA have been reported in the literature. One of the patients had a nodule, whereas the other appeared endoscopically normal. Our case had an endoscopically normal-appearing post- ablation esophagus. These emerging reports of subsquamous adenocarcinoma highlight important aspects regarding the endoscopic management of dysplastic BE. First, surveillance biopsies should be performed from the entire length of the original Barrett’s segment despite endoscopically normal-appearing esophageal mucosa. Second, the biopsies should be performed meticulously (Seattle protocol), and ensuring adequate depth to include subepithelial tissue. Finally, utilizing dedicated gastrointestinal pathologists and consensus diagnosis and management plans are abso- lutely imperative.

Purpose: We describe a minimally invasive treatment option for chronic refractory dysphagia due to presbyesophagus-associated acute angulation of the distal esophagus. The patient is an 80-year- old man who has had chronic post-prandial vomiting and dysphagia for over 10 years. EGD with biopsies, manometry and imaging studies were all normal. Antacids, Savary dilation and Botox therapy yielded only slight improvement. Patient had been on a liquid and pureed diet, but solid foods continued to cause dysphagia with regurgitation. Repeat esophagram revealed a torturous distal esophagus with a 90-degree angulation causing a “zig-zag” appearance where a barium pill had obstructed [FIG 1A]. This angulation was further verified by EGD [FIG 1B]. The patient was not a surgical candidate, so a 22 x 120-mm fully covered SEMS (Boston Scientific) was placed unde1 endoscopic and fluoroscopic guidance. Distal stent migration was prevented by the acute angu- lation, causing a stricture-effect below the proximal flare. Proximal migration was prevented by

Purpose: A 47-year-old African-American male presented to the emergency room after a fall resulting in an open tibial and fibular fracture. He underwent incision and debridement (I&D), external fixation, with vacuum-assisted closure device (VAC). Over the following two weeks, he had six subsequent I & D for a persistent non-healing wound. On day 14, he developed symptoms of rapidly progressing solid and liquid dysphagia over one day, associated with the sensation of something “stuck” in his upper esophageal region. Most liquids caused immediate regurgitation. Head maneuvers allowed esophageal transit of liquids. He had no other esophageal or abdominal symptoms. In retrospect, he had noticed blurry vision, slurring of his speech and voice changes worsening over the past two days prior to the occurrence of dysphagia symptoms. On exam, he was found to have bilateral ptosis, restricted range of motion in all gazes, mildly reactive pupils, and no proptosis or conjunctival injection. He had no cervical lymphadenopathy, no oral thrush or lesions, no skin rash. Laboratory values were within normal limits. Esophagogastroduodenoscopy was normal. Manometry demonstrated severe ineffective peristalsis and poor bolus movement with both liquids and viscous swallow. His upper-esophageal sphincter pressure was decreased, 1s were proximal muscle and pharyngeal contractions. Barium esophagram with pill was not con- sistent with achalasia. Subsequently, the diagnosis of wound botulism was confirmed. Supportive care was maintained and he required parenteral nutrition via dobhoff tube for two weeks. One month later, he was able to tolerate a regular diet, and all symptoms resolved. Botulism is the most lethal toxin known with spores that can survive in boiling temperatures for up to three to 4 hours. Traumatic injury to an extremity can cause local production of toxin by Clostridium botulism in devitalized tissue at the site of a wound causing a lack of acetylcholine release and disabling muscle contractions, resulting in descending paralysis. Little data exists regarding the effects of the toxin on esophageal function. This case suggests the infection results in dysfunction of both proximal and smooth muscle.

Purpose: A 53-year-old male with a history of alcohol abuse presented to the emergency room with melena and weakness. The patient had melena 3 months prior to presentation. He also notec abdominal distention for 2 months, as well as chest pain, which was described as sharp, sub-ster-

Esophageal Rupture in a Patient with Community-Acquired Clostridium difficile Colitis and Ulti- mately Diagnosed with Systemic Sclerosis Wael El-Nachef, MD, Dilrukshie Cooray, MD, Viktor Eysselein, MD. Harbor-UCLA Medical Center, Torrance, CA. Conclusion: Our aim was to raise awareness of this potentially life-threatening complication of BP When recognized early, EDS is easily managed with oral corticosteroids; later manifestations require hospitalization and systemic therapy, leading to increased morbidity and mortality.

Discussion: Foreign body ingestion by mentally impaired individuals is not uncommon. The size of object (4 x 3 x 1 inch) in this case is particularly startling. Our review reveals this to be the first instance of soap bar impaction in the esophagus. Additional object impaction should be considered when encountering an otherwise typical food bolus that is difficult to remove.

[653A] Barium swallow showing extrinsic compression. Purpose: Mediastinal granulomas are fibrocaseous masses usually found in association with fungal infections such as histoplasma. Esophageal involvement secondary to mediastinal histoplasmosis is rare and reported in 5-13% of cases. We present 22-year-old female recently relocated from Indiana with no medical history who complained of dysphagia to solid foods of 4 months duration. She denied fever, weight loss, odynophagia, hemetemesis or melena. She denied smoking, alcohol, or illicit drug abuse. Family history was positive for Non Hodgkin's Lymphoma in mother and maternal grandfather. Physical exam was normal. Initial labs: CBC, CMP, lactate dehydrogenase, vitamin D, and ACE level were normal. Barium esophagogram

{653B] CT chest showing enlarged lymph node with central calcification.

[654] Distal esophagus with melanoma metastases. Introduction: Metastatic malignant melanoma of the esophagus is a very rare disease. Since 1985, only 11 cases of metastatic malignant melanoma of esophagus have been reported1. We report another case of this type.

[658A] Upper endoscopy demonstrating esophageal mass. Purpose: Most patients with esophageal cancer present with dysphagia, odynophagia and/or weight loss. We describe an unusual presentation of esophageal cancer. A previously healthy 58-year-old female presented to the clinic with acute onset of obstructive jaundice. Laboratory work-up for viral, autoimmune and metabolic causes of liver disease was negative. Abdominal ultrasound and, subsequently, CT chest/abdomen/pelvis showed extensive thrombosis involving the left hepatic vein, intra- and extra-hepatic portal veins, superior mesenteric vein and splenic vein, along with extensive bilateral pulmonary emboli. There was no evidence of malignancy. She was then

[658B] CT abdomen demonstrating portal vein thrombosis.

A 20-year-old healthy AAM was seen for a 2-year history of intermittent dysphagia associated with heartburn and regurgitation of solid food several times per day. He denied odynophagia, chest pain, cough, waterbrash, hoarseness or abdominal pain. His appetite and weight were unchanged. He was initially prescribed an H2RA without improvement. An upper endoscopy showed no

Zhiwei Xia, DO. Digestive Department, The Third Hospital of Peking University, Beijing, China. Purpose: A 53-year-old male underwent upper endoscopy for Barrett’s screening, revealing a smooth, 7-mm subepithelial nodule just proximal to GE junction. Though the diagnostic yield is low for subepithelial lesions with standard biopsies, the lesion was sampled and the patient was counseled that endoscopic ultrasound would likely be needed to define the lesion further. Micros- copy demonstrated fiber deposition in the lamina propria suspicious for amyloid, but Congo-red staining was negative. Van Gieson staining was positive, consistent with elastosis (Image 1). Elas- tosis is typically a degenerative change in the dermal connective tissue that results in the deposi- tion of an increased amount of elastic fibers. Rare cases of elastotic change have been reported within the gastrointestinal (GI) tract, usually within the distal colon appearing as polyps or within the small intestine and stomach, manifesting as ulcers or inflammation. Ours appears to be the first reported case of elastosis involving the esophagus. Though typically sporadic, elastosis in the GI tract is a form of granulomatous inflammation that can result from a genetic predisposition for inherited fibrous tissue abnormalities such as Down’s syndrome, Marfan’s syndrome, Ehlers- Danlos or Gronblad-Stranberg (Pseudoxanthoma Elasticum). It can be seen with neuroendocrine tumors or elastosis perforans serpiginosa disorder, characterized by the transepidermal elimination of elastic fibers. Elastosis has also been associated with certain medications, such as D-penicilla- mine. Notably, elastosis carries no known malignant potential. Microscopically elastosis appears as finely granular and/or fibrillar, pale, eosinophilic to gray-tinged amphophilic material. It may have a fibrous component, which can involve the submucosa and muscularis mucosa, and may be centered around submucosal blood vessels. Hematoxylin-Eosin stained sections are similar in appearance to that of amyloidosis. Elastic van Gieson staining reveals increase in elastic fibers that built band- like formations and ovaloid structures. Unlike amyloid, Congo red staining is negative. Though the yield for standard biopsies of submucosal pathology is low, this case highlights that “low” yield is not “no” yield. The technique is safe, and may be sufficient to make a diagnosis, avoiding additional testing. Further, though rare, gastroenterologists should be aware of elastosis’ benign nature and how it may mimic amyloid. Purpose: A 28-year-old female had nighttime paroxysmal dyspnea. She experienced the first epi- sode two years ago while sleeping. She fell from bed and broke her right knee when attempting to seek help. She has had four similar awakening episodes, each with the inability to breathe or speak and inspiratory stridor lasting from 60 to 90 seconds. She is otherwise healthy, on no medications. and has no allergies. Her only GI symptoms are an intermittent globus sensation for several years and acid regurgitation one to two times per month, which she has ignored. Physical exam, routine lab tests, chest Xray, pulmonary function tests and bronchial provocation tests were all normal. Laryngoscopy showed chronic inflammation and edema of the posterior laryngeal wall. Barium Xray showed a small sliding hiatus hernia, and 24h esophageal pH monitoring showed acid exposure normal in the distal esophagus, but multichannel intraluminal impedance showed a slight increase

[662] Normal upper esophageal sphincter.

Purpose: Acute esophageal necrosis (AEN) is rare, with prevalence reported to range from 0.001 to 0.2%. It is often seen in critically ill patients. We present a 68-year-old male with a history of diabe- tes mellitus and chronic kidney disease stage IV, who presented with acute onset of coffee ground emesis during his hospital admission. He was initially admitted for acute mental status change secondary to sepsis with pneumonia and urinary tract infection. At the time of his admission, he was septic with a blood pressure reading of 98/62 mmHg. He was stabilized on a medical floor with intravenous fluids and antibiotics. On day nine of his hospital course, he presented with multiple episodes of coffee ground emesis. He had no melana or abdominal pain. He had no other recorded instances of hypotension. During the episodes of coffee ground emesis, he was hemodynamically stable with HR 77 and BP 130/63. BUN was 44 mg/dL, and creatinine was 2.8 mg/dL, which was his baseline. INR was 1.2, hemoglobin was remarkably stable at 11.6 g/dL. Endoscopy showed diffuse circumferential necrosis in the middle and lower third of the esophagus. The gastro-esophageal junction was clean. The pathogenesis of AEN is not very well known, but it is unlikely to be the result of a single event. Risk factors for AEN are often multifactorial and include low flow states, vasculopathy, or direct corrosive injury to the esophagus. AEN tends to occur in older males and presents as an upper GI bleed. AEN develops at least 18 hours after the ischemic insult. In this case, however, we report the development of AEN days after the initial insult of a hypovolemic state. The diagnosis of AEN is established with endoscopy, characteristically showing black pigmenta- tion, often in the distal part of the esophagus with a sharp demarcation of normal pink mucosa at the gastro-esophageal junction. Mortality of AEN is higher than other upper GI bleeds because it tends to occur in very sick patients. In many reported cases, death from AEN is often attributed to the underlying critical illness. By itself, however, AEN is self-limiting. In healthy patients, the mucosa heals rapidly and should acquire its normal endoscopic appearance by week two or three post ischemic injury. Delia Calo, MD, Anjani Jammula, MD, Emmy Ludwig, MD. Gastroenterology, Memorial Sloan Kettering Cancer Center, New York, NY. Purpose: Esophageal squamous papillomatosis (ESP) is a rare condition. We present a case o! a male adult survivor of childhood cancer with abdominal pain who was found to have HPV- negative ESP. A 22-year-old man was referred to gastroenterology for abdominal discomfort His past medical history was significant for a retroperitoneal embryonal rhabdomyosarcome diagnosed at age 6 months. He was definitively treated with resection of the mass, followed by adjuvant chemotherapy and radiation, now disease free for 20 years. He presented with two year: of intermittent mid-abdominal discomfort, lasting 1 hour, primarily after eating fatty foods, now

{665] Linear columns of frond-like nodules in distal esophagus. increasing in frequency and severity over the past 6 months. He could not identify other incit ing factors. Bismuth suspension provided no relief. His alcohol intake had increased during thi: time (from 2 to 7 drinks per week), but he denied similar pain in the past, and denied tobacco fever, chills, nausea, vomiting, difficult or painful swallowing, abdominal distention, diarrhea constipation, rectal bleeding, black stool, or weight loss. His abdominal exam was benign withou tenderness. Hemoglobin was normal. He underwent upper endoscopy (EGD) for investigation EGD revealed linear columns of frond-like 8-10 mm nodules in the esophagus from 35-40 cm Pathology demonstrated superficial fragments of squamous papilloma without evidence of dys plasia or carcinoma. In-situ hybridization for low- and high-risk HPV subtypes was negative ESP is most often found incidentally on EGD in the distal esophagus. Risk factors include HPV infection, heavy alcohol use, and tobacco use. Pathogenesis is thought to be related to chroni inflammation. ESP was considered an entirely benign condition with some cases of spontane ous regression of lesions. More recent case reports, however, describe malignant transformation Despite this possible risk, the rarity of ESP precludes therapeutic or surveillance recommenda tions. Our patient’s (unrelated) abdominal pain improved on a proton pump inhibitor. Repea EGD was scheduled in 6-12 months.

Esophageal Sarcomatoid Carcinoma: A Case Report and Review of Endoscopic Resection Bashar Hmoud, MD, Maen Masadeh, MBBS, Sarpreet Basra, MD, Andrea Duchini, MD, FACG. Internal Medicine, University of Texas Medical Branch, Galveston, TX. Conclusion: It is important for endoscopists to examine proximal esophagus carefully and recognize endoscopic appearances of an inlet patch.

{673] Figure 1: Distal esophageal adenocarcinoma 1 year after restrictive bariatric surgery.

[676B] Pre-myotomy pressures. [676A] Myotomy extending 16 cm. Case description:The patient is a 65-year-old Caucasian obese female who presented with heart- burn and indigestion with episodes of nausea for about 3 years. Initially, she would get occasional

{677B] Figure 2. Esophagus on EGD. Purpose: A 57-year-old Caucasian man with a 60-pack-year tobacco history and HIV on antiret- roviral therapy (CD4 954 cells/mm’, undetectable viral load) presented with 3 weeks of frontal headache upon awakening and a single episode of diplopia. He denied gastrointestinal symptoms or weight loss. Physical exam and laboratory analysis were unremarkable. A MRI of the brain revealed multiple high-density lesions in both cerebral hemispheres and the cerebellum with vasogenic edema, obstructive hydrocephalus, and partial effacement of the fourth ventricle (Figure 1). A work-up for tuberculosis, syphilis, cryptococcosis, toxoplasmosis, and cysticercosis was negative. The patient was started on intravenous corticosteroids for cerebral edema. A chest CT was notable for mild circumferential wall thickening of the distal esophagus with no intra-abdominal lymph- adenopathy. He then underwent an esophagogastroduodenoscopy, which revealed a nodular, fri- able, non-obstructive 4-cm mass in the distal esophagus (Figure 2). Pathology showed moderately differentiated invasive adenocarcinoma in a background of intestinal metaplasia. The incidence of brain metastasis from esophageal cancer has been reported to be 1.5% in retrospective studies, with the brain rarely being the only site of distant disease. Our patient presented solely with neu- rologic symptoms. Only two other cases have been reported in which symptoms related to a brain lesion preceded the diagnosis of the esophageal primary. The mechanism of spread to the brain is

[682] Figure 1A: Barium swallow shows dilated esophagus but no extravasation of con- trast; B: CT of chest shows collection adjacent to esophagus.

[689A] Figure 1. Esophageal protuberance with ulceration and arterial bleed due to Dieulafoy lesion. A Difficult Pill to Swallow

[689B] Figure 2. Post-endoscopic injection of epinephrine and clip placement.

[691A] Figure 1: Typical features of eosinophilic esophagitis: pale mucosa, stacked circular rings, linear furrows, microabscesses and narrowed lumen. Purpose: We highlight complications of untreated eosinophilic esophagitis. A 33-year-old African American male Army veteran presented 4 hours after acute onset of severe substernal chest pain associ-

[691B] Figure 2: Mid-esophageal ulcer, 4 cm, exposing the muscularis propria.

[692] CT image showing dilated esophagus filled with food debris and associated tra: cheal compression.

[702] Endoscopic views of mass and CK20 stain. Discussion: There have been only two documented case reports of colon adenocarcinoma metasta- sizing to the esophagus. One case was treated with surgical bypass and the second with irinotecan and cetuximab chemotherapy. Of the cases reported, the endoscopic presentation has varied from an esophageal stricture to small nodular lesions. We present this case of colonic adenocarcinoma with metastasis to the esophagus with an endoscopic appearance of a fungating, friable mass on EGD, which responded to systemic chemotherapy with FOLFOX. In the setting of known colorectal carcinoma and dysphagia, metastatic disease remains a rare possibility, warranting a high index of suspicion. The treatment approach is dictated by the status of the primary tumor as well as the extent of metastasis.

(704] Figurel. Case: A 54-year-old man came to the hospital with complaint of tearing sensation in his lower chest after he tried to force down a beefsteak, which he felt got stuck in his throat. He mentioned that he has had multiple episodes of food getting stuck in throat in the past but he was able to resolve all of those by himself using fluids. This time, he developed intense pain and tearing-like sensation in his abdomen followed by spontaneous hematemesis. His chest X-ray on presentation did not show any abnormality and blood work revealed 13% eosinophilia. He underwent upper endoscopy, which showed severe grade D erosive esophagitis and also a 3-cm linear deep tear in the esophageal mucosa (Figure 1) involving the mid-esophagus with marked inflammation around it. There was no active bleeding. CT scan of chest was done, which showed pleural effusion and extra luminal air on the right side. He was managed conservatively with complete bowel rest and broad-spectrum intravenous antibiotics. The patient left against medical advice in less than 48 hours after admission. He was contacted 3 months later and he has been doing fine except for the persistent dysphagia.

Revisiting Radio-Frequency Ablation for Recurrent High Grade Dysplasia in Barrett’s Esophagus Kaartik Soota, MD, Manish Madan, MD, Deerajnath Lingutla, MD. Unity Health System, Rochester, NY. Revisiting Radio-Frequency Ablation for Recurrent High Grade Dysplasia in Barrett’s Esophagus Discussion: Increased incidence of achalasia in DS patients may be secondary to their increased susceptibility to infections and organ-specific autoimmunity caused by immune system dysfunction. In our patient, esophageal motility disorder was suspected but was never evaluated further. Achala- sia may present with atypical features in a patient with Down's syndrome and requires high clinical suspicion to prevent life-threatening complications.

Purpose: A 33-year-old female with prior laparoscopic adjustable gastric band (LAGB) in 2010 for morbid obesity (BMI before surgery=34.5 kg/m?) presented with vomiting, epigastric pain, odyno- phagia, and heartburn without melena during the past 3 weeks. She had a similar episode 1 year earlier that resolved by removing fluid from her adjustable band. Physical examination revealed only mild epigastric tenderness. Routine blood tests showed no abnormalities. Abdominal roentgen- ography revealed the adjustable band mostly inflated in the proper position (Figure 1). Esophago- gastroduodenoscopy showed multiple acute linear ulcers with surrounding erythema arising from the GE junction and extending proximally 8 cm, highly consistent with reflux/emetic esophagitis (Figure 2). Pathologic analysis of distal esophageal biopsies showed acute and chronic inflammation without Barrett’s esophagus. Her bariatric surgeon removed 8 mL of fluid from the LABG to loosen the gastric band. The patient subsequently did well without further nausea, vomiting, or abdominal pain. LAGB, is a popular, minimally invasive bariatric procedure that involves placement of a band around the gastric cardia. This band is adjusted by inflating or deflating with saline, to constrict or restore patency of the stomach outlet. If the band is too tight, chronic reflux and regurgitation can occur. This case characterized the endoscopic appearance of the esophagitis from an overly restrictive adjustable band.

[709B] Esophagus. [709A] See the metal hook.

[709C] Partial dentures pushed into stomach using upper scope.

[713] Atrial diverticulum in the circle. Purpose: We are reporting a case of upper GI bleed in a patient with atrioesophageal fistula where EGD could have been fatal. This case also underlines the importance of complete procedural his- tory in patients with GI bleed. A 57-year-old male with hypertension, dyslipidemia, and atrial fibrillation on rivaroxaban presented with chest pain, dyspnea on exertion, and one episode of coffee ground emesis. He was hemodynamically stable on admission with a normal CBC and BMP. Hemoglobin was 13.5 g/dL. He suddenly experienced an episode of severe chest pain and went into PEA arrest. He was resuscitated, intubated, and placed on a mechanical ventilator. NG was placed and 300 mL red blood was aspirated. Patient went into coma, but vital signs and remaining exam was normal. CT head revealed pneumocephalus and multiple cerebral infarcts. Repeat hemo- globin was 12.2 g/dL. EGD was not performed. Blood culture grew S. aureus and Strep. viridians. Later on it was found that he had catheter ablation for atrial fibrillation 18 days ago. Left atrial- esophageal fistula was suspected. CTA thorax showed a 5-mm posterior left atrial diverticulum raising a suspicion of pseudoaneurysm. A fistula between the esophagus and left atrium was found intra-operatively and it was repaired. Patient showed no neurological improvement and remained in coma, so life support was withdrawn after 11 days and patient died. Atrioesophageal fistula (AEF) is a rare complication of A Fib catheter ablation procedures, incidence rate 0.2%. It is associated with high mortality rate (70%). It can present 1-6 weeks after the ablation. Presenta- tion is nonspecific: fever, neurological deficits, and chest pain. None of the previously reported cases described GI bleeding symptoms. EGD can cause fatal air-embolism so it should be avoided. CT chest can help to establish diagnosis. Surgery can be lifesaving. AEF should always be on the differential diagnoses of UGI bleeding in appropriate setting: unexplained fever and neurological deficit after recent ablation procedure.

[717] Barrett’s metaplasia arising from gastric heterotopia. Purpose: A gastric inlet patch (GIP), also known as a cervical inlet patch or gastric heterotopia, is a discrete island of columnar mucosa found in the cervical esophagus. Its origin may be congeni- tal or acquired. GIPs are seen in up to 10% of patients on upper endoscopy. Although most GIPs are asymptomatic, some patients present with dysphagia, globus sensation, or even reflux. These symptoms may arise from GIPs with oxyntic acid-secreting mucosa. Cases of high-grade dyspla- sia and adenocarcinoma arising from GIPs have been reported. However, there are no published reports confirming the presence of Barrett’s metaplasia arising from a GIP. A 46-year-old woman presented for evaluation of multiple gastrointestinal complaints. Her greatest concern was “reflux” that worsened during each day. She also noted dysphagia to solid foods and rare odynophagia. Evaluation included esophageal manometry, which demonstrated elevated lower esophageal sphinc- ter pressures with normal amplitude peristalsis. Upper endoscopy identified 2 rectangular-shaped salmon-colored patches in the cervical esophagus, each measuring 1 x 1.5 cm. Biopsies showed squamoglandular oxyntic mucosa with intestinal metaplasia, consistent with Barrett's esophagus, as well as reflux esophagitis. Forty-eight hour pH testing off PPI confirmed increased acid exposure to the distal esophagus, but only mild reflux esophagitis with no Barrett’s metaplasia seen on biopsies of this region. Given her symptoms and endoscopic findings, treatment of the GIPs was planned. Two sessions of focal radiofrequency ablation (RFA) were performed using the Halo” device (Covi- dien GI Solutions, Sunnyvale, CA), resulting in complete endoscopic eradication of both GIPs. Post- ablation biopsies confirmed the absence of gastric heterotopia and Barrett’s metaplasia. The patient noted complete resolution of her symptoms, even after stopping proton pump inhibitors. To our knowledge, this is the first case with biopsy-proven Barrett's metaplasia found to arise from a GIP.

Fig 1a-Submucosal granular cell tumor showing squamous epithelium with abundant eosinophilic granular cytoplasm Fig 1b-Cytoplasmic staining for CD68

did admit to using chewing tobacco on and off for the past 20 years. His medical history was positive for being treated for prostate cancer 4 years prior with radiation. The initial head com- puted tomography (CT) demonstrated a left frontal lobe mass measuring 25 mm with metastatic

[727] Recurrent tumor before LN2SC (A), after 3 treatments (B), and after 2 years of palliation (C).

[733B] Axial CT demonstrating gastric pneumatosis (circle). [733A] Axial CT demonstrating air in portal vein (circle).

Conclusion: Symptomatic gastric pneumatosis with PVG usually presages the need for surgical inter- vention. This case suggests that under the proper clinical scenario, with a thoughtful multidisciplinary approach, experienced clinicians may successfully manage this problem non-operatively, and there is not always a mandate for surgical intervention.

{734B] CT Scan showing hiatal hernia. [734A] CXR showing hiatal hernia.

symptoms. We concluded that her atrial flutter was caused directly by the mechanical effect of the large hiatal hernia pressing against her heart, as the flutter resolved after the operation and she was in sinus rhythm during follow-up.

Conclusion: Sarcina ventriculi is a rare bacterium, seen predominantly in patients with delayed gastric emptying. Review of the published cases, along with our case, suggests that it is frequently an innocent bystander, rather than a pathogenic organism. Given its association with life-threat- ening illness in two reported cases, it may be prudent to treat with antibiotics until further understanding is achieved.

Coconut Bezoars in Patients with Prior Bariatric Surgery: Report of Two Cases Himanshu Verma, MD, David Burns, MD, FACG, Dmitry Nepomnayshy, MD. Lahey Clinic, Burlington MA.

[746] Figure 1: A. Retroflexed view of the lesser curve gastric hematoma / tear (arrow) B. CT-gastric hematoma (arrow). C. Tearing on insufflation. D. Biopsy-Congo Rec stain. Discussion: Incidence of AL amyloidosis in the U.S. is 6-10 cases per million person- years, with 10-15% of multiple myeloma patients having AL amyloid. Only 1% have symp- toms from gastric involved AL amyloidosis. Patients can present with peri-orbital pinch purpura. Endoscopic features include ulcerations, granular and friable mucosa, irregular gastric folds, submucosal hemorrhage, and hematomas. Bleeding in AL amyloidosis is due to capillary fragility from amyloid deposition, coagulation factor deficiency, especially low factor X, and abnormal platelets. The goal of therapy is to suppress the synthesis of light chains by treating the underlying disorder.

[750] Hypertrophic gastric folds. Purpose: We present a 59-year-old male with a history of hypertension, Helicobacter pylori infec- tion two years prior to admission status post triple therapy who presented with bilateral lower extremity edema that had become excruciatingly painful 2 weeks prior to his admission. On exam, he was cachetic with temporal wasting. He had no jugular venous distention and his lungs were clear. Abdominal exam was significant for tenderness in the epigastrium. Murphy’s sign was negative. There were no appreciable abdominal masses, and stool guaiac was negative. He had 4+ bilateral pitting edema in the lower extremities. Hemoglobin was 7.6g/dl with an MCV of 70.6 fl. Kidney and liver function tests were unremarkable. Albumin was 2.6g/dl. Brain natriuretic

[751] Massively dilated stomach measuring 33.1 x 12.8 x 11.3 cm. Conclusion: Acute gastric dilatation is a rare and poorly understood condition. Complications including gastric perforation have been attributed to elevated intra-gastric pressure. There is a well documented association with anorexia/bulimia nervosa. Our case of acute gastric dilation in a malnourished patient with ulcerative colitis suggests that co-existing malnutrition may contribute to the pathogenesis of this entity. We also highlight the importance of nasogastric decompression.

[752A] Figure 1. Initial EUS of gastric mass. Purpose: Accessory spleens are an asymptomatic, develop from residual tissue following a sple- nectomy and found incidentally. A 58-year old male went to his PCP for complaints of consti- pation. The patient’s PMH includes left nephrectomy and splenectomy secondary to a MVA. Previous EGD showed a lesion in the fundus of the stomach. He was transferred to our hospi- tal for EUS (Figure 1). Sonographically, the lesion appeared to originate from the muscularis propria. Surgical pathology was diagnostic for accessory spleen (Figures 2). Accessory spleens can mimic abdominal tumors. On ultrasound, it appears as a round or oval mass with a mildly echogenic and homogenous texture; CT and MRI it appears as the same density as the spleen. EUS is a better modality for differentiating between an externally compressing lesion and a sub- mucosal tumor.

[752B] Figure 2. EGD view of gastric mass.

[752C] Figure 3. Surgical pathology slide.

[754] Image showing three pyloric openings into duodenal bulb.

[759A] Firm antral submucosal mass. Conclusion: Gastric schwannomas are a rare benign tumor of the gastrointestinal tract. The endo- sonographic features mimic the appearance of gastrointestinal stromal tumors. The hypocellular- ity of the fine needle aspirate further complicates identification of this tumor prior to surgical resection.

Purpose: A 60-year-old Caucasian woman was referred for an endoscopic ultrasound after a thorough evaluation for intermittent epigastric and right hypochondriac abdominal pains revealed

Srikala Meda, MD,’ Sindhu Kaitha, MD,' Krishna Ayyagari, MD,’ Ravikumar Vemuru, MD’. 1. Permian Gastroenterology Associates LLP, Odessa, TX; 2. Texas Tech Health Sciences Center, Odessa, TX.

[767A] H&E illustrating anaplastic GIST.

[767C] MRI of a 6.8 x 7.7 cm complex splenic mass and a hepatic cyst.

{767B] Immunohistochemical staining of the spleen indicating c-kit/ CD117 negative GIST.

An Unusual Case of Gastrointestinal Hemorrhage Due to a Large Phytobezoar Dhyan Rajan, MD, Rabab Hajar, MD, Prakash Viswanathan, MD, Krishnaiyer Subramani, MD, Kaleen Rizvon, MD, Paul Mustacchia, MD. Nassau University Medical Center, East Meadow, NY. Conclusion: Gastric polyps are usually asymptomatic. They rarely can present with gastrointestina bleeding. Large polyps could also present with gastric outlet obstruction. Hyperplastic polyps are most common in H. pylori-prevalent areas. Average size is 1 cm. Risk of malignant potential i: reported as 0.5-7%, with highest risk in polyps greater than 2 cm in size. All patients with hyper- plastic polyps should be tested for H. pylori and treated, if detected. Any gastric polyp more thar 2 cm in size needs to resected. Follow-up endoscopy is recommended for surveillance of residua’ idenomatous polyps and new polyps. Our patient is a rare case of large gastric hyperplastic polyr presenting with obscure GI bleeding.

[772] Nodular gastritis. Purpose: Kaposi's sarcoma (KS) was a rare neoplasm that comprised close to 0.1% of all malignancies worldwide. However, due to the increasing prevalence of patients with human immunodeficiency

Case Report: We present a 50-year-old female who presented with a sharp epigastric pain of 4/10 in intensity after eating, not related to any particular food, lasting for an hour, associated with nausea and bloating, of 6 months’ duration. No history of weight loss, fever, chills, fatigue, or anorexia was given. An upper GI series was performed which showed nodular gastritis. Esopha- gogastroduodenoscopy (EGD) showed nodular mucosa in body and antrum of stomach. Multiple biopsies were taken from them and histopathology showed lymphoplasmacytic infiltrate withn the lamina propria. Giemsa stain was negative for Helicobacter pylori. Immunohistochemistry showed marginal B cell lymphoma - mucosal associated lymphoid tissue with CD 20 positivity.

[773] Semi- circumferential hemorrhagic gastropathy. Conclusion: Post-TACE hemorrhagic erosive gastropathy is a rare but potentially serious complica- tion and is often due to non-target arterial embolization. Preoperative angiography may outline arterial variants and allows for superselective embolization. Discussion: Peri and post-procedural complications occur in approximately 10% of patients under- going TACE. GI bleeding occurs in less than 1%. It is usually related to preexisting pathology or directly related to the procedure. Possible risk factors include prior history of portal gastropathy/ varices, peptic ulcer disease, or direct toxicity of administered embolizing or chemotherapeutic agents. Bleeding under these circumstances is often delayed for days after the procedure. Rarely, an ischemic injury may be precipitated from emobolizing small nontarget arterial branches of the hepatic artery. This type of non-target arterial injury may be predicted from the pre-operative angio- graphy, and typically induces bleeding during the early post-operative period, as in this case. Conclusion: Post-TACE hemorrhagic erosive gastropathy is a rare but potentially serious complica-

Discussion: Gas in the gastric wall is a rare finding associated with a high mortality rate of 50%. Different etiologies include gastric outlet obstruction, damage from instrumentation, extensive CPR, ulcers, steroids, and caustic ingestion. The presence of gastric dilatation with gastric and portal venous air on CT narrows the differential to two main diseases with very different symptoms and prognosis. EG must be differentiated from gastric emphysema early in order to avoid adverse outcomes. EG has concomitant air in the portal venous system and presents acutely in a hemodynamically unstable person as opposed to gastric emphysema which is usually asymptomatic and incidentally found on imaging with air only in the stomach. EG is a severe and rare form of gastritis due to invasion of

[777] Figure 1. EUS demonstrating a hypoechoic, oval shaped, gastric body mass. Case Presentation: A 66 year-old man with history of stage III squamous cell lung carcinoma presented with dyspnea and cough. The patient had known regional lymph node metastatic disease but no distant metastases. During his emergency department evaluation, a CT of the chest demonstrated a 5.7 cm x 4.7 cm mass in the greater curvature of the stomach. Of note, lower cuts of a prior CT scan of the chest 4 months previous had not shown any gastric mass. On EUS, an oval intramural, subepithelial 5.8 cm x 4.2 cm lesion was found in the greater curvature of the stomach 7 cm distal to the gastroesophageal junction. The lesion was hypoechoic, homo- geneous and extended from the submucosal layer to the serosa. There was an intact echo-interface seen between the mass and the liver and celiac trunk (Figure 1). Transgastric FNA using a 22g needle revealed metastatic keratinizing squamous cell carcinoma (immunostains positive with cytokeratin AE1/3, p63 and negative with CD117, cytokeratin 7; equivocal staining with DOG-1). A PET-CT

An Uncommon Cause of Abdominal Pain, Vomiting, Weight Loss, Melena - Gastric and Intestina Diffuse Large B-cell Lymphoma (DLBCL) Surya Davuluri, MD, Vivek Reddy Garlapati, MD, Hilary Hertan, MD, FACG. Montefiore Medical Center, Bronx, NY.

[782A] Figure 1. Purpose: Schwannoma is a rare gastrointestinal mesenchymal tumor comprised of encapsulated nerve sheaths most commonly found in the stomach. Usual presentation is epigastric discomfort and/or bleeding. Although gastric schwannomas are usually benign, malignant transformation has been reported. A 72 year old Caucasian female presented to our institution with 3 days of melena with associated epigastric pain in the setting of anticoagulation with warfarin. The patient under- went urgent endoscopy after correction of coagulopathy and hemodynamic resuscitation, which revealed a 2.5 - 3 cm submucosal mass along the greater curvature of the body of the stomach with a clean-based 8 mm ulceration (Figure 1). Biopsies were taken with resultant pathology being non- diagnostic. Imaging revealed a 3.2 x 2-cm solid mass within the body of the stomach (Figure 2). No evidence of perigastric lymphadenopathy or metastatic disease was noted. The patient underwent laparoscopic partial gastrectomy with wedge resection of the mass. The tumor consisted of a well- circumscribed proliferation of spindle cells with approximately 1 mitotic figure per 50 high power fields. The tumor stained strongly with S-100 and GFAP and was negative for DOG-1, CD117, CD34, smooth muscle actin, and CD57. These histological and immunohistochemical findings were diagnostic of a schwannoma. Most instances of upper gastrointestinal bleeding from a submucosal mass are from GIST tumors; however, schwannomas must be considered in the differential. Despite published CT characteristics of schwannomas, differentiation between other submucosal masses is difficult. Complete resection is usually curative and malignant transformation is rare. In this case, the patient did well and was discharged home on postoperative day 4. No additional treatment is planned.

[785] H & E Stain. Helicobacter heilmannii are significantly larger in size and a more tightly coiled appearance than Helicobacter pylori.

[787] LNA 1 immunostain. Background: Kaposi’s sarcoma (KS) is a low grade vascular tumor. In the United States, the major- ity of affected patients have human immunodeficiency virus infection. It is the most common acquired immunodeficiency syndrome associated malignancy. Skin lesions are typical features with visceral organ involvement occurring less commonly. Gastrointestinal tract (GI) KS is usu- ally asymptomatic and often unrecognized in clinical practice. In this case, we present a patient

Meira Abramowitz, MD,! Cherif El Younis, MD, FACG?. 1. Downstate Medical Center, Brooklyn, NY; 2. Brookdale University Hospital Medical Center, Brooklyn, NY. Sowjanya Kanna, MD, Imran Sheikh, MD, Raja Shekhar Sappati Biyyani, MD, FACG, Kevin Mullen, MD, FACG. MetroHealth Medical Center, Cleveland, OH.

Peripheral eosinophil count increased with increased abdominal symptoms Conclusion: We presented an unusual case of a patient with a history of uncontrolled asthma presenting with eosinophilic gastritis manifested as a recalcitrant giant gastric ulcer. To our knowledge this is only the second case described in the literature of eosinophilic gastritis presenting this way, and highlights the importance of considering eosinophilic disorders of the GI tract in patients with severe asthma. Discussion: EG is a very rare disease, usually presenting as abdominal pain, vomiting and dis- tention. A diagnosis of eosinophilic gastritis is made when >30 eosinophils are seen per high power field. About 50% of patients with EG have asthma or other atopic disorders, which may be diagnosed at the same time or years beforehand. Previously reported peripheral eosinophilia to >4000/ul have been noted. These patients may have thickened gastric mucosal folds, nodularity, or ulcerations seen on radiographs, reflecting intense eosinophilic infiltrate. Endoscopy may reveal normal or edematous mucosa with prominent gastric folds or surface erosions. Treatment with systemic corticosteroids led to bronchial and abdominal symptom resolution.

Purpose: An 18-year-old healthy male presented with suicidal ingestion of approximately 3 ounces of elemental Mercury (Quicksilver) about 20 minutes after ingestion. Patient remained asymp- tomatic. Vital signs were normal and physical exam unremarkable. Complete blood count, basic metabolic panel, liver function tests, serum salicylate, acetaminophen, alcohol, creatine kinase and prothrombin time were within normal limits. Blood mercury level was 0.185 ug/L (normal blood mercury level less than 5ug/L). The patient was diagnosed with acute mercury ingestion without toxicity and admitted for observation. Mercury exists in three forms: elemental, organic and inorganic salts, each with differing toxicities based upon method of introduction to the body. Elemental mercury can be introduced to the body via intravenous (IV) injection, inhalation, cuta- neous exposure or ingestion. Whereas cases of IV injection leading to pulmonary embolism have been reported, toxicity from elemental mercury is best known from inhalation of vapors, leading to widespread organ distribution, especially the nervous system, kidneys, lungs and Gastrointestinal tract (GIT). On the other hand, cutaneous exposure and oral ingestion rarely result in absorption of significance and the classic symptoms of tremor, salivation and changes in personality are gener- ally absent. Because orally ingested quicksilver is poorly absorbed in the GIT and eliminated well in feces, in collaboration with poison control center, patient was observed and daily abdominal roentgenograms obtained. Although numerous chelating agents are available,treatment is gener- ally reserved for patients exhibiting the symptoms described above. Abdominal films showed the majority of quicksilver had been excreted, patient was discharged to follow up with psychiatry clinic.

Malignant Gastrocolic Fistula: The Reported Case of Non-Surgical Fistula Closure Arvind Mathur, MD, MPH, Robert Basseri, MD, Kendrick Che, DO. Division of Gastroenterology Department of Medicine, Loma Linda University Medical Center, Loma Linda, CA.

[796] Figure 2. Histopathology revealing foveolar hyperplasia, vascular ectasia, granula- tion tissue, and scattered selective internal yttrium 90-labeled radiation microspheres. Purpose: Colon cancer (CRC) is one of the most common cancers in the world. Although sur- gical resection with neoadjuvant therapy is effective in most patients, some develop unresectable metastatic disease, commonly to the liver. One novel approach, selective internal radiation therapy (SIRT) with yttrium 90-labeled microspheres (Y-90), administered via hepatic artery branches, is a method used to selectively deliver radiation therapy to inoperable liver metastases. A few reports have shown benefit. However, there have been reports where microspheres get caught in the gastric and duodenal capillary beds leading to complications. We report herein a case of selective inter- nal radiation (SIR)-microsphere-induced gastritis. A 66-year-old woman was diagnosed with CRC in 2010. Imaging demonstrated a right colonic mass and liver metastases. She underwent right hemicolectomy with neoadjuvant chemotherapy. She subsequently underwent SIRT with Y-90 in 2011. Several weeks after therapy, she developed abdominal pain and progressive weight loss. An esophagogastroduodenoscopy (EGD) revealed gastric ulcers. Pathology revealed foveolar hyper- plasia, vascular ectasia, granulation tissue, and scattered Y-90 microspheres (Figure). Treatment with proton pump inhibitors (PPIs), carafate, and misoprostol did not provide benefit. Hyperbaric oxygen therapy was considered. The liver represents the most common site of metastases of CRC. Although surgical resection of solitary liver metastases can result in long-term survival, not all patients are candidates for surgery. For those patients, chemotherapy or other modalities including SIRT with Y-90 become options. However, retrograde migration of the microspheres into the gastric or duodenal circulation may occur. This can cause ulceration of the stomach and the duodenum. Treatment options include PPIs, carafate, misoprostol and hyperbaric oxygen therapy. With the anticipated increase in use of SIRT for hepatic malignancy treatment, clinicians should be aware of the potential for gastrointestinal complications from retrograde migration of Y-90 microspheres into the gastroduodenal circulation.

[797C] Figure 3. The cytomegaloviral (CMV) gastritis demonstrates a granuloma, com- prised of aggregated epithelioid histiocytes with admixed lymphocytes, plasma cells, and eosinophils; there is associated foveolar injury (hematoxylin and eosin, high mag- nification). {797B] Figure 2. The cell with viral cytopathic effect (as shown in figure 1) shows nuclear-pattern immunoreactivity for cytomegalovirus (CMV) (immunostain for CMV, high magnification).

[797A] Figure 1. The antral gastritis is characterized by a lymphoplasmacytic infiltrate with neutrophilic component, few eosinophils, and foveolar/pit injury; as indicated by the arrow, a pit epithelial cell shows classic cytomegalovirus-induced cytopathic effect, characterized by cell enlargement and a large intranuclear eosinophilic inclusion with surrounding halo (hematoxylin and eosin, intermediate and high magnifications, respectively).

Bleeding Serpiginous Lesions in the Upper Gastrointestinal Tract: A Diagnostic Challeng Rajesh Ramachandran, MD, Meira Abramowitz, MD, Asra Batool, MD, David Lee, MD. Gastroenterology, SUNY Downstate Medical Center, Brooklyn, NY. Purpose: We present a 47-year-old female with history of Grave's disease, history of longstanding dysphagia in the setting upper esophageal Killian Jaimeson diverticulum that later underwent open neck surgical procedure (diverticulopexy), who developed new persistent symptoms of severe dys- phagia. Upon further investigation of dysphagia, via upper gastrointestinal series, patient was inci- dentally found to have findings consistent with cascade stomach. Upper gastrointestinal series under fluoroscopy showed aerophagia with significant swallowed air in the esophagus, stomach, and duode- num, with slight delay in barium transit but no obstruction or stricture. The stomach was found to be rotated in its long axis with initial pooling of barium in the retroflexed gastric fundus followed by slight delayed emptying in to the body. Findings were consistent with cascade stomach. Cascade stomach is diagnosed from the characteristic appearance of the stomach on barium studies. The cascade stomach consists of a biloculation of the gastric cavity into a ventral and dorsal recess and is a rare cause of upper abdominal symptoms. The causes of gastric cascade described in the literature are manifold, some of which include reflux symptoms, dyspepsia symptoms, or epigastralgia symptoms. This disorder is often difficult to diagnose or is not recognized, therefore, its true incidence is currently not known. We summarize and highlight a case of cascade stomach incidentally found in a patient who was being evaluated for dysphagia.

[809] EUS-guided fine-needle aspiration of the pancreas,shows an exclusive popula- tion of small lymphocytic cells. Case Report: We report a 69-year-old female with history of chronic lymphocytic leukemia (CLL)/ small lymphocytic lymphoma with breast involvement, who presented with one-day history of acute abdominal pain associated with nausea and vomiting. The patient had experienced multiple episodes of acute pancreatitis in the past without clear etiology. On examination, she had mild epigastric ten- derness without organomegaly. Laboratory data showed lipase of 849 unit/L, amylase of 126 unit/L, hematocrit of 36.8, white blood cells count of 20,000 with 76% lymphocytes and moderate amount of smudge cells. Abdominal ultrasound was performed with limited results due to overlying bowl gas. Abdominal computerized tomography revealed mild splenomegaly with no intraabdominal masses or lymphadenopathy. Endoscopic ultrasonography (EUS) discovered multiple masses in the body/tail junction of the pancreas with the largest size of two centimeters. No stones or ductal filling defects were detected. EUS-guided fine-needle aspiration of the largest pancreatic mass was performed, which revealed a population of exclusive small lymphocytic cells likely small lymphocytic lymphoma. Given her history of CLL, the diagnosis of secondary CLL of the pancreas was rendered. Conclusion: Even though recurrent acute pancreatitis is an extremely rare presentation of secondary pancreatic lympho- proliferative lesions, physicians should be aware of this condition as a cause of recurrent pancreatitis, especially in patients with known history of CLL/SLL. The diagnosis of these disorders requires patho- logic confirmation to distinguish lymphoma from other tumors or autoimmune processes.

[814] CT scan abdomen showing pancreatic tail mass invading to colon and spleen, also shown liver lesions.

[816] CT abdomen showing dilated intrahepatic duct and presence of biloma. jaundice, right upper quadrant tenderness. Labs: T. bilirubin 10.6, direct bili 8.3, AST/ALT 130/265, alk phos 361, normal INR & CBC. CT abdomen showed intrahepatic biliary dilation. She underwent unsuccessful ERCP with inability to cannulate common bile duct. Percutaneous 8.5 French biliary drain was placed with improvement in bilirubin and symptoms on discharge. She returned 2 weeks later with hemetemesis, bile leak from the site of percutaneous drain and right upper quadrant pain. T. bilirubin 11.5, AST/ALT 146/195, alk phos 850, Hb 8.2, which was 11.2 two weeks ago. Repeat CT abdomen showed right sub-diaphragmatic fluid collection consistent with biloma. Tagged red blood cell scan and EGD were negative. Transhepatic cholangiogram showed dye extravasation into biloma, distal drain

[818] MRI: abnormal foci of ill-defined signal and enhancement in both kidneys, anc pancreas.

Post-ERCP Pancreatic Phlegmon: An Uncommon Presentation of a Common Condition Krittapoom Akrawinthawong, MD, Pornchai Leelasinjaroen, MD, Wuttiporn Manatsathit, MD. St. John Hospital, Detroit, MI. Discussion: Pancreatic polycystic disease is a rare condition, usually asymptomatic, although it may present with nonspecific abdominal pain, vomiting, jaundice or pancreatitis. It may occur singly or in association with renal cysts, liver, central nervous system or retinal abnormalities. Bleeding, infection, rupture or obstruction of the cysts may develop, and treatment includes monitoring, drainage or resection. Conclusion: We present a patient with dysontogenetic pancreatic cysts and no evidence of cystic lesions of the central nervous system. It is questionable whether this patient will have involvement of the central nervous system in the future. Introduction: Post-ERCP pancreatitis (PEP) is the most common complication of endoscopic ret rograde cholangiopancreatography (ERCP), occurring in approximately 3.5% of cases. PEP witl phlegmon is rarely observed in current clinical practice. We herein describe a case of severe PEI complicated by phlegmon formation presenting as acute pyelonephritis.

[823] Polyp prolapsing into the second part of the duodenum; gross and endoscopic sonogram.

A Case of Chronic Hepatobiliary Fascioliasis Mimicking Acute Choledocholithiasis: A Case Rep and Review of Literature Varun Takyar, MD, Bianca Afonso, MD, Terence O'Keeffe, MB, ChB, MSPH. University of Arizona Medical Center, Tucson, AZ. Purpose: A 52-year-old female with a history of morbid obesity presented with 2 days of abdominal pain, chest pain, and dyspnea. EKG and chest X-ray were unremarkable. CT PE protocol did not reveal a pulmonary embolism, but did show a large amount of hypoattenuating tissue in the epigastric area, consistent with severe lymphadenopathy. Patient was referred to our facility for further evaluation. On further questioning, patient endorsed intermittent abdominal pain for 2 years, about 1 year of early satiety, and 100-pound intentional weight loss. Physical exam was remarkable for tachycardia to the 120s, abdominal tenderness in the epigastric and right upper quadrant regions, and 1+ bilateral lower extremity pitting edema. Otherwise the patient was normotensive, anicteric, with clear lung sounds, without JVD; no lymphadenopathy was noted. Initial EKG, troponins, CBC, LFTs, lipase, and amylase were normal. Echocardiogram showed an ejection fraction of 35-40%. CT of the abdomen/pelvis was obtained and revealed diffuse lymphadenopathy including a 2.6 x 4.3 cm hypodensity near the celiac axis. This mass partially displaced an otherwise unremarkable pancreas. Gastroenterology was con- sulted to perform a biopsy. An EUS was performed. A large paraesophageal lymph node was biopsied. An irregular, 13 x 20-mm hypoechoic mass was identified and biopsied in the pancreatic head. Cytol- ogy of both biopsies revealed adenocarcinoma of the pancreas. Patient had a complicated hospital course that included massive thrombosis of bilateral iliac veins and IVC causing severe hypotension and acute renal failure. Patient was treated with heparin and IV fluids. Patient’s hemodynamic and renal status improved and she received one dose of gemcitibine prior to discharge. We present an atypical presentation of pancreatic cancer with severe lymphadenopathy and no pancreatic lesion on cross-sectional imaging. This type of presentation can lead to a delay in diagnosis. Hypercoaguable state, associated with malignancy, can lead to severe complications. Trousseau’s syndrome is a well- recognized condition originally described as “unexpected, unusual, or migratory thrombosis.” Heparin is the treatment of choice for this condition. Introduction: Hepatobiliary fascioliasis is a rare trematode-associated zoonotic infection. The disease is caused by Fasciola hepatica and rarely found in the United States. Here we present one such case

[828] Pancreatic hemorrhage. Discussion: Rivaroxaban is an orally available direct factor X inhibitor, recently approved by the FDA. Its primary benefit over prior forms of anticoagulation is its ability to provide convenient oral anticoagulation, without the need to monitor levels. Studies comparing this agent to older forms of anticoagulation have demonstrated increased risks for critical bleeding and need for transfusion, most commonly from the GI tract or intracranial hemorrhage. The lack of a clinically proven reversal agent has also been a cause for concern. While spontaneous bleeding when taking this medication may rarely occur, its occurrence in this patient with no history of trauma raised suspicion for underlying pathology. This suspicion was confirmed on the follow-up CT scan, which documented a pancreatic mass. This case is notable for a novel pancreatic source of major bleeding in a patient on rivaroxaban, as well as a clinically significant improvement upon adminis- tration of profilnine SD. Spontaneous pancreatic hemorrhage or hemoperitoneum while on rivar- oxaban should raise suspicion for an underlying pancreatic pathology including pancreatic tumors.

Case Report: We report a case of a 37-year-old male with no significant medical history who pre- sented with multiorgan dysfunction syndrome, DKA, and acute pancreatitis. This patient had a pro- longed hospital course with initial resolution of his acute pancreatitis; however, was later complicated by fevers, jaundice, and abdominal distension. Imaging revealed pancreatic necrosis. The patient was managed via medical therapy and underwent an ERCP for biliary decompression. Over the course of the year, his pancreatic necrosis and biliary obstruction resolved without surgical intervention. On 1-year follow-up, his diabetes also resolved.

[833] CT scan before and after irradiation and CT simulation before radiation treatment.

[837] Contrast enhanced CT scan of abdomen showing a cystic lesion in the pancreatic tail extending into the spleen (arrowhead).

Figure1; Graphs showing serum lipase, serum triglyceride and anion gap level during hospitalization. Case 1 in solid line and Case 2 in broken line.

[850] Fluoroscopic image showing proximal CBD stricture; endoscopic image showing SEMS.

Pancreatic Arteriovenous Malformation as a Rare Cause of Acute Pancreatitis Shunya Onoue, MD,' Muneji Morishita, MD,' Masahiro Matsushita, MD,' Hirokazu Kanayama, MD,' Masahiko Takahashi, MD,! Hiroyuki Mabuchi, MD,' Kohei Ishibashi, MD,' Kazuyasu Kamimura, MD,? Kazufumi Kimura, MD’. 1. Shimada Municipal Hospital Division of Gastroenterology and Hepatology, Shimada, Japan; 2. Shimada Municipal Hospital Division of Surgery, Shimada, Japan; 3. Shimada Municipal Hospital Division of Radiology, Shimada, Japan.

[855] Fistulous tract between pancreas and stomach on CT and endoscopy. Purpose: To identify pancreatogastric fistula as a rare complication of necrotizing pancreatitis presenting as hematemesis and melena. Case: A 48-year-old male with history of alcohol abuse presented with severe epigastric pain for 5 days. He also reported six episodes of hematemesis and associated melena which started 24 hours prior to presentation. He denied fever or chills. On admis- sion, he was hypotensive (96/62), tachycardic (107), afebrile (98.3 F) with epigastric tenderness and maroon stool in rectal vault. Hbg dropped from 7.7 g/dL to 4.8 g/dL. WBC count was 22.1 K/mm* and lipase was 16 U/L. A CT scan showed chronic pancreatitis and pancreatic pseudocyst abating the stomach. EGD showed clotted blood in the entire stomach but no site of active bleeding was identified. A large fistula leading to pseudocyst was found in the cardia noted to be draining pus and debris. The cyst was accessed by the gastroscope for possible irrigation and debridement. However, bleeding of arterial nature appeared from within the cyst that could not be stopped despite epineph- rine injections and the procedure was aborted. A tagged RBC scan showed no evidence of active bleed suggesting that bleeding had ceased. In the absence of active bleed and ongoing necrotizing and inflammatory process emergent surgical intervention was deferred and he was monitored in the ICU. His Hbg remained stable requiring no further transfusions. Patient was pain-free and tolerat- ing regular diet at day 3 of hospitalization. A CT was done that showed reduction of cyst size to less than half within a week of initial presentation. Discussion: Fistula formation is one of the most feared complications of pancreatitis. Secondary to close proximity, fistula in most cases connects the pseudocyst to either the transverse colon or splenic flexure, but in our patient, it formed between a pseudocyst and the stomach. A study by G.G. Tsiotos, et al evaluating the incidence of fistula forma- tion following necrotizing pancreatitis showed that none of the 64 patients had gastropancreatitic fistula prior to surgery. The inflammatory process which results in fistula formation can also lead to vascular invasion and in the presence of communication with GI lumen and the patient can present with hematemesis and melena, which can be misleading. Fistula by providing a drainage path can facilitate healing.

Obstructive Jaundice as the Initial Manifestation of Hodgkin's Lymphoma Sweta Kochhar, MBBS, Meghana Bansal, MD, Abhishek Agarwal, MD. Internal Medicine, UAMS, Little Rock, AR.

[862] Figure 1. Endoscopic retrograde cholangiopancreatography demonstrating multiple intrahepatic segmental strictures and dilations.

Discussion: Splenic abscess is a rare entity with frequency of 0.14-0.7% in autopsy series. It may lead to life-threatening hemorrhage, erosion into hilar vessels, rupture into the peritoneal cavity, lead- ing to diffuse peritonitis. Clinical manifestations may include left upper quadrant abdominal pain, fever, nausea, vomiting, and anorexia. Our patient presented with chief complaint of left-sided chest pain and hemoptysis leading our initial differential towards cardiopulmonary etiology. Diagnosis was made when imaging studies were performed. Therefore this case suggests that clinical presen- tation for splenic abscess can be nonspecific. Diverse etiologies have been discussed in literature which includes infective endocarditis with systemic embolization. Also, hematogenous spread from infective focus elsewhere in the body such as pancreatitis, diverticulitis, retroperitoneal, and sub- phrenic abscess. In this case, we suspect splenic abscess resulting from hematogenous spread from antecedent diverticulitis. Our patient initially had percutaneous drainage placed but due to clinical deterioration, splenectomy was performed. Due to narrow therapeutic window and high mortality with delayed treatment, we hope to bring this rare entity to the attention of most clinicians.

Right Upper Quadrant Abdominal Pain Ten Years Post-laparoscopic Cholecystectomy Anne Bartels, BS,? Arvind Murali, MD,' Jose Gonzales Zamora, MD”. 1. John Stroger Jr. Hospital of Cook County, Chicago, IL; 2. Rush University Medical Center, Chicago, IL. Conclusion: ANET are a rare cause of recurrent abdominal pain, and local exision of small ANETs car be an alternative, less morbid treatment for young patients.

[868] ERCP image: cystic duct filling defect.

An Interesting Case of Cholangiocarcinoma Masquerading as Bile Duct Stones Mandeep Singh, MD, Vinay Sood, DO. Gastroenterology, Albany Medical Center, Albany, N

and uncontrolled diabetes mellitus. Physical examination was unremarkable except for scleral icterus. Liver function tests demonstrated a total bilirubin of 16.9 mg/dL, AST of 118, ALT of 213, and alkaline phosphatase of 438. A CT scan demonstrated mild biliary tree dilatation. No definite obstructing mass or gallstone was visualized. The pancreas demonstrated no surrounding inflammatory change or ductal dilatation. A left renal mass measuring 30 mm was also noted. ERCP and EUS-FNA were performed. The radial EUS disclosed diffuse hypoechogenicity of pan- creatic parenchyma with small pancreatic duct measuring 1.3 mm in size. The pancreatic head was prominent with no discrete mass identified. ERCP showed distal common bile duct stricture measuring 20 mm in length located in the region of the head of the pancreas. The stricture was brushed, biopsied, and stented. EUS-FNA was subsequently performed with biopsies taken form the head of the pancreas. The pathology was negative for malignancy. Based on endoscopic find- ings an IgG subclass analysis was performed resulting in an elevated IgG4 of 388 mg/dL consisted with AIP. Prednisone was initiated which led to complete resolution of his symptoms. Repeat ERCP after 2 months revealed a patent biliary tree and the stent was removed. The patient was maintained on 20 mg of prednisone. Five months into the course of treatment a repeat CT was performed to re-evaluate the renal mass, initially suspected to be an extrapancreatic manifestation of AIP. On repeat imaging the left renal mass had increased in size to 34 mm. The patient under- went partial left nephrectomy which revealed RCC. Majority of renal masses associated with AIP are benign and considered a part of the extrapancreatic manifestations of the disease. However, it is imperative to have a low threshold for suspecting RCC particularly if the mass is not responsive or increasing in size during treatment. These cases highlight the need for continued follow-up and potential biopsy or surgery.

[882] Extracted daughter cyst wall. Discussion: Hepatic hydatid cysts are usually asymptomatic. Symptoms occur due to the size of the cyst causing pressure on the liver parenchyma or from possible intrabiliary rupture. Intrabili- ary rupture can occur occultly when the cystic fluid only drains into the biliary tree or as a frank rupture with intracystic material and/or daughter cysts draining into the biliary tract. ERC per- formed preoperatively in a patient with hydatid cyst with or without biliary dilation may avoid an unnecessary CBD exploration. It can be used for definition of biliary anatomy providing a roadmap of cystobiliary fistulas prior to cystectomy. Additionally, daughter cysts may be extracted from the

[903] Sclerosing cholangitis. Conclusion: AIDS cholangiopathy classically presents with intrahepatic sclerosing cholangitis and ampullary stenosis. Treatment is primarily endoscopic, with biliary sphincterotomy in cases with ampullary stenosis. Eradication of the viral or protozoal infection does not influence symptoms or chol- angiographic abnormalities.

[905] Figure 1. T2 image showing enhancing 2.8 cm mass in the body of pan- creas with an additional lesion in tail (not shown in this image) and otherwise normal looking pancreas. Discussion: Metastatic pancreatic disease constitutes about 2% of all pancreatic malignancies. There are very few reports about pancreatic metastases from LMS. Although the pancreas is a retroperitoneal organ and is located in close proximity to the primary lesion, the above case demonstrates unpredictable lesion characteristics, with pancreatic metastases occurring nearly 9 years after primary diagnosis succeeding metastases to distant regions like lungs and lower extremities. A high index of suspicion is needed with unusual pancreatic findings in patients with other primary malignancies. When feasible, surgical exci- sion of the pancreatic metastases is an effective treatment strategy. The report highlights the utility of EUS to detect and diagnose metastatic lesions to the pancreas.

[907] Figure 1. FNA of the nodules in pancreatic head performed through an avas: cular plane.

Acute Pancreatitis as a Complication of Endoscopic Ultrasound Fine Needle Aspiration: A Case Report Neha Nigam, MD, Shervin Shafa, MD, Nadim Haddad, MD. MedStar Georgetown University Hospital, Washington, DC. Another attempt to break the basket yielded the same result, leaving the basket intact over the stone. At this point, a duodenoscope with a rat tooth forceps was advanced into the bile duct to grasp and break one of the basket wires at the metal tip, successfully disengaging the basket from the stone (Image 2). The basket was retrieved and a pigtail stent was placed in the CBD to allow for drainage of the bile duct. An impacted lithotripsy basket is as a rare complication of mechanical lithotripsy. Salvage devices are often the first line approach in the management of an impacted basket; however, management options are lim- ited when the salvage device fails as seen in this case. Extracorporeal shock wave lithotripsy, intracorpo- real electrohydraulic lithotripsy, and tipping the basket tip using a second basket have all been described as nonsurgical methods to retrieve an impacted basket. However, most of these rescue procedures are not readily available. Our purpose in presenting this case is to highlight a simple yet innovative method of management of an impacted basket when a salvage device has failed. Purpose: Endoscopic ultrasound fine needle aspiration (EUS-FNA) is increasingly used to assess pan- creatobiliary pathology, as it allows for real-time visualization while sampling tissue. Data on com- plications of EUS-FNA of pancreatic tissue, particularly involving cystic lesions, is scarce and mostly describes patients with solid lesions or recurrent pancreatitis in those with prior symptoms. We report a case of acute pancreatitis as a complication of EUS-FNA in a patient with no prior pancreatic pathology. A 69-year-old male, otherwise healthy, was evaluated for right upper quadrant abdominal and flank pain. Vital signs and laboratory results, including a liver panel, amylase, and lipase, were normal. A computed tomography (CT) and subsequent magnetic resonance cholangiopancreatography (MRCP) revealed a 1.8-cm cystic lesion in the pancreatic uncinate process, as well as a small fluid collection at the junction of the body and tail without any other pathology. An EUS was performed which detected two anechoic lesions in the pancreas, a 1.7-cm lesion in the head and a 1.3-cm lesion in the body of the pancreas. Both lesions underwent FNA. The patient received ciprofloxacin for infection prophylaxis and remained hemodynamically stable during and after the procedure. Approximately 4 hours after discharge, he presented with emesis, chills, and severe epigastric pain radiating to the back and flank. Vital signs remained stable. Lipase was 2,388. CT of the abdomen and pelvis showed peripancreatic fat stranding and free fluid without evidence of free air, consistent with acute pancreatitis. The patient received supportive care for treatment of pancreatitis, and was discharged 2 days later after resolution of symptoms. Cytological analysis showed the cysts to be benign and he was scheduled for an MRCP in 1 year. EUS-FNA of cystic pancreatic lesions may result in acute pancreatitis, even in those with no prior history. The mechanics of the procedure likely induce local inflammation, as seen by an increase in pre- and post-procedure lipase levels, regardless of whether clinical sequelae develop. The location of the pancreatic lesion, size of the needle, number of needle passes, and amount and duration of needle suction may also play a role in inflammatory changes and clinical manifestations. In addition, endoscopic insufflation, which allows for enhanced ultrasonographic images, may cause mechanical compression of surrounding structures, resulting in further inflammation. Acute pancreatitis is a considerable com- plication of EUS-FNA of pancreatic lesions, and gastroenterologists must be mindful of this potential complication as more cases are reported.

[911] EUS view of the pancreatic neck mass. abnormal soft tissue along the retroperitoneum encasing the celiac axis origin and the superior mes- enteric artery. There was also presence of splenic vein occlusion with numerous left upper quadrant varices, as well as diffuse biliary ductal dilatation with a transition point near the level of the ampulla. At this time, surgical pathology resulted as a moderately differentiated adenocarcinoma extending through the bowel wall into the subserosa, but sparing the mucosal layer, suggesting it was metastatic. EUS was performed and revealed a large hypoechoic mass in the neck of the pancreas measuring 2.3 x 2.4 cm with involvement of the celiac and superior mesenteric arteries. Both the mass and a large celiac lymph node were biopsied, and FNA cytology confirmed pancreatic adenocarcinoma within both. This is a rare presentation of metastatic pancreatic adenocarcinoma with metastasis to the sigmoid colon presenting as a large bowel obstruction.

[912] Proximally migrated pancreatic duct stent as seen on endoscopic retrograde pancreatogram. Purpose: A 43-year-old Caucasian woman with a medical history significant for obesity was evaluated for intermittent right upper quadrant abdominal pain for several months. Abdominal ultrasound showed gallstones and a dilated common bile duct of 9 mm. Laboratory studies showed elevated transami- nases. An initial endoscopic retrograde cholangiopancreatogram (ERCP) was performed for suspected

[916A] The ruptured SAPA as seen on EGD with overlying fibrin clot. Purpose: A 44-year-old man with past medical history of alcohol abuse presented to the ER with a com- plaint of three episodes of hematemesis and two episodes of syncope in the 2 days preceding presenta- tion. Initial hemoglobin was 3.5 mg/dL, heart rate was 120 beats per minute, and systolic blood pressure was approximately 70 mm/Hg. Emergent EGD displayed what appeared to be a gastric varix with overly- ing fibrin clot. CT of the abdomen displayed chronic pancreatitis and a splenic artery pseudoaneurysm (SAPA). The patient underwent CT angiography and the SAPA was treated via transcatheter arterial embolization (TAE). Only 160 cases of SAPA have been reported in the literature. Chronic pancreatitis is the leading etiology. Rupture of a SAPA can lead to rapid exsanguination and is associated with 90% mortality rate when untreated. EGD remains the procedure of choice in a patient with hematemesis; however, a SAPA is not likely to be visible on EGD. Our case is unique in that the SAPA was immediately visible on EGD. This case champions the early use of CT angiography when EGD can not elicit the cause of upper GI bleeding. Prior to the advent of interventional radiology, surgery was the only treatment for SAPA. Currently, TAE is the recommended treatment for those patients who are hemodynamically stable enough to undergo the procedure. The success rate for management of a SAPA with TAE is approxi- mately 85% and carries a minimal risk of complication. Size of the SAPA has not been shown to be a determinant of likelihood of rupture; thus, when discovered, a SAPA warrants treatment regardless of size or symptoms.

[916B] The SAPA as seen on CT angiography.

[919A] Biopsy of the mass in the common bile duct; red arrow showing squamous cells with keratinization and intracellular bridging, consistent with squamous cell carcinoma. Purpose: Primary squamous cell carcinoma is a rare and a very aggressive form of carcinoma of the gallbladder. We have recently seen a 63-year-old man, a chronic smoker, with an aggressive squamous cell gallbladder cancer, presenting with obstructive jaundice. He underwent CT scan and was found to have a mass engulfing the entire gallbladder, with extensive local invasion to the liver and bile ducts. Histology from ERCP-guided biopsy of CBD and CT-guided biopsy the liver mass confirmed the diagnosis of pure squamous cell cancer. The patient underwent ERCP and biliary stent placement, leading to improve- ment in clinical status and cholestatic jaundice. Squamous metaplasia, or squamous cell differentiation of preexisting adenocarcinoma, are believed to be the most acceptable hypotheses to explain the existence

of squamous cell carcinoma of the gallbladder. Risk factors may include choledocholithiasis, intrahepatic lithiasis, and inflammatory disorders, among others. Squamous cell carcinoma of the gallbladder may be treated by cholecystectomy with hepatic resection, if diagnosed during the early stages. In later stages, only palliative efforts, such as biliary decompression, may be feasible.

[920A] SB video capsule endoscopic picture revealing ileal edema and narrowing. Case Report: A 70-year-old male presented with iron deficiency anemia. He complained of diarrhea, and colonoscopy results from five months earlier was normal to the cecum, with ileal intubation. Colon biop- sies were negative for microscopic colitis. The patient then presented with severe fatigue, and bloodwork revealed microcytic anemia and a HgB = 10.4 gm % (N=12-16). Given that the patient had undergone a

[920B] Axial non-contrast CT of the abdomen demonstrating a 3.6 cm spiculated mesenteric mass with desmoplastic reaction (red circle). Conclusion: Metastatic neuroendocrine tumor of the ileum can present with iron deficiency anemia. SB video capsule endoscopy was helpful in diagnosing this disorder.

[922] Chronic inflammatory cell infiltrates and foci of brown-black pigment in lamina propria consistent with melanosis in duodenum. Conclusions: Melanosis duodeni: endoscopically seen as discrete, flat, small, brown-black dark pig- mented spots in the duodenal mucosa, and is generally considered to be local deposition of iron from oral iron intake. There is no known association with pigmentation elsewhere in the GI tract, or with the use of laxatives. On literature review, the exact mechanism is unknown; it is found to be associated with history of oral iron intake, upper GI bleeding, co-morbid conditions like HTN, ESRD, CHF, DM and certain medications like hydralazine or diuretics, most of which were present in our case. Although it is a benign condition of unclear clinical importance that does not require any specific therapy, endoscopists and pathologists must be aware of this rare entity.

Tsegaw Egziti, MD, Gerald Mank, MD. UTSW Austin, Austin, TX.

Case report: We report a 54-year-old Caucasian female who presented to ER with epigastric pain and intractable vomiting 18 days after undergoing LSG for morbid obesity. The surgery was uneventful. During the previous hospitalization, the patient appropriately received subcutaneous heparin for DVT prophylaxis. The patient was subsequently discharged without any complication. She denied alcohol

Purpose: A 38-year-old male was referred to a rheumatologist for non-specific findings, including a one-year history of weight loss, progressive weakness, arthralgias, recurrent falls and progressive dys- arthria. Subsequent CT of the abdomen and pelvis demonstrated enlarged right femoral and inguinal lymph nodes for which biopsies were performed, revealing non-necrotizing granulomas. Upon further investigation, the biopsied tissues were found to stain PAS positive (Figure 1), which was highly sugges- tive of Whipple's disease. The patient was subsequently referred to gastroenterology for further workup. Upper endoscopy and biopsy revealed diffusely atrophic mucosa found within the entire duodenum (Figure 2), as well as villi that were markedly expanded by dense infiltrate of bloated, foamy macrophages demonstrating strong PAS positivity—both findings which are consistent with a diagnosis of Whipple’ disease. As the patient had progressive dysarthria with frequent falls (as well as a few episodes of altered mental status and uncharacteristically aggressive behavior), neurologic manifestation of the disease was suspected. MRI of the brain was performed revealing periventricular white matter lesions consistent with Whipple's disease, with cerebral involvement (Figure 3).

Adult Intussusception: A Rare Cause of Bowel Obstruction Secondary to a Tubulovillous Adenoma Ala Abdel Jalil, MD, Deepak Chowdhary, MD. McLeod Regional Medical Center, Florence, SC. Background: Intussusception in adults is a rare entity, accounting only for 1-5% of cases with bowe obstruction. In contrast to children, it presents usually with indolent symptoms; it’s less likely to be idio- pathic in nature and a pathological leading point or a predisposing factor is more frequently encountered Therefore in the majority of patients it requires surgical intervention. Case Presentation: A 30 year-old female presented to the hospital with intermittent abdominal pain, nausea and vomiting and passage of dark stool for few days. In the emergency room, she received a computed tomography scan of abdomen and pelvis with contrast (Figure A) which showed an invagi- nating terminal ileum into the ascending colon confirming the presence of ileocolic intussusception. Barium enema was attempted to reduce the intussusception with partial success. The patient was taken subsequently to surgery where she had resection of the terminal ileum and right colon. Intraoperatively, she was found to have a 2-cm luminal mass located few centimeters proximal to the intussusceptum (terminal ileum), pathology of that mass was consistent with tubulovillous adenoma. The patient did well postoperatively and was discharged home after a week.

[930] Cross-sectional computed tomography view of the terminal ileum (intussuscep- tum) within the ascending colon (intussuscipens). Discussion: Adult intussusception is rare and it’s usually secondary to an underlying etiology or a leading point. It’s idiopathic in about 10% only. In the small intestine, it's mainly secondary to a benign etiology including benign neoplasms, adhesions, Meckel’s diverticulum, lymphoid hyperplasia, celiac disease,

[931A] Capsule endoscopy of small bowel telangiectasia. Case Report: A 67-year-old man presented with breathlessness, symptomatic anemia for 3-4 days and was found to have HB <7. He had no overt bleeding, abdominal pain, nausea and vomiting. He had a his- tory of repeated hospitalization for symptomatic anemia. He had 12 admissions in 10 months for symp- tomatic anemia and received 34 U of pecked RBC transfusion in 10 months. Physical examination was unremarkable except for marked pallor. Lab data were within the reference range except positive stool occult and low hemoglobin of 5.2 to 7.9 on every admission with iron deficiency anemia. He had multiple endoscopies, including four upper endoscopies, three colonoscopies, three enteroscopies and three 3 capsule endoscopies. EGD and colonoscopy on first admission showed AVM in esophagus, caecum and ascending colon and clipping was done. Capsule endoscopy showed multiple non-bleeding telengiecta- sia in jejunum and ileum. Treatment with push enteroscopy and endotherapy was recommended, and he had three push enteroscopies with endotherapy. However, he continued to require frequent admis- sion with blood transfusion, and he is not keen for further enteroscopic treatment. Therefore, octreotide 50 mcg bid was given as a last option. Result: After treatment with octreotide, our patient has no further episode of symptomatic anemia in 20 weeks follow up period, and his hemoglobin level is stable in the range of 9-9.5 g/dl.

GI Sarcoidosis (932] Figure 1. Case Report: 54-year-old female with no reported past medical history initially presented to an outside physician with complaint of sudden onset of abdominal pain and some associated nausea. CT scan of the abdomen revealed small bowel intussusception with a transition point in the proximal small bowel. Initial laboratory including hemoglobin was unremarkable. The patient underwent an endoscopy, which revealed diffuse moderately scalloped mucosa in the first through the third part of the duodenum

[936] Bread bag clip in the duodenal sweep. References: 1. Morrissey SK, Thakkar SJ, Weaver ML, Farah K. Bread bag clip ingestion: A Rare Cause of Upper Gastrointestinal Bleeding. Gastroenterol Hepatol 2008 July;4(7):499-500.

Intestinal Behcet’s Disease (BD): A Rare Cause of Lower Gastrointestinal (GI) Bleeding Wasseem Skef, MD, Asim Shuja, MD, Anisha Varma-Wilson, MD, FACG. St. Elizabeth’s Medical Center Brighton, MA. Shiga toxin antigen enzyme immunoassay, Clostridium difficile stool polymerase chain reaction, ova anc parasites were negative. Duodenal biopsies from EGD showed extensive necro-inflammatory exudate: on hematoxylin and eosin stain. Stool culture returned positive for methicillin-resistant Staphylococcu: aureus (MRSA). The patient showed no clinical symptoms by hospital discharge. MRSA is an unusua cause of enteritis. Severe cases of staphylococcal enteritis with mucosal ulcerations and pseudomem branes have been previously reported. Diagnosis is established with growth of MRSA on stool cultur with typical symptoms. Early recognition after exclusion of other causes is paramount. We present ar unusual case of severe MRSA enteritis complicated by multi-organ failure presenting with hematochezia which promptly improved with antibiotic therapy.

[938] Image 1. Actively bleeding 20-mm ulcer in the TI. Introduction: BD is characterized by recurrent oral and genital ulcers, uveitis and skin lesions. Preva- lence of BD is highest in countries along the ancient silk road. By comparison, prevalence in Western countries is rare: 1 per 15,000-500,000. The frequency of GI involvement amongst patients with BD is variable. Low frequency has been reported in Turkey (2.8-5%), moderate frequency in the USA (30%) and the highest frequency has been reported in Japan (50-60%). Ileocecal and colonic involvement are most commonly reported.

[950] Figure 1. Submucosal ulcerated polyp found approximately 180 cm from the pylorus with antegrade single balloon enteroscopy. Purpose: A 26-year-old woman presented with one-day history of hematochezia beginning shortly after undergoing dilation and evacuation for retained products of conception. On initial evaluation, the patient was hypotensive, tachycardic and acutely anemic (hemoglobin/hematocrit 8.6/25.5). An emergent CT scan with rectal contrast ruled out bowel or uterine injury. Urgent EGD and colonoscopy were performed, however, no sign or source of bleeding was identified. A tagged RBC scan showed only vaginal bleeding. The patient subsequently stabilized; however, two days later, she had recurrent hema- tochezia and worsening anemia with a hemoglobin of 6.4. She denied any vaginal bleeding at that time, having used a tampon to avoid confusion. Thus repeat EGD and colonoscopy were performed, which, again, did not identify a source of bleeding. However, a capsule endoscopy revealed fresh blood in the proximal to mid-small bowel. She thus underwent an urgent antegrade single balloon enteroscopy, where a 1.5-cm submucosal polyp with an ulcerated and necrotic surface was found at approximately 180 cm from the pylorus (Figure 1). The lesion was tattooed with India ink and injected with diluted epinephrine. A diagnostic laparoscopy with segmental small bowel resection removed the lesion and pathology of the polyp returned as intravascular papillary endothelial hyperplasia (Masson's tumor). Masson’s tumors are benign vascular lesions that arise from intravascular endothelial proliferation in the setting of thrombus. They primarily affect the extremities, head and neck and have rarely been described within the abdomi- nal cavity. To the best of our knowledge, only five other cases of Masson's tumor in the small bowel have been reported in the literature. When involving the GI tract, patients typically present with abdominal pain, melena, and anemia. The case described here is unique in that it is the only known instance of a patient with a Masson's tumor of the small bowel presenting with hematochezia.

Fatal Clostridium difficile Infection of the Small Bowel after Total Colectomy: A Case Report and Review Kenechukwu Chudy-Onwugaje, MD, MPH, Daniel Brelian, MD, Pierre Hindy, MD, Yuriy Tsirlin, MD Ira Mayer, MD, FACG, Rabin Rahmani, MD. Maimonides Medical Center, Brooklyn, NY. Case Presentation: A 67-year-old caucasian male with PMH of CAD, COPD, NSCLC post radiotherapy presented with 3 weeks of abdominal pain with one day history of melena and coffee ground emesis Patient had a normal colonoscopy 4 years ago with no prior episodes of GI bleed. Labs revealed an acut 3-gram drop in hemoglobin. Examination revealed hypotension, tachycardia, and epigastric tendernes with 800 cc coffee ground emesis in NG tube. Significant medications included 2 weeks ingestion of aspirit 4 times a day for abdominal discomfort. Endoscopy showed linear superficial gastric erosions from NC trauma. In the absence of an obvious bleeding source, endoscope was advanced further into the SB whict revealed an ulcerated circumferential, friable mass in the third part of duodenum and proximal jejunum, witl adherent blood clot. Biopsies revealed poorly differentiated tumor, favoring metastases from NSCLC. Patien had incidental left lingual lung mass on CT scan performed 2 years ago for dyspnea. CT-guided biopsy revealed NSCLC, AJCC Stage IB, T2MONO and completed radiotherapy 1 year ago. After finding SB metas tasis, repeat CT scan showed 5cm mass in the third part of the duodenum with adjacent lymphovascular anc retroperitoneal fat invasion. The mass was unresectable due to its location and lymphovascular invasion, anc he was started on palliative chemotherapy Conclusion: Our report emphasizes that solitary metachronous SI metastasis from primary NSCLC can occur and physicians should keep past diagnosis of lung cancer in minc when evaluating abdominal symptoms like perforation, GI bleeding. Timely diagnoses of GI metastases by surveillance imaging may allow surgical resection for symptom relief and potential long-term survival.

955] Retroperitoneal mass with areas of necrosis and calcification. Conclusion: XGI in a retroperitoneal mass with tumor implants in the small bowel causing obstruc- tion has not previously been reported. Although rare, this case demonstrates that clinicians should be aware of the possibility for XGI to occur in the retroperitoneal space and the small bowel with subsequent SBO.

for dysphagia/globus sensation revealed an esophageal inlet patch, but no gross abnormalities otherwise. ACT scan on this admission revealed marked distention of the stomach and proximal duodenum with air fluid levels. The 3rd of duodenum tapered abruptly at the level of the SMA, suggestive of SMA syndrome. She underwent a duodenojejunostomy and did well post-operatively. The prevalence of SMA compres- sion seen by radiographic studies is between 0.2% and 0.78%. The clinical presentation is variable and non-specific, and may include bilious vomiting, postprandial epigastric fullness, bloating, and abdominal pain.Relief of symptoms is sometimes attained by placing the patient in the knee-to-chest position. Many factors may predispose to the development of SMA syndrome, and they all involve sharp narrowing of the aortomesenteric angle. One etiology for the development of the syndrome is rapid weight loss attributed to the reduction of the mesenteric fat around the SMA. The diagnosis of SMA involves clinical suspicion from presenting symptoms, as well as radiographic evidence. A succussion splash may be iden- tified on physical examination. Radiographic studies used to establish the diagnosis include upper GI series, CT/CT angiography, conventional angiography, and abdominal sonography. Radiographic criteria include an abnormal aortomesenteric angle of 6-15 degrees (normal, 25-60 degrees), aortomesenteric distance <8mm (normal, 10-28mm), or proximal duodenal dilation with obstruction of the third portion of the duodenum. Conservative management includes NG decompression, IV fluids, electrolyte replace- ment, and NJ tube feeding, which may improve the symptoms. Surgical management options include duodenojejunostomy, gastrojejunostomy, or a combination of both. Laparoscopic duodenojejunostomy has been shown to be the most successful surgical option. Javier Rosales, MD,' Xochiquetzal Geiger, MD, Victoria Gomez, MD’. 1. Mayo Clinic- Gastroenterology, Jacksonville, FL; 2. Mayo Clinic- Pathology, Jacksonville, FL.

[970] Left image: hemoclip placed for active bleeding. Right image: bleeding ileal carcinoid. Case presentation: A 26-year-old otherwise healthy female presented with four episodes of rectal bleed- ing at home, initially described as hematochezia which evolved to appear more consistent with melena. Purpose: A 55-year-old white male presented with a four day history of nausea, vomiting, diarrhea and abdominal pain. The patient denied fever, chills, night sweats or unexplained weight loss. There was no history of melena or hematochezia. He denied recent travel or contact with individuals with similar symptoms. No previous surgeries. No family history of colon cancer or IBD. Vital signs: T102.2F, P117bpm, RR20br/min, and BP127/78. Abdominal exam revealed prominent distention, normoactive bowel sounds, and diffuse minor tenderness on deep palpation. No rebound or guarding. A tubular- shaped mass was palpated in the RLQ. Lab data: WBCs 1.5 x 103/uL with 35% bands. H/H, Plt, CMP, amylase, CEA, UA normal. Stool was Hemoccult positive. C. difficile toxin, fecal leukocytes, blood cul- tures, and toxicology were negative. Flat plate of the abdomen showed a mild high grade small bowel obstruction (SBO) without free air. CT revealed moderate to high-grade partial SBO with a transition point in the distal ileum. No evidence of free air or abscess. Exploratory laparotomy divulged small bowel largely dilated proximally with a large 6 x 5-cm Meckel’s diverticulum two feet from the ileocecal valve with no ischemia or necrosis. Adhesions from the Meckel’s tip to small bowel created a SBO that was resected. Pathology confirmed diagnosis. Meckel’s diverticulum is the most common congenital anomaly of the GI tract. It is usually clinically silent. If symptomatic in adults it generally presents as painless GI bleeding. Isolated cases have been reported in adults with SBO caused by adhesions from a Meckel’s diverticulum. Predisposition to develop symptoms is age less than 50, male sex, histologically abnormal tissue within the diverticulum and a diverticulum greater than two cm in length. As concluded in other case reports on SBO, there should be a high level of suspicion of Meckel’s preoperatively if there are no other obvious causes. Had we suspected this we could have ordered a Meckel’s scan, with a sensitivity of approximately 50%. Laparotomy can diagnose causation and lead to resection of Meckel’s diverticulum causing small bowel obstruction. Purpose: Video Capsule Endoscopy (VCE) and double balloon enteroscopy (DBE) are frequently uti- lized modalities to evaluate the small bowel in an elective outpatient setting. We present a case in which an actively bleeding carcinoid tumor was identified, treated for hemostasis, and localized with tattoo on an urgent, inpatient basis. This process assisted the surgeons in their pre-operative planning and inpa- tient management of the patient. Fg eT aT ORC WEL SRI CRR ESET Bes piers & PaaeCR! Pee: Dynes Fo PRT A ROR. BS EMeS RAP IEMONY date Bona eh FRY co Acie We: pe aED PaiAet xyeiemps Rat Ut Pas Urtiaee

Purpose: Autoimmune enteropathy (AIE) is a rare disease that causes intractable diarrhea not responsive to a gluten free diet and must be distinguished from refractory sprue. It is associated with circulating autoantibodies against goblet cells and enterocytes. AIE mainly involves the small intestines and is most commonly found in children, with very few cases reported in adults. Due to the paucity of cases, the epi- demiology of the disease remains unclear. This is the case of a 28-year-old female who presented due te diarrhea with 20-40 episodes of voluminous green liquid stool per day. Stool cultures for bacteria, viruses. ova and parasites were all negative as were workups for secretory diarrhea, neuroendocrine causes, and testing for celiac disease. The patient underwent endoscopic gastroduodenoscopy and colonoscopy: which revealed mild diffuse hyperemia with no ulcerations. Biopsies showed intensely destructive enteri- tis, far more than would be expected from infection, with crypt abscesses, reduced intraepithelial lym- phocytes, and abundant apoptosis, characteristic for adult onset autoimmune enteropathy. The diagnosis was confirmed by positive staining of IgG along the apex of the erythrocytes and positive circulating anti-enterocyte antibodies. She was started on methylprednisolone, and after a few days, started to have more formed stool with gradually decreased frequency. She was started on adalimumab therapy with good response and control of her diarrhea. The lack of data regarding this disease and subsequent short- age of histologic expertise makes the diagnosis difficult to make. In addition to the fact that our patient developed adult-onset AIE, she was also noted to have intense inflammation in the colon. AIE is most often restricted to the small bowel but there have been a small number of case reports showing manifesta- tions outside of the small bowel, mostly seen in children. To our knowledge, this is the first reported case of adult onset autoimmune enteropathy with colitis, successfully treated with adalimumab. jejunal Le1romyoma as a Cause of Ubscure Gastrointestinal lract bleeding Nongnooch Poowanawittayakom, MD,' Kongkiat Chaikriangkrai, MD”. 1. Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago, IL; 2. The Methodist Hospital, Houston, TX.

[977] Large duodenal vrices with red wale sign in the second portion of the duodenum. Case report: A 71-year-old man with profound mental retardation was admitted with recurrent coffee- ground emesis. His care facility reported that his long-term PEG tube was functioning normally and it was confirmed to freely flush saline. There were no records available at their facility or at our institution regarding initial placement or subsequent replacements of the PEG tube. Examination showed a balloon- type replacement PEG tube that could be freely inserted and rotated, but only withdrawn to the 6-cm marking with traction. On review, a chest x-ray performed in the Emergency Department to confirm Discussion: Duodenal varices in the absence of cirrhosis are usually secondary to anomalies of the inferior vena cava, portal vein, splenic vein or superior mesenteric vein. Reported etiologies of vascu- lar associated varices include pancreatitis, surgical complications, congenital malformations, and crush injury. Interestingly, our patient recalled a crush injury secondary to motor vehicle accident (MVA) 40 years prior which necessitated exploratory laparotomy. Presumably, his mesenteric vein stenosis is a complication of the remote MVA. Due the paucity of cases, management is controversial. Endo- scopic injection sclerotherapy (ESL) is a promising modality; in our case 5% ethanolamine caused near complete resolution of his duodenal varices. Since the risk of bleeding is directly related to the size of the individual varix, routine surveillance and repeat ESL of high risk lesions could provide long term management of this condition, thus avoiding a risky surgical repair in an individual with multiple medical co-morbidities.

[980A] Axial CT scan image showing dilated small loops with bowel wall edema.

{980B] Coronal CT scan image showing dilated small loops with bowel wall edema.

Purpose: A 77-year-old man with no significant past medical history presented to an outside institution with worsening shortness of breath and melena. Hemoglobin 7.6 g/dL on admit. Transfused 3 units pRBC. Incremented to 9.2 g/dL but then fell to 7.2 g/dL the following day. EGD was normal. Colonos- copy with TI intubation showed pan-colonic diverticulosis without active bleeding. He continued to pass melena and require pRBC transfusions. Second EGD and small bowel (SB) enteroscopy performed show- ing diverticulum in proximal and mid-jejunum without bleeding. Abdominal CT angiography showed no active hemorrhage. He was transferred to our institution. Capsule endoscopy showed large jejunal diverticula with old blood. Balloon-assisted enteroscopy showed multiple large-sized diverticula in distal duodenum, proximal/mid-jejunum. Diverticula contained old blood/clots, but no actively bleed- ing lesion or recent stigmata seen. Surgical consultation obtained andopined since diverticula involved proximal duodenum and no active bleeding seen, any surgical intervention involving resection of this area would be technically difficult. Mesenteric angiogram showed no active bleeding. Patient required daily pRBC transfusion (total of 12 units since admission). Then began to pass maroon colored stools. Urgent SB enteroscopy with cap-fitted pediatric colonoscope performed. Fresh blood found in proximal jejunum. Large diverticulum with fresh clot/oozing blood identified (Fig 1) but no definitive target seen for endoscopic therapy. Tattoo marking applied. Patient taken for urgent surgery. Laparotomy showed jejunal tattoo with multiple surrounding large diverticuli. 40 cm segment containing tattooed jejunum resected (Fig 1) and fresh blood found inside. Pathology confirmed tattooed region of the diverticuli to be source of bleeding. No further episodes of rebleeding post-surgery or at 60 days. This case illustrates the importance of endoscopic timing in reaching the appropriate diagnosis and the multidisciplinary approach used in successful management. Evaluation of the SB during an episode of active bleeding, particularly in cases when EGD/Colonoscopy are non-diagnostic, can be the key to finding the cor- rect diagnosis. In cases where the etiology of intestinal bleeding is unclear or other diagnostic testing is inconclusive, more urgent endoscopy at the time of active bleeding may have a role in establishing the diagnosis and providing treatment.

Incidentalomas of the Gastrointestinal Tract: A Case Report of Appendiceal “Mucocele” Resected b Laparoscopic Right Hemicolectomy Sachin Mohan, MD, PhD,! Punitha Shivaprasad, DO,? Shaffer Mok, MD, MBS,’ Cynthia Griech- McCleery, MD,’ Satyajeet Roy, MD, FACP'. 1. Department of Medicine, Cooper University Hospital of Rowan Medical School, Camden, NJ; 2. Department of Gastroenterology, Cooper University Hospital of Rown Medical School, Camden, NJ.

[986A] Figure 3.Histopathology of mucinous cystadenoma showing intestinal type epithelium lining with large amount of apical mucin. Purpose: A routine colonoscopy on a 52-year-old female revealed an enlarged appendix with a wide base prolapsing into the cecum. CT-abdomen revealed a 3.0 x 1.2-cm uniform hypodense “mucocele” involv- ing the appendix. As the lesion involved the base of the appendix and prolapsed into the cecum, laparo- scopic hemicolectomy for resection was performed. Histopathology revealed a mucinous cystadenoma of the appendix with no dysplasia. A detailed intra-operative exploration of the gastrointestinal tract, ovaries and peritoneum for coexisting malignancies was negative. Follow-up colonoscopies and pelvic exams were unremarkable. Here, we report successful resection of a low-grade appendiceal mucinous neoplasm by laparoscopic right hemicolectomy, strengthening the evolving consensus that laparoscopic approach is safe and feasible and a hemicolectomy can allow safer laparoscopic resection by avoiding direct handling of tumors.

[986B] Figure 1. Colonoscopic view of cecum showing base of the appendix prolapsing into the cecal lumen.

[986C] Figure 2. CT scan of the abdomen and pelvis showing mucocele.

[989] Arrow indicates “hooked” appearance of celiac artery due to compression by medial arcuate ligament from above. Discussion: Patient with chronic abdominal pain associated with weight loss and exacerbations with exercise should have MALS in the differential. Eating stimulates increased metabolic demand for the stomach leading to mismatched perfusion via a compromised celiac artery. During exercise, the dia- phragm expands at a higher frequency and force to accommodate for increased oxygen demand. This leads to further reduction of celiac artery flow in patient with MALS. CT Sagital images demonstrating acute angulation and narrowing of the proximal celiac artery causing a “hooked” appearance (arrow) is characteristic of median arcuate ligament syndrome.

Purpose: Heyde’s syndrome pertains to the association between aortic valve stenosis (AS) and gastro- intestinal (GI) hemorrhage due to angiectasias. The reported incidence is 3% among patients with AS. Aortic valve replacement (AVR) has been reported to be therapeutic for refractory GI hemorrhage in Heyde's syndrome. We present a rare case of Heyde’s syndrome in the setting of bioprosthetic aortic valve mismatch. Our case involves a 68 year-old woman without any prior history of GI bleeding who presented with dyspnea two weeks after bioprosthetic AVR for severe AS. The dyspnea was attributed to acute anemia as she was found to have a hemoglobin of 7 g/dl from her baseline of 12 g/dl. There were no signs of overt GI bleeding. Extensive body imaging did not show any evidence of occult hematoma. Laboratory work up was negative for hemolysis. Fecal occult blood testing was positive. She underwent an EGD and colonoscopy that showed no obvious source of GI bleeding. A capsule endoscopy was per- formed and showed angiectasias and superficial erosions in the proximal jejunum. Antegrade double balloon enteroscopy (A-DBE) detected the same actively bleeding jejunal angiectasia. This was treated with argon plasma coagulation (APC) and hemoclip application (Figure 1). On further cardiac evalua- tion, she was found to have severe AS due to patient-bioprosthetic valve mismatch. She had to undergo a mechanical AVR. A month later she was admitted for melena. She underwent a second A-DBE which found the same bleeding angiectasias which were treated with epinephrine injection and hemoclip appli- cation. In our literature search using PubMed, Scopus and Embase from inception to June, 2013, there were only 22 published cases of Heyde’s syndrome. Fifty-three percent were males. The mean age was 72 years (range: 48-88 years old). The most common presenting symptom was melena (45%). Most of the angiectasias were colonic (55%). AVR was performed in 16 (73%) out of 22 patients. Only two of these patients received mechanical valves while the rest received bioprosthetic valves. Resolution as defined by cessation of bleeding or anemia after AVR was observed in 13 (81%) patients. Metastatic Lerminal eum Carcinoid 1umor Masking as Gastroenteritis John Wang, MD, PhD, Robert Basseri, MD, Christian Jackson, MD. Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA.

[995] EGD: periampullary diverticular ulcer.

[998B] Figure 2. Image demonstrates narrowing of the distance between the SMA (arrow) and the aorta (A) at the level of the 3rd portion of the duodenum (arrowhead). [998A] Figure 1. Axial contrast CT image obtained during the portal venous phase demonstrates a non-occlusive thrombus within the right portal vein (arrow).

Purpose: This is a case of a 62-year-old man who presented with complaints of periumbilical abdominal pain and vomiting of 2 days’ duration. He noted a 4-month history of watery, non-mucoid diarrhea with 15lb unintentional weight loss. Prior workup for chronic diarrhea included stool studies, colonoscopy, and CT scan abdomen, all of which were normal. The patient appeared cachectic with a diffusely tender abdo- men and voluntary guarding. Initial labwork was pertinent only a mild leukocytosis. Liver function tests, amylase, lipase, and lactate levels were all normal. A CT scan abdomen revealed changes consistent with portal vein thrombosis and SMA syndrome (Figures I and 2). An abdominal ultrasound was obtained. revealing changes confirming SMA syndrome. An EGD revealed a dilated stomach with large amounts of gastric contents. A decompressive gastrostomy tube with a feeding jejunal extension was placed radio- graphically. The patient was started on heparin and broad-spectrum antibiotics. The patient was managed medically with improvement in his clinical status. He was discharged to a rehabilitation facility in stable condition. This case highlights the effects of SMA syndrome on the portal vasculature. Review of the literature reveals a paucity of similar cases, most involving the pediatric population with SMA syndrome. complicated by gastric wall pneumatosis and portal venous gas. In our case, local compression on the SMV well may very well have been the single most important contributing factor. Special attention should also be paid to pressure effects of a dilated proximal duodenum and/or dilated stomach. We should remain alert to the possible association of SMA syndrome with the portal vasculature and rule it out on imaging.

Purpose: A 33-year-old male presented with 4-day history of postprandial abdominal distention, epigas- tric pain, and vomiting. Past medical history was significant for systemic lupus erythematosus, diagnosed 6 months prior to presentation. The patient had stopped his immunosuppressive medications as he had been asymptomatic. Admission labs included: WBC count: 13.2 x 10E9/L; CRP: 1.38 mg/dL (0-0.80); ESR: 28 mm/h (0-10); ANA 1:640. Twelve hours after admission, patient's clinical status deteriorated as he developed worsening severe abdominal pain and distention. CT abdomen/pelvis was performed, which showed evidence of small bowel obstruction with marked wall thickening, edema, and dilation of the jejunum. There was a large amount of ascites, abnormal bowel wall enhancement (target sign), and engorgement of mesenteric vessels with increased number of visible vessels (comb sign), consistent with mesenteric vasculitis (see Figure). A diagnostic laparoscopy showed no evidence of impending bowel infarction or necrosis. Based on a clinical diagnosis of lupus mesenteric vasculitis, treatment with high- dose pulse intravenous steroids and cyclophosphamide was initiated. The patient's symptoms resolved. This case highlights a rare, poorly understood condition associated with lupus along with pathogno- monic CT findings. Because of potential fatal consequences, mesenteric vasculitis should be included in the differential diagnosis for patients with lupus that present with abdominal pain. As in this case, response can be rapid if appropriate therapy is instituted promptly. Sreedevi Atluri, MD, Jiten Kothadia, MD, Kinesh Changela, MD, Sushil Duddempudi, MD, Mahesh Krishnaiah, MD, Sury Anand, MD. The Brooklyn Hospital Center/Division Of Gastroenterology and Hepatology, Brooklyn, NY.

Purpose: Duodenal diverticular bleeding is an uncommon cause of upper GI bleeding where endoscopic hemostasis in patients with ongoing need of antiplatelet agents poses a diagnostic and therapeutic chal- lenge. We present a rare case of periampullary duodenal diverticular bleeding in a patient receiving dual antiplatelet therapy. An 80-year-old female presented with dizziness, diaphoresis and melena. Her signifi- cant past history included coronary disease with recent stents on dual anti-platelet agents. On admission, she was found to be anemic (Hb 6 g/dL) requiring blood transfusions for hemodynamic stabilization. EGD showed two large periampullary diverticuli in the duodenum (Figure 1) with a slow active oozing on one of the diverticular folds with underlying visible vessel. Two hemoclips were applied to achieve hemostasis. Area up to mid-jejunum showed other small non-bleeding, duodenal and jejunal diverticuli. After volume resuscitation, patient recovered uneventfully and discharged home on PPI and aspirin. She was readmitted three days later with anemia and melena, requiring blood transfusion. Aspirin was held and she was discharged home on a single antiplatelet agent. Incidence of duodenal diverticular bleeding in patients on dual antiplatelet therapy is not currently known. A meta-analysis from 50 clinical trials showed higher rate of GI bleeding associated with aspirin at doses >325 mg/d; 2.5% (95% confidence interval [CI] 1.8-3.1%) A recent pooled analysis report the incidence of major bleeding necessitating hospitalization to be 1% in patients on 325 mg/d or less of aspirin alone, 0.85% with clopidogrel alone, and 1.7% with aspirin plus clopidogrel. The prevalence of duodenal diverticuli has been described to be from 0.06-22%; however, given its infrequency, the incidence of bleeding and impact of antiplatelet therapy remains unclear. Our case illustrates a potential higher bleeding risk due to dual-antiplatelet therapy in patients with duodenal diverticuli. It is imperative for the endoscopist to be cognizant of this rare complication to be able to recognize and institute appropriate endoscopic therapy.

Discussion: Classically, duodenal leiomyomas and leiomyosarcomas are classified under gastrointestinal stromal tumors (GIST) because most of them express a protein KIT, also called CD117. But it is important to recognize LMS as a separate entity as they have a worse prognosis. The exact incidence of KIT negative tumors is not known while KIT positive tumors of duodenum have an incidence of 10% of all GISTs. Duodenal LMS can present with abdominal pain, GI bleed, anemia or obstructive jaundice in 50-70 year age group. Diagnosis is made by histology and immunochemical staining using which our patient was diagnosed with KIT negative poorly differentiated LMS. Most common sites of metastasis include liver, pancreas and peritoneal cavity. Our patient showed extensive pulmonary metastasis along with liver metas- tasis, which is rarely, if ever reported in the literature. The primary treatment option is surgical resection. Metastatic disease, KIT negative on immunostaining and non resectable lesion confer poor prognosis. Conclusion: Duodenal leiomyosarcoma should be differentiated from GIST and treated accordingly. Primary Aorto-Enteric Fistula: A Kare Clinic Entity with high Mortality Risk Kaartik Soota, MD, Mohamad Jandali, MD, Matthew Ferrantino, MD, Sandy Sorrentino, MD. Unity Health System, Rochester, NY.

[1008] Left image: Severe duodenitis caused by WG. Right image: Multiple duodenal ulcers caused by CMV. Purpose: A 55-year-old male presented with arthralgias, fevers, cough, abdominal pain, and melena. Initial evaluation demonstrated elevated ESR and CRP, eosinophilia, hematuria, and proteinuria. Abdominal CT revealed duodenitis, following by EGD with ulcerated duodenitis. Biopsies had increased eosinophils and submucosal hemorrhage. A biopsy of palpable purpura of the feet suggested vasculitis. C-ANCA was positive with an elevated proteinase-3 antibody. This constellation was diagnostic of Wegener's granulomatosis (WG). Symptoms improved with high-dose IV corticosteroids and he was transitioned to oral prednisone at discharge. His WG relapsed and he was treated with rituximab. His course was complicated by C. difficile-associated diarrhea which responded to metronidazole. Three days after the last infusion of rituximab, he returned with severe C. difficile colitis requiring colectomy with end-ileostomy. Despite antibiotic therapy after surgery, he had persistent high ileostomy output and anemia. Repeat endoscopy showed severe ulcerated duodenitis, despite the absence of other systemic or cutaneous vasculitis. Several ulcers were successfully treated endoscopically. Several hours later the patient became unstable with a duodenal perforation requiring surgery. Further complications followed, including bacteremia, fungemia, and sepsis. Ongoing GI bleeding not amenable to endoscopic therapy required more transfusions and surgical intervention. Results of serum serologies and the second duo- denal biopsies eventually proved cytomegalovirus (CMV) duodenitis. Antiviral therapy was added to his other therapies, but ongoing sepsis, bleeding, and pulmonary failure resulted in the patient’s demise less than three months from his initial presentation. WG is a systemic disease characterized by necrotiz- ing granulomatous inflammation and small- to medium-sized vasculitis in multiple organs. Commonly involving the respiratory tract and kidneys, GI tract involvement is rare. WG treatment requires immu- nosuppression, risking development of opportunistic infections. A high degree of suspicion for CMV is needed to identify immunocompromised patients that may benefit from empiric therapy during severe illness. Endoscopy carries a high risk of perforation in this setting. Purpose: Bariatric surgery is a highly effective treatment for morbid obesity and its associated conditions. Meanwhile, surgery in obese patients is associated with worse outcomes than in non-obese patients. In this report, we describe our first experience with a two-stage procedure for a morbidly obese patient with type 2 diabetes mellitus (T2DM) and a nonfunctioning pancreatic neuroendocrine tumor (PNET). A morbidly obese, 63-year-old woman presented to our unit for the evaluation of a pancreaticoduode- nectomy (PPPD) to treat a pancreatic tumor. Her body mass index (BMI) was 40.0 kg/m2. Computed tomography revealed a 30-mm tumor in the pancreatic head, and she was diagnosed with PNET. She had several obesity-related diseases, including T2DM. She had received insulin treatment for 6months. Because PPPD is highly risky in morbidly obese patients, we planned a two-stage surgery—laparoscopic sleeve gastrectomy (LSG) followed by laparoscopic-assisted PPPD. First, LSG for morbid obesity was performed. The length of the postoperative hospital stay was 5 days, with no morbidity. Six month after LSG, her BMI had decreased from 40.0 to 29.3 kg/m2. Ghrelin levels before the operation and 2 weeks, 1 month, and 6 months after the operation were 129, 21, 28, and 25 fmol/ml, respectively. The patient also experienced complete remission of her T2DM without medication 2 weeks after LSG. Seven months after LSG, laparoscopic-assisted PPPD was performed. The length of the postoperative hospital stay was 23 days, with no morbidity. Glucagon-like peptide 1 (GLP-1) levels increased (Figure) and glucose- dependent insulinotropic peptide (GIP) levels decreased after PPPD. In conclusion, we have reported an important case in which two-stage surgery comprising laparoscopic-assisted PPPD, after LSG, was per- formed in a morbidly obese patient. The findings in this case suggest that two-stage surgery may be useful for decreasing postoperative complications and can help explain the changes in glucose metabolism. It is suggested that the post -prandial changes of ghrelin and GLP-1 levels lead to be complete remission of T2DM, whereas pancreatic resection is considered a risk factor for diabetes due to insulin deficiency.

Laparoscopic Pancreaticoduodenectomy after Laparoscopic Sleeve Gastrectomy in an Obese Patient with Pancreatic Tumor Hiroaki Omori, MD, PhD,! Akira Sasaki, MD, PhD,? Hiroyuki Nitta, MD, PhD,’ Takeshi Takahara, MD, PhD,’ Yasushi Hasegawa, MD, PhD,’ Go Wakabayashi, MD, PhD, FACS”. 1. Shizukuishi Omori Clinic, Shizukuishi Town, Japan; 2. Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan. Discussion: Diagnosis of PAEF is usually very difficult requiring a high amount of suspicion and carries a very high mortality rate. The classic triad of abdominal pain, gastrointestinal bleeding and pulsatile abdominal mass is present only in approximately 11% of patients. Many patients have a ‘herald’ bleeding followed hours, days or weeks later by catastrophic hemorrhage. CT with contrast is the most sensitive diagnostic test. In our patient, the diagnosis was probably missed initially when he complained of back pain in the first hospitalization and due to the fact that he never had screening for AAA. At the second hospitalization, PAEF was already formed and his hemodynamic instability precluded surgical repair. Conclusion: PAEF carries high mortality risk and must be kept in mind in patients with risk factors.

Wegener’s Granulomatosis and CMV: Two Rare Causes of Duodenitis, One Leading to the Othe Aaron Lewis, MD, Eric Lavery, MD, Brett Partridge, MD. Gastroenterology, Naval Medical Center, San Diego, San Diego, CA.

[1015A] Figure 1. Discussion: Splenic artery embolization has not been studied well in cases of SRS secondary to IM. The majority of the literature is on splenectomy in unstable patients or non-operative watchfulness in stable patients. This methodology preserves spleen and prevents the dreadful complication of over- whelming post splenectomy infection, risks of laparotomy and the consequent morbidity and mortality in apslenic patients.

Superior Mesenteric Vein Thrombosis in a Patient with Primary Protein S Deficiency Vijaya Rao, MD, Minh Nguyen, MD, Constance Pietrzak, MD, Jennifer Dorfmeister, MD. Loyo University Medical Center, Maywood, IL.

[1019] Low-grade follicular B cell lymphoma, jejunum. 1021

presentation calls for vigilance for this association in the setting of unexplained hypoprothrombinemi: and or B12 deficiency.

Purpose: Isolated superior mesenteric artery (SMA) dissection without associated aortic dissection is a rare occurrence. Clinical presentation varies from asymptomatic to acute mesenteric ischemia. While advances in radiologic imaging have enabled more frequent diagnosis, the pathophysiology of this phe- nomenon remains unclear. Due to the low prevalence of this disease process, no established treatment guidelines exist. Treatment modalities available include conservative management with surveillance imaging, anticoagulation, endovascular stenting and surgical revascularization. Herein we describe the case of a 65-year-old male with a history of hypertension, chronic pancreatitis, remote tobacco and alcohol abuse, diverticulosis, hemorrhoids status post banding who presented to the emergency depart- ment with abdominal pain and bright red blood per rectum. He was found to be hypotensive and tachy- cardic, which resolved after fluid resuscitation. His laboratory values were notable for a hemoglobin of 11.0 g/dL, creatinine of 1.24 mg/dL and a lactate of 0.66 mmol/L. Shortly after admission, his epigastric

[1026] Case descriptions with endoscopic and histopathological findings

{1031] Abdominal CT scan demonstrating small bowel intussusception. Purpose: A 47-year-old lady presented to the emergency room with abdominal pain associated with vom- iting and non-bloody diarrhea for 2 days. She was hemodynamically stable and her physical examination was unremarkable. A contrast-enhanced CT scan of the abdomen revealed numerous dilated fluid-filled small bowel loops with a small bowel intussusception in the right lower quadrant (Figure 1). She subse- quently underwent an exploratory laparotomy which showed a severely dilated bowel with a large segment of intussusception. On the proximal portion of the intussusception, there was a 3-cm intraluminal mass as well as large 5-cm mass at the distal end of the intussusception. There was an additional non-obstructing 2-cm mass in the distal small bowel. Frozen section of the mass was suggestive of malignant melanoma. The intussuscepted bowel was resected and a side-to-side anastomosis was performed. There was no other evidence of metastatic disease in the abdomen. The diagnosis of BRAF-positive small bowel melanoma was confirmed on subsequent examination of the resected specimen. The resected margins were tumor free and 3 out of 15 resected lymph nodes were involved by tumor spread. A detailed skin survey did not reveal any suspicious lesions to account for a primary site. Melanoma of the small intestine in the absence of an obvious skin lesion is a rare tumor and an unusual cause of intussusception in adults. In a large cohort of 84,836 cases of melanoma, approximately 2% had an unknown primary site. Whether primary small bowel melanoma is a separate entity is a matter of ongoing debate. Some authorities believe that all small bowel melanomas are metastatic from unknown or regressed primary cutaneous melanoma. The presence of a solitary lesion, the lack of distant metastasis, and a long disease-free survival after bowel resection all favor a diagnosis of primary small bowel melanoma. The small bowel is a common site for metastatic melanoma and these patients have a better prognosis compared to those with primary bowel melanoma. Management is aimed at wide local resection and adjuvant chemotherapy with close surveillance.

[1033] Cholecystectomy clip in duodenum. Purpose: Laparoscopic cholecystectomy with use of metallic surgical clips is a safe procedure with a less than 3% overall complication rate. We are reporting a rare case of migrated cholecystectomy clips into the duodenum associated with postbulbar stricture and ulcer. 68 year old female with history of cholecys- tectomy, metastatic colon cancer treated with right hemicolectomy, chemotherapy, and radiofrequency ablation of liver lesions. She was disease free for 5 years until a new right hepatic lobe lesion was discov- ered and treated with stereotactic radiation therapy with incomplete success. A year later, she presented with obstructive jaundice from malignant biliary stricture which was treated with a metal stent. Recently, she presented with acute cholangitis and gastric outlet obstruction. EGD showed an intrinsic postbulbar duodenal stricture requiring balloon dilation to 15 mm. There were no complications post dilation and cholangitis was treated with stenting. Progressive duodenal stricture lead to repeat endoscopic evaluation showing the postbulbar stricture and a deep ulcer with metallic clips seen at the ulcer base. Simultaneous fluoroscopic imaging confirmed that these were cystic duct clips eroding into the duodenum. This was also confirmed with CT scan. Many clip-associated complications, such as biliary leaks, clip migration into the common bile duct, and clip embolism have been reported. Migration of endo-surgical clips into the duodenum is a rare complication, previously reported in only five cases. In all the reported cases, an ulcer was present as in our case. Additionally, the ulcer was large and bleeding, and endoscopic or surgical treatment was required. Our case is the first report of migrated cholecystectomy clips into the duodenum to be associated with stricture and previous radiation. Proposed mechnisms: 1. the base of the

Purpose: A 75-year-old female was admitted with crampy abdominal pain and non-bloody diarrhea lasting 5 days. Medical history included metastatic renal cell carcinoma status post nephrectomy, cur- rently receiving sunitinib, chronic kidney disease, pulmonary embolism on warfarin and laparoscopic gastric banding four years ago. Upon evaluation she was afebrile, hemodynamically stable with perium- bilical tenderness on deep palpation. Lab work showed acute kidney injury and normal white cell count. Enhanced computed tomography (CT) scan of the abdomen confirmed retroperitoneal fat infiltration surrounding a proximal jejunal diverticulum consistent with jejunal diverticulitis. The diverticulum contained fecalized material suggestive of a bezoar. Treatment with metronidazole and ciprofloxacin resulted in rapid improvement of abdominal pain and diarrhea; the patient was discharged home with a three-week course of antibiotics. Follow-up CT showed complete resolution of diverticulitis. Small bowel diverticulosis is an uncommon disease occurring in 2-8% of the general population. Diverticula are more common in the jejunum than ileum, presumably due to the larger vasa recta of the jejunum. Jejunal diverticula also tend to have a larger diameter than distal diverticular disease and can be up to 10 cm. Most patients are asymptomatic and are diagnosed incidentally. When symptoms do occur, they are nonspecific and include abdominal pain, diarrhea and bloating. Barium enhanced upper GI studies can be helpful in detection, though CT scan can provide a definitive diagnosis and rule out other etiologies in the acute setting. Complications include obstruction, small intestinal bacterial overgrowth, perforation and abscess. Diverticulitis occurs in less than 3% of patients and management depends on the clini- cal presentation. Medical management with antibiotics is appropriate for uncomplicated diverticulitis. However, surgical treatment is needed for complications or refractory symptoms. Clinical awareness and a high index of suspicion are required for early detection due to the high mortality rate (up to 24%) associated with this clinical entity. Varun Gaur, MD,' Mazen Albeldawi, MD,’ Luke Weber, MD”. 1. Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH; 2. Cleveland Clinic Gastroenterology, Cleveland, OH.

ee eae ee nee ee ee N NNE EEE EEN SOE PD IOI IIS DLE OIE NE ONO Raji Shameem, MD, Niket Sonpal, MD, Benyam Alemu, MD, Ladan Ahmadi, MD. Lenox Hill Hospital, Dix Hills, NY. [1035A] Stomach biopsy.

questioning it was found that the patient was started on olmesartan 20 mg daily in 2008 for HTN. The dose was subsequently increased to 40 mg daily for better BP control, confirmed by his PCP. Patient began experiencing symptoms in March, 2009. A recent case series from the Mayo clinic describes 22 patients with symptoms of chronic diarrhea and weight loss who reported marked clinical improve- ment after stopping olmesartan. Review of small bowel biopsy slides showed, partial villous blunting and increased intraepithelial lymphocytes that were similar to the reported histological findings in the Mayo case series. Olmesartan was held indefinitely and he was discharged home. Telephone follow-up 4 weeks after discharge confirmed complete resolution of diarrhea, improvement in appetite and 15-Ib weight gain. He is scheduled for a repeat endoscopy with biopsies to establish histological response. This case sheds light on a new entity of olmesartan induced enteropathy and provide an impetus for further studies and research in this field.

1040 [1038B] Images showing petechial hemorrhaging of small bowel with no ischemia.

[1038A] Small bowel circumferential wall thickening and edema.

Introduction: Rivaroxaban, an oral direct factor Xa inhibitor, is being increasingly used for stroke pro- phylaxis in patients with atrial fibrillation and as prophylaxis/treatment for venous thromboembolism. It is an attractive option as it does not require monitoring, however, it has been linked to higher rates of major and minor gastrointestinal bleeding compared to traditional anticoagulants. Currently there

{1041] Image 1. Retroperitoneal mass on endoscopic ultrasound.

brie Sa _s Discussion: Enterogenous cysts are a rare anomaly. The most widely accepted explanation for cyst for- mation is that duplication of the gut occurs due to pinching off of a diverticulum during embryological development. Symptoms most commonly present between the ages of 6 months to 2 years. Gastrointes- or = tinal bleeding is more common with enterogenous cysts that communicate with the bowel lumen and are lined with gastric mucosa. Bleeding is caused by peptic ulceration within the cyst or adjacent bowel secondary to acid secretion by ectopic gastric mucosa that may line the cyst. Rarely, enterogenous cysts may cause intussusception when lead points are retracted into the distal bowel. As such, CT is recom- mended as the major diagnostic tool for identification of lesions. Treatment of choice is resection of the lead point with adjacent small intestine.

[1050] Figure 1. CT of the patient's spine showing metastases (arrow is pointing to T10).

Fig 1c and d- Strong immunoreactivity for Chromogranin A of carcinoid tumor Figia-CT abdomen showing cecal mass Fig 1b-Invasive adenocarcinoma with desmoplasia

-urpose: A 49-year-old white female with history of sarcoidosis was referred to GI when her liver wa: 10ted to be nodular during laparoscopy for an ovarian cyst. She denied fatigue, hematemesis, abdomina' listension and pain, ankle swelling, itching, yellow discoloration of skin and eyes and episodes of confu- ion or sleepiness. She denied alcohol abuse. Physical examination revealed normal VS and no icterus pider nevi, clubbing, ascites, hepatosplenomegaly or edema. LFTs revealed mild elevation in alkaline yhosphatase and PT was slightly prolonged. CBC showed mild thrombocytopenia. Hepatitis serologies \NA, AMA, ASMA, Ferritin, Ceruloplasmin, and al-AT level were unremarkable. A liver biopsy con- irmed cirrhosis. Biopsy did not show any granulomas, but showed sinusoidal dilatation, which promptec _ referral to cardiology. ECHO showed enlarged IVC and was otherwise unremarkable. A left and righ 1eart catheterization was done. LHC showed normal coronaries, and RHC showed RAP 12 mm Hg -AP 32/15 (mean 21) mm Hg, PAWP 18 mm Hg, LVEDP 18 mm Hg and CO 5.2 |/min. She developec vorsening shortness of breath and was referred to pulmonology here. PFTs showed mild restriction, bu °XR was unrevealing. CTPA ruled out PE and showed scattered pericardial calcification. Bubble ECHC lid not show a right to left shunt. She developed SVT and was hospitalized here. She underwent a repea eft and right heart catheterization: RAP was 25 mm Hg, PAP 52/25 (mean 37) mm Hg, PAWP 32 mm 1g, LVEDP 36 mm Hg, and CO 4.12 l/min. Simultaneous measurement of left and right sided pressures onfirmed constrictive pericarditis. In retrospect, the cirrhosis is “cardiac” cirrhosis and the result o ong-standing elevated right sided heart pressures. Similarly, her dyspnea on exertion can be explainec vy constrictive pericarditis. We believe that constrictive pericarditis resulted from Sarcoidosis. She is nov yeing evaluated for pericardiectomy. Clinical pearls: 1.) A cardiac etiology should be considered in the

Introduction: Hepatogastric fistulalHGF) is a rare but serious complication of Transcatheter arterial embolization [TAE ] of hepatic artery for hepatocellular carcinoma. We present a case of

[1073] Table 1. Laboratory findings Purpose: A 36-year-old Caucasian male without prior medical history initially presented to another facility with one week of right upper quadrant (RUQ) abdominal pain, jaundice and fatigue. After abnor- mal lab values (Table 1) were found, he left that facility and presented to this hospital. He admitted to weekend binge drinking and drank 10 beers three hours prior to symptom onset. He denied taking herbal remedies, homeopathic medications or other supplements. He drank up to three energy drinks (Figure 1) on a daily basis for the past year. Physical exam showed stable vital signs, jaundice, spider nevi and RUQ tenderness. Initial work-up was negative for viral, ischemic or autoimmune hepatitis. On HD #6,

[1070] Liver biopsy showing portal inflammation with bile duct injury, pericholangitis, and kupffer cell and histiocyte hypertrophy with occasional erythrophagocytosis.

Acute Liver Failure Following a Year of Consumption of a Popular Sugar-free Energy Drink Brian Huang, MD,’ David Kunkel, MD,' Mohamed El Kabany, MD’. 1. David Geffin School of Medicine University of California Los Angeles (UCLA) Medical Center, Los Angeles, CA; 2. Pfleger Liver Institute, UCLA Medical Center, Los Angeles, CA; 3. Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA. as bleeding, viscus perforation and metabolic disturbances. We present a rare complication of thera- peutic paracentesis: immediate post-procedure incarcerated umbilical hernia. A 57-year-old woman with alcoholic cirrhosis (Child’s classification B) was admitted to ambulatory surgery unit for an elective paracentesis. She had massive ascites and a 6-cm umbilical hernia filled with fluid. Seven liters of clear, straw-colored fluid were removed with a 14-gauge needle, and this appeared to be a total paracentesis. She was given 50 grams of salt-poor albumin and prepped for discharge. After standing and dressing for discharge, the patient developed abdominal pain and distension. On examination, it was obvious that she had gas-filled bowel loops in a hernia that could not be reduced (figure). Abdomen was tympanic, con- sistent with bowel obstruction. Surgical consult was obtained and she underwent reduction and repair of the umbilical hernia, which she tolerated well. Elective repair of umbilical hernias in patients with cirrhosis is usually frowned upon, as hernia recurrence is common unless the ascites can be controlled with diuretics. In addition, this patient group is generally a poor surgical risk due to infection, bleeding and poor wound healing. However, there was not an option in this case, as the hernia presented acutely. Incarceration can occur due to a decrease in tension in the umbilical ring following large volume para- centesis. It may be reasonable to consider TIPS in patients with a significant umbilical hernia whose ascites cannot be controlled with diuretics and whose hernia size runs a risk of incarceration. At the very least, clinicians should be aware of this complication and evaluate patients complaining of pain and distention after paracentesis to rule out this life-threatening condition and be prepared to act quickly to avoid poor outcomes in this compromised group of patients.

Acute Liver rallure with Mepatitis & and Epstein-barr Virus Coinfection Joshua Peck, MD,' Lana Alghothani, MD, Steven Campbell, MD,’ John Davis, MD, PhD,? James Hanje, MD». 1. The Ohio State University Wexner Medical Center/Nationwide Children’s Hospital, Columbus, OH; 2. The Ohio State University Wexner Medical Center, Columbus, OH. Discussion: Type 2 diabetes mellitus, hyperlipidemia, and obesity are recognized risk factors for NAFLD. NAELD is now considered a hepatic component of the metabolic syndrome. Variceal bleeding as a first manifestation of NAFLD-Cirrhosis is rare, but associated with high mortality. Patients with variceal bleeding require betablockers and frequent surveillance endoscopy, along with modulating the risk fac- tors, such as weight reduction, glycemic and hyperlipidemic control, and avoiding hepatotoxic agents.

Discussion: Hepatic infarcts following hepatic artery compromise are very rare because of the dual blood supply from the portal vein and the hepatic artery, along with the extensive hepatic arterial collateral sys- tem. The vast majority of cases of hepatic artery thrombosis are reported as complications of orthotopic liver transplantation; it also complicates various procedures, such as placement of hepatic catheters/Port

{1076] Bladder varices on CT abdomen/pelvis (red arrow). Discussion: This case demonstrates an uncommon etiology of symptomatic anemia and gross hematuria from urinary bladder varices due to portal hypertension. Indeed, reports of bleeding bladder varices appear in only a handful of cases in the literature. Ectopic varices are portosystemic shunts that can occur anywhere in the GI tract. Intra-abdominal surgery with subsequent adhesions can impede the normal port-systemic anatomy, forming unusual collateral routes. This is the purported mechanism of bladder variceal formation, which is consistent with the patient’s history of appendectomy. Treatment of ectopic varices depends on the clinical scenario, but can range from variceal embolization to beta blockade. With a patent portal vein, TIPS can successfully control bleeding via portal decompression, as was performed in this case. In any patient with portal hypertension, it is important to consider the possibility of ectopic varices in the presence of unexplained visceral bleeding.

AST: Aspartate aminotransferase ALT: Alanine aminotransferase ALP: Alkaline phosphatase GGT: Gamma glutamil transferase LDH: Lactate dehydrogenase.

Discussion: Iron overdose causes rapid onset multi-organ failure with high mortality. Iron-induced oxida- tive damage results from hepatocyte exposure to high quantities of non-transferrin bound iron via the portal venous system, resulting in excessive free radical production. Peak serum iron levels occur 4-6 hours after ingestion. Bowel irrigation is indicated if tablets are identified on KUB. IV deferoxamine should be admin- istered early if systemic signs such as metabolic acidosis are present. NAC can be given empirically. AKI is thought to be from direct mitochondrial injury and lactic acidosis. In case B, survival may, in part, have been due to the history of gastric bypass surgery, which may have limited absorption. These patients were enrolled in the Acute Liver Failure Study Group registry, supported by U-01-58369-014 from NIDDK. Discussion: Non-traumatic splenic rupture (NSR) is a rare, but life threatening condition. Diagnosis is often suspected based on clinical symptoms. Paracentesis with aspiration of fresh blood is useful to diagnose intraperitoneal hemorrhage. Abdominal ultrasound is especially useful in hemodynamically unstable patients. CT can shows grade of splenic damage severity and intraperitoneal free fluid. In a review of 845 cases of NSR, the spleen was normal in 7%. The major pathologic etiological groups were neoplastic (30%), infectious (27%), and inflammatory (20%). In our patient, we ascribed the splenic rupture to congestion resulting from steatohepatitis. This patient had patent portal and splenic vein, ruling out congestion due to thrombosis. This is a unique case for rarity of atraumatic splenic rupture as presenting manifestation of steatohepatitis with early changes of bridging fibrosis.

{1085] Figure 1. A) CT Abdomen with mass in the RLQ. B) Polygonal crystals with “fish scale” appearance.

[1091] Table 1. Laboratory data on hospital admission One Train Can Hide Another: Ascites in a Cirrhotic Patient Kawtar Alkhalloufi, MD, Juan Blum Guzman, MD, Edula Raja, MD, Zahid Vahora, MD, Hicham Khallafi, MD, Kamran Qureshi, MD. Florida Hospital, Orlando, FL. Purpose: Although there are several reported cases of niacin-induced hepatotoxicity, niacin-induced cholestatic hepatitis (CH) is very rarely reported in the medical literature. We report a case of niacin- induced CH in a patient with liver cirrhosis. A 61-year-old man with CAD, hyperlipidemia, prostate cancer and status-post prostatectomy was referred for abnormal liver function tests (LFTs). He had thrombocytopenia, which was incidentally found during the preoperative work-up of an elective her- nia repair. Home medications included omeprazole, aspirin, clopidogrel, metoprolol and niacin. He wa: taking niacin-SR 2 gm daily for approximately 6 months. He denied history of alcohol abuse. Physical examination was remarkable for jaundice, ascites and mild pitting edema of legs. Lab data is shown in the table. Patient was admitted to the hospital for further work-up of the progressively worsening LFTs. Niacin was held for severe hepatitis. MRI of the abdomen showed small nodular liver, moderate ascites and a distended gallbladder with multiple gall stones. HBsAg, Hep C antibody and Hep A IgM anti- body were non-reactive. Serological work up for hemochromatosis (including gene mutation analysis). autoimmune hepatitis and Wilson's disease were negative. Tumor markers including serum alpha-fetc protein, serum carcinoembryogenic antigen and serum prostate specific antigen levels were non-signifi- cant. Liver biopsy showed moderate-severe chronic active hepatitis, bridging fibrosis without evidence of malignancy. Liver enzymes gradually trended down with conservative management after stopping niacin. Niacin was not initially suspected as the cause of this decompensation due to the primary cho- lestatic profile. However, it was later attributed to niacin as he developed CH during treatment with the drug; he improved immediately after stopping the drug, while other potential causes were ruled out. Tc our knowledge, there is only one reported case of niacin-induced CH (Patel SD et al., 1994). Clinicians should be aware of this rare association of niacin with CH; cirrhotic patients may be more vulnerable.

Discussion: The relationship between MGN and AIH is unclear. Although typically idiopathic, MGN can be associated with autoimmune conditions. The causative agent in this particular case could be the deposi- tion of immune complexes due to active AIH, which can disrupt the basement membrane in renal glom- eruli. Particularly interesting is that although management of secondary MGN is to treat the underlying process, our patient’s proteinuria persisted, despite near resolution of hepatocellular inflammation.

{1103] Arrow indicates gallstone within an intrahepatic abscess. with conservative therapy, and emergent transplant was not necessary. Direct evidence for suppressive antibiotic therapy does not exist, but given the uneven, porous surface of gallstones and the experience with retained renal stones, it is reasonable to continue antibiotics in such cases.

[1106] H &E staining of liver biopsy showing accumulation of glycogen in hepatocytes.

{1116A] Figure 1. Histology reveals cholestatic hepatic tissue with a subtle infiltration by deeply pigmented, hepatoid cells which clearly mark as melanocytes. there have only been a few cases reported in the literature with metastatic melanoma of unknown origin initially presenting as fulminant hepatic failure.

Don’t Oversee It When It Happens with HCV: A Case of HCV-induced Porphyria Cutanea Tarda Raphael Quansah, MD, Sarmad Said, MD, Jorge Bizet, MD, Richard Guerrero, MD. Internal Medicine, Texas Tech Health Science Center, El Paso, TX.

Purpose: A 55-year-old morbidly obese male patient who is status post gastric bypass surgery and liver cirrhosis secondary to non-alcoholic steatohepatitis (NASH) was admitted to the hospital in the set- ting of upper gastrointestinal (GI) bleed. Endoscopic evaluation revealed that the cause of the bleeding was related to dehiscence of the staple line of a previous gastric bypass surgery, with associated friable mucosa. Patient was treated medically, and his GI bleeding stopped. Over the course of the next few days, the patient became encephalopathic, requiring intubation. This was thought to be due to a combination of renal failure and sepsis, as the patient’s blood cultures were positive for coagulase-negative Staphylo- coccus. Despite treatment with the appropriate antibiotics, lactulose, rifaximin, and the resolution of the patient’s renal failure, his mental status failed to improve. An MRI of the brain was significant for evi- dence of posterior reversible encephalopathy syndrome (PRES). Supportive care was continued, and the patient was discharged to a long-term care facility, where his symptoms slowly improved over the course of the next few months. PRES is seen in patients after liver transplantation, often as a result of the use of calcineurin inhibitors, and is seen in patients with elevated blood pressures and renal failure. Failure of encephalopathy resolution in patients with liver cirrhosis after reversal of possible precipitating factors should prompt consideration of less common factors that can result in an altered mental status. Ruptured Hepatocellular Carcinoma of Caudate Lobe Causing Hematoma of Lesser Sac and Hemoperitoneum Yezaz Ghouri, MD, Katherine Jelinek, MD, FACG, Victor Machicao, MD, FACG. Internal Medicine University of Texas Health Science Center at Houston, Houston, TX.

{1122] Figure 1. CT abdomen with contrast showing cirrhotic liver with heteroge- neously enhancing 3.1cm ruptured lesion within the caudate lobe with hematoma of the lesser sac. Discussion: Spontaneous rupture of HCC is associated with a high inpatient mortality of 25-75%. Hema- toma of lesser sac as a consequence of a ruptured HCC with hemoperitoneum is a relatively rare presen- tation. Surgical resection of tumor is associated with higher risk of complications, especially in patient: with concomitant cirrhosis. Radiofrequency ablation is technically difficult, due to the deep location o: the tumor. TACE is the preferred loco-regional approach for tumor in caudate lobe, with good rate o: success in controlling bleeding.

{1131] Figure 1. Liver histology, hematoxylin and eosin stain. A. Infiltration of a portal tract with predominantly eosinophils. B. High power view demonstrating ballooning changé and eosinophilic infiltrate. C. Submassive hepatic necrosis. D. High power view of adjacent preserved liver with eosinophilic infiltrate. Introduction: Clinicians have become increasingly reliant on imaging studies to make diagnoses. Despit improved sensitivity of these imaging modalities, some diagnoses cannot be made without biopsy Purpose: Data on the adverse event profiles of the incretin-based hypoglycemic agents are limited. We present the first case of drug-induced liver injury (DILI) secondary to the glucagon-like peptide 1 (GLP-1) agonist liraglutide. Case: A 29-year-old woman with type 2 diabetes and vitiligo presented with 10 days of nausea, emesis, and acnte henattic Other than starting lirachitide 1:7 mo daily faur manthe nrine the nathient rennrted no

fiepatomesaly Evaluated intra-Operativery at Darliatric oUrsery Ekta Gupta, MD, Farzin Rashti, MD, Won Cho, MD, Timothy Shope, MD, Timothy Koch, MD. Washington Hospital Center/ Georgetown University, Washington, DC. anemia (8.9 g/dl), thrombocytopenia (92/micl), prolonged prothrombin time/INR (17.9 sec/1.5), and low albumin (1.8 g/dl). Emergent EGD showed large esophageal varices with red whale sign, Mallory- Weiss tear, gastric varices, and cardiac ulcer with visible vessel and oozing blood. The oozing ulcer was treated with epinephrine injection and clip hemostasis. Six esophageal bands were placed. CT abdomen showed minimal ascites and mild right-sided pleural effusion. Following another episode of hemateme- sis, he became hemodynamically unstable, and required aggressive resuscitation with intravenous fluids, packed RBCs, and cryoprecipitate. Afterwards, he had no further overt GI bleeding, with improvement in his vital signs, but six hours later, he had tachypnea, tachycardia, and hypoxia, requiring high-flow oxygen (50% oxygen, 10 L/min). Chest X-ray showed a tension right-sided hydrothorax, and arterial blood gas revealed acute hypoxic respiratory failure. Thoracentesis drained 2.1 L of transudative fluids, and his vitals improved. CT thorax showed hydrothorax, minimal ascites, and no pericardial effusion. He was restarted on spironolactone and furosemide, with significant reduction in his hydrothorax. In the setting of gastric varices, esophageal varices, significant upper gastrointestinal bleeding, and hepatic hydrothorax, he was offered evaluation for TIPS but refused, and was discharged on diuretics. Hepatic hydrothorax develops due to the passage of ascitic fluid from the peritoneal cavity to the pleural space through diaphragmatic defects. This is driven by the hydrostatic gradient of negative intrathoracic pres- sure, along with the positive intraabdominal pressure, producing a unidirectional flow of ascitic fluid into the pleural space. We believe that clinicians should be aware of the possibility of developing tension hepatic hydrothorax following aggressive resuscitation with IV fluids and blood products in cirrhotic patients, especially if it is associated with severe hypoalbuminemia.

Hepatic parenchyma with non-necrotizing epithelioid cell granuloma (hematoxylin-eosin, original magnification x400).

Glatiramer acetate (copolymer 1) is an immunomodulator-approved for treatment of relapsing-remitting MS (RRMS) with no known hepatotoxic effects, unlike the interferon beta preparations. We report a case of severe acute hepatitis after commencing treatment for multiple sclerosis with glatiramer acetate. A 31-year-old female with multiple sclerosis presented with anorexia, lethargy, and jaundice, five weeks after commencing glatiramer acetate. She had never received beta-interferon treatment. Investigations revealed a bilirubin of 1.2 mg/dl AST of 879 u/L, ALT of 1215 u/L. Her liver function tests were normal before commencing glatiramer acetate. A liver biopsy performed approximately six weeks after com- mencement of glatiramer acetate showed marked centrilobular congestion and hemorrhage with hemo- siderin laden macrophages. Mild periportal chronic inflammatory infiltrate with scattered eosinophils.

The features were not suggestive of autoimmune hepatitis, but were consistent with drug toxicity. The liver tests returned to normal within a month of cessation of glatiramer acetate. Adverse reactions should be considered in patients with liver injury and on glatiramer therapy. Mainstay therapy would be stop- ping the medication. Consideration should be given to monitoring liver function tests during long-term glatiramer therapy. Diagnosis rests on the identification of temporal association between drug and liver injury, and exclusion of other conditions.

Hepatic encephalopathy is rare in the absence of acute liver failure, cirrhosis, or collateral portosystemic shunting. We present a case of hyperammonemic encephalopathy in the setting of diffuse liver metasta- sis. Our case involves a 56-year-old man with metastatic islet cell pancreatic carcinoma. He was admitted for acute confusion and altered sleep pattern. He had no exposures to benzodiazepines, narcotics, 01 recent gastrointestinal bleeding. Physical examination did not reveal any signs of cirrhosis, infectious processes, or neurologic deficits. Laboratory work-up was negative for both infectious and metabolic causes. Ammonia level was elevated at 174 umol/L. The rest of the liver panel shows aspartate transami- nase of 51 U/L, alanine transaminase of 32 U/L. The alkaline phosphatase was elevated at 362 U/L, with normal bilirubin of 0.9 mg/dL. The INR and albumin were also within normal range. CT scan of the hea¢ showed no acute intracranial pathology. Multiple liver metastases were noted on CT scan (Figure 1) and confirmed by biopsy and octreotide scan. He was started on lactulose, but continues to have intermit- tent hepatic encephalopathy. He is currently being evaluated for hepatic artery embolization to reduce the tumor burden in the liver. In our literature search using PubMed, Web of Science, and Scopus, there are only seven reported cases of hyperammonemic encephalopathy in the setting of metastatic neuro- endocrine. Microvascular portosystemic shunting has been proposed as the underlying mechanism that contributes to hyperammonemic encephalopathy. Hepatic artery embolization has been shown to be an

{1154B] MRCP: enhanced ill-defined liver mass.

{1154A] CT scan: intrahepatic biliary dilation, no hilar mass. Discussion: Cholangiocarcinoma, histologically classified as adenocarcinoma, appears as bile duct thickening or biliary dilation on CT scan. On MRI, malignant tissue appears hypointense, as compared to liver parenchyma on T1 images and hyperintense on T2 images.

Discussion: PHE in patients with cirrhosis can cause significant morbidity and mortality due to gastroin- testinal bleeding. Capsule endoscopy may be a useful diagnostic tool if endoscopic findings correlate with disease severity. Additional studies are needed. Treatment options are limited, and include beta blockade, octreotide, or APC of accessible lesions. Liver transplantation can be curative, and severe cases may war- rant consideration for MELD exception points in patients awaiting liver transplantation. Purpose: The prevalence of acute liver failure is increasing, and acetaminophen is still the leading cause in the West, generating the highest risk of developing cerebral edema. Only around 53% of patients

[1173A] Figure 1. Coronary angiogram showing normal coronary arteries.

[1173B] Figure 2. T2 weighted MRI of bilateral hips showing area of enhancemen' showing avascular necrosis of left hip.

{1180] Thorotrast-induced enhancement of spleen. Ascites also present. Purpose: We present the case of an 83-year-old female who presented with recurrent ascites and chronic liver disease of uncertain etiology. Paracentesis revealed fluid with a SAAG >1.1, suggestive of portal hypertension. Liver work-up, including autoimmune labs, viral hepatitis serologies, and iron studies, were unremarkable. Additional lab work was significant for thrombocytopenia and a normal CEA. Medical history was negative for alcohol abuse, diabetes, and obesity. Liver ultrasound with Doppler was normal, with no evidence of thrombosis, focal intrahepatic abnormalities, or biliary duct dilatation. CT of the abdomen with contrast demonstrated a cirrhotic-appearing liver along with prominent, con- trast-enhancing high density material within the spleen and peripancreatic lymph nodes. Transjugular liver biopsy demonstrated periportal fibrosis, along with focal granular foreign body material. Upon further inquiry, it was elucidated that the patient had received Thorotrast for imaging of a cirosoidal aneurysm in the 1950s. Thorotrast, a radioactive suspension containing thorium dioxide, was used as a contrast agent in the United States up until the late 1950s. Thorotrast offered high image quality and, at that time, no immediate side effects were noted. As was the case in our patient, it was primarly used for cerebral angiography. Worldwide, approximately 100,000 people were exposed to Thorotrast from 1930 to 1964. Subsequently, it was discovered that Thorotrast induced liver disease and tumors decades after its use. Our case is unique in that Thorotrast-induced chronic liver disease is seldom seen in modern-day clinical practice.

Conclusion: Visceral artery aneurysms carry a high mortality rate if not readily diagnosed and treated. Most of them are due to atherosclerosis, and their association with vasculitis is rare. In our literature search, this is the first reported case of such aneurysms in SS. Furpose: ihe current treatment algorithm OF iC V involves the use oF three medications targeting the viruses’ replicative mechanisms. Several alternatives, such as milk thistle, ginseng, and colloidal silver; however, no evidence exists to support that these alternative therapies have any effect on the virus. Furthermore, many clinics outside the U.S. prey upon desperate, infected individuals, promising cures and regenerative therapy for hepatic pathology; one such clinic is Regenerative Cellular Therapy, located in Mexico. Though it is possible that the research being done at these institutions has potential for posi- tive clinical implications, the side effects of unmonitored and unsanctioned treatments can lead to severe consequences. We present a patient who had alternative HCV treatment abroad, that succumbed to overwhelming sepsis and disseminated intravascular coagulation (DIC). A 66-year-old female with a history of leukemia and splenectomy presented to the emergency room with altered mental status, diar- rhea, and abdominal pain that began the day prior to admission. On arrival, the patient was severely obtunded and in respiratory distress, and was immediately intubated. A family friend stated she had been injecting herself with an unknown substance she received from a clinic in Mexico for her HCV and cirrhosis. She had no recent sick contacts, and was feeling well until her recent trip from Mexico. On exam, the patient was hypotensive (70/35), tachycardia (122), and saturating well on the ventilator. Her skin was mottled with non-blanching purpuric skin lesions throughout her thorax and extremi- ties. Labs demonstrated a lactic acid of 20, AST/ALT ratio of 162/235, with an alkaline phosphatase of 134 and bilirubin of 1.4. The patient was also in frank renal failure with BUN/Cr ratio of 34/2.9. Her coagulation times had no endpoint detected. A chest x-ray showed no abnormalities. Despite aggressive hemodynamic resuscitative efforts, including vasopressors and antibiotic therapy, the patient expired from overwhelming septic shock and DIC. Her blood cultures eventually grew Streptococcus pneumonia. This case demonstrates the inherent dangers of alternative HCV treatments. This patient self-injected unknown vials of “medications” which may not have been rigorously cleaned or checked for infectious properties. The timing of her presentation and return from Mexico implicate the injectable as a possible source of the Streptococcus pneumonia. That, coupled with her inherent immunocompromised state from her splenectomy, created the perfect storm for septic shock due to encapsulated organisms. We recom- mend patients should be educated on the dangers of treatments not approved by the FDA for hepatitis C and other chronic illnesses. Discussion: Visceral artery aneurysms are usually associated with atherosclerosis, but can also occur with mycotic infections and vasculitis. They have a high mortality rate of 21%, and rupture is most often the initial presentation. The classic triad consists of abdominal pain, jaundice, and gastro-intestinal hem- orrhage. Arteriography is the gold standard for diagnosis, and the treatment is either surgical or endo- vascular repair. Our patient had SS, which is known to cause small and medium vessel vasculitis. She also had a remote history of intra-cranial bleed due to aneurysmal rupture, which has been reported in SS. Of note, she did not have any abdominal artery aneurysm, which is expected in a patient with atherosclero- sis, but not with SS. Hence, we believe that she had these aneurysms secondary to her SS.

[1183] Direct portal venography during TIPS demonstrates hepatofugal flow in the SMV with a dense network of duodenal varices (arrow). PV-portal vein, GV-gonadal vein. Conclusion: Portosystemic shunting can occur in unusual locations, leading to atypical location of varices and hemorrhaging in the cirrhotic with high morbidity and mortality, if not quickly identified. While no guidelines exist on management of these varices, treatment ultimately requires a multidisci- plinary approach.

[1188A] Incomplete septal fibrosis. requiring transplantation. Liver biopsy remains the gold standard in diagnosing NCPH and in identify: ing typical vascular and architectural changes of NCPH.

[1198] Table 1. Peritoneal cultures with intraperitoneal and intravenous antibiotic therapy 1200

arteriography showed hepatic vein pressure gradient of 3 mmHg and hepatic arterial to portal vein shunt- ing (B). Liver biopsy was notable for focal sinusoidal dilatation, unremarkable bile ducts, portal tracts, and hepatocytes, with no fibrosis. Prior imaging showed normal hepatic anatomy (2/2012, 6/2012) and fatty infiltration of the liver without vascular abnormalities (11/2012). The occurrence of APF with pre- sinusoidal portal hypertension and the temporal relationship with chemotherapy led to the final diagno- sis of NCPH from CI-APF. Several cases of NCPH in patients undergoing chemotherapy for metastatic colorectal cancer have been reported. It is believed that severe hepatic injury from chemotherapy results in benign transformation of the hepatic parenchyma into nodular regenerative hyperplasia (NRH). In our case, the presence of pre-sinusoidal portal hypertension is more supportive of obliterative portal venopa- thy leading to APF, rather than NRH. Shunt reduction with minimally invasive techniques such as trans- catheter hepatic artery embolization have been successfully performed without severe complications. Mustafa Nawaz, DO,' Fares Hamad, DO,' Faizan Khan, DO,' Rizwan Jafri, DO,’ Yameen Rashid, DO,' John Kniaz, DO, FACG?. 1. St. James Hospital, Olympia Fields, IL; 2. St. Margaret Mercy, Dyer, IN.

[1209A] Endoscopic view of toothpick embedded in antrum. Purpose: A 46-year-old male presented on an outpatient basis for upper gastrointestinal endoscopy and endoscopic ultrasound after being diagnosed with elevated liver enzymes, unexplained weight loss, and a mildly dilated pancreatic duct on an outpatient CT of the abdomen and pelvis. His liver function tests were unavailable to us at the time, but pre-procedural labs showed an AST of 71 U/L (high normal 59) and an ALT of 115 U/L (high normal 72), with normal total bilirubin and alkaline phosphatase. Dur- ing upper gastrointestinal endoscopy, a wooden object was seen embedded into the medial aspect of the antrum, thought to be a toothpick. Endoscopic ultrasound revealed a sharp tip to the object with its tip exiting the stomach and invading the liver. Laparoscopic surgery was performed which clearly showed the sharp end of a toothpick penetrating the liver, and upon removal, the liver bed began to bleed profusely, which was stopped using Surgicel. The antral perforation was also sealed using Evicel. Upon further questioning during the workup, the patient did remember accidentally swallowing a toothpick a few weeks prior. Of note, there were no other abnormalities on endoscopic ultrasound other than the presence of the toothpick.

{1209B] Endoscopic ultrasound showing toothpick penetrating the liver.

[1209C] Laparoscopic view of toothpick exiting stomach with laparoscopic forcep covering the liver puncture site. An Unusual Cystic Mass of the Liver 1210

{1210] Different treatment time points and changes to tacrolimus dose. [1210] Laboratory tests and virological responses

[1214] Primary hepatic leiomyosarcoma: 32 x 23 x 13.5 cm specimen. mass in the epigastric area, and +3 lower extremity edema. He had anemia (9.9 g/dL) and abnormal liver function tests. Radiologic imaging revealed a 17-cm complex mass in the right lobe of the liver. A liver biopsy was performed. Immunohistochemistry revealed tumor cells reactive for smooth muscle actin and desmin, which was consistent with high-grade leiomyosarcoma. He underwent right hepatic lobec- tomy via a thoracoabdominal approach. A 32 x 23 x 13.5 cm hemihepatectomy specimen was resected with portions of adherent diaphragm, leaving the diaphragmatic margin free of involvement. The patient subsequently received chemotherapy with Ifosfamide and mesna for residual tumor, which was well tol- erated. The patient is doing relatively well 24 months after tumor resection, with no recurrence to date. This rare case of PHL is one of 30 cases reported in the English literature. Prognosis is influenced by the ability to resect the tumor completely. Liver transplantation (OLT) in such patients was accompanied by early high recurrence with poor outcomes after 1 year. In our patient, a good outcome was obtained with resection and chemotherapy, despite having advanced disease. International multi-registry efforts need to be established to assess the most effective therapeutic modalities for PHL.

{1219A] Thickening in the ascending colon. Discussion: S. Mississippi makes up 0.9% of U.S. Salmonella infections, typically limited to the Eastern US. S. Mississippi is commonly reported in Tasmania, Australia, with an annual rate of 17/100,000 peo- ple. Indirect contact with native birds, untreated drinking water and travel within the state are predictors for the disease. On average, the illness lasts for 6 days and 68% of those infected experience >11 bouts of diarrhea per day. No reports of colonic masses with salmonellosis exist. Investigation is needed to deter- mine whether a colonic mass is a possible manifestation specific to S. Mississippi or if it is an incidental finding overlooked in many Salmonella infections.

[1220] CT of the abdomen and pelvis showed an IUD (red arrow) and a 4.7 x 1.4.cm hypodensity with fluid attenuation (blue arrow). —————— Case Report: A 50-year-old woman presented for a routine colonoscopy to screen for colon cancer. She had not disclosed a medical history of menstrual cramping and menometrorrhagia, for which an intra- uterine device (IUD) was placed two years prior. Colonoscopy revealed a sessile tubular adenoma in the ascending colon, which was removed via cold biopsy forceps. Three hours post-colonoscopy, she devel- oped lower abdominal pain that progressed to fevers. Upon presentation to the emergency department, a physical exam revealed vaginal discharge, cervical motion tenderness, and left adnexal tenderness. Computed tomography (CT) of the abdomen and pelvis showed a 4.7 x 1.4-cm left adnexal hydrosalpinx and a displaced IUD, suggestive of pelvic inflammatory disease. After 3 days of inpatient treatment with intravenous antibiotics, she was discharged home on oral antibiotics and had an unremarkable recovery. Discussion: We present a TOA exacerbation as a possible cause of acute pelvis after colonoscopy. Although impossible to prove, the likely culprit was traction on the pelvic organs by colonoscopic manipulation, which may have resulted in direct trauma or irritation of the TOA and IUD. Gynecologic pathologies are infrequently discussed as a cause for post-colonoscopy pain, but there are prior reports of post-colonoscopy complications associated with endometriosis, pelvic actinomycosis, ovarian malig- nancies and TOAs. Awareness of these rare, but potentially serious, complications may lead to earlier wrornntnitinn and awnidanca nl lifes therantanina cannalasa

[1224] Figure 1. Sigmoidoscopic view of solitary rectal ulcer. Conclusion: SRUS must be borne in mind when patients present with symptoms of a defecatory disor- der and hematochezia, in association with rectal ulceration (with associated typical histologic findings). Conservative medical therapy may improve symptoms, reserving biofeedback, and surgical intervention for more refractory cases.

[1226A] Figure 1. Retroflexed view of polypoid distal rectal mass.

1229 Purpose: A 64-year-old male with a history of rheumatoid arthritis and alcohol abuse was started on plaquenil for the treatment of rheumatoid arthritis as an outpatient. Seven days after treatment initiation, papular eruption developed on his chest and progressed to diffuse erythematous eruption with symptoms of burning. He presented to the emergency room with these complaints, and was noted to have tachy- cardia and a prominent leukocytosis of 32,000 per microliter. He was subsequently admitted to the ICU, and developed mental status changes attributed to alcohol withdrawal. On day one, patient was noted to have significant abdominal distention, and an abdominal X-ray was obtained, which showed an isolated cecal dilation of 15 cm, with the cecum rotated centrally toward the midline and no evidence of any small bowel dilation. Conservative measures failed to improve his continued dilation. Gastroenterology consult service was then consulted, and after discussion with radiology and general surgery, it was felt that there was low probability of cecal volvulus, and the decision was made to attempt a colonic decompression. Colonoscopy showed stool in the ascending colon, and there was difficulty in intubating the cecum. A follow up X-ray showed a continued cecal dilation of 12 cm. Six hours later, and on follow up imaging, it was noted to be 16 cm, and at this time the patient was taken to the operating room. Intra-operatively a cecal bascule was noted. Cecal bascule is a rare type of intestinal obstruction that occurs when a mobile cecum folds upward over the ascending colon and obstructs the ascending colon. It is a rare diagnosis, and it is estimated that 0.2% of all intestinal obstructions are cecal bascules. Over the last 20 years, only a handful of cases have been reported (less than 10). It is frequently confused with cecal volvulus on x-rays , and plain films will frequently demonstrate a massively dilated cecum with or without evidence of small bowel obstruction. Computed tomography scan is much more sensitive and can clearly define the large bowel anatomy. Cecal bascule is defined as type 3 cecal volvulus, and is a rare diagnosis that should be considered in all patients who present with findings of cecal dilation and if there is concern for volvulus.

{1226B] Figure 2. Anterograde view of mid rectal polypoid masses.

Discussion: Rectal syphilis is rare and can be misdiagnosed or missed due to absence of symptoms. Clinically, patients may present with anorectal pain, tenesmus, bleeding, itching, or anal discharge. Endo- scopically, rectal syphilis can appear as a destructive rubbery lesion with single or multiple ulcers. The combination of clinical and endoscopic features mimic other anorectal pathologies, such as rectal cancer. inflammatory bowel disease (ulcerative proctitis), solitary rectal ulcer, or viral anorectal ulcers (herpes simplex virus, gonorrhea, Chlamydia, and lymphogranuloma venereum). Tissue biopsy is recommended for diagnosis with dark-field microscopy or PCR. A detailed sexual history is important, and evalua- tion for other sexually transmitted infections should be performed. Once diagnosed, patients should be treated with intramuscular benzathine penicillin (or doxycycline in those with a penicillin allergy). Ou patient received intramuscular benzathine penicillin G, 2.4 million units weekly for 3 weeks and had complete resolution of his symptoms. [1228] Colonoscopy: rectal lesion.

Abdominal Actinomycosis: Initial Presentation Mimicking Colonic Ferforation/Complication of ¢ Screening Colonoscopy Sree Kowsika, MBBS,' Murthy Madhira, MD, FACG,' Martin Tobi, MD,? Divya Sadaram, MBBS," 1. Monroe Gastroenterology Clinic, Monroe, MI; 2. University of Pennsylvania, Philadelphia, PA.

Purpose: In the United States and other Western countries, colonic volvulus causes 1-4% of all cases of intestinal obstruction, and 10-15% of cases of colonic obstruction. A 36-year-old woman with a history of systemic lupus erythematosus (SLE) presented with shortness of breath, abdominal pain and disten- tion for 4 days. The patient’s last bowel movement was 5 days prior to presentation, and she had not passed flatus in 2 days. Laboratory data were unremarkable. On physical examination, her abdomen was distended with diffuse left-sided tenderness and hypoactive bowel sounds. Examination of the chest was significant for right-sided heart sounds and diminished breath sounds on the left side of her chest. Plain films of the chest revealed a large amount of bowel in the left upper quadrant projecting into the left hemi-thorax with a consequent rightward mediastinal shift (Figure A). Computed tomography (CT) of the thorax, abdomen and pelvis demonstrated a volvulus of redundant mid-descending colon with dilated loop of colon causing elevation of the left hemi-diaphragm. The patient underwent emergent colonoscopic decompression of the descending colon volvulus. Surgical intervention was not neces- sary, given that the patient’s symptoms had significantly improved after colonoscopy. Two days later, she underwent repeat colonoscopy, demonstrating that the descending, transverse and ascending colon were redundant and tortuous. Surgical consultation was recommended for consideration of an elective partial colon resection to prevent recurrent volvulus. The sigmoid colon and cecum are the most frequent sites of colonic volvulus, accounting for about 75% and 22% of all cases, respectively. Uncommon sites of colonic volvulus include the transverse colon (2%) and the splenic flexure (<1%). There have only been a few cases of descending colon volvulus previously reported in medical literature. Limited reports of sigmoid and splenic flexure volvulus associated with eventration of the diaphragm have been seldom described. This case highlights a rare finding of descending colon volvulus leading to a markedly elevated left hemi-diaphragm.

Purpose: Colovesical fistula is an abnormal communication that occurs between the epithelium-linec lumen of the colon and of the bladder, either directly or via an abscess cavity “the foyer intermediaire o: Chavannaz.” An 88-year-old Hispanic woman presented with a2-day history of chills, pneumaturia, fecal- uria, dysuria and generalized body pains. Review of systems was unremarkable. The patient was treated fot UTI with E. coli two months prior presentation, with nitrofurantoin. Past history includes diverticulosis HTN, CAD, osteoarthritis, DM, diastolic heart failure, dyslipidemia, and total abdominal hysterectomy 14 years ago. On admission, the patient was febrile; BP of 75/32 mmHg, tachycardic, abdomen soft and non-tender, normal bowel sounds, no organomegaly or flank tenderness. The rest of the systemic exam wa: normal. Laboratories: Leukocytosis 12.2 with normal distribution and acute kidney injury with Cr of 1.5 mg/dl. A urine analysis revealed turbid urine with large leukocyte rsterase, 50-100 wbc/hpf, and was loaded with bacteria. The urine culture grew E. coli (MDRO) and Enterococcus species sensitive to vancomycin Daptomycin and vancomycin started with marked clinical improvement on the second day of admission. A computed tomography scan of the abdomen and pelvis revealed colovesical fistula and diverticulosis of sig- moid colon. Urology service was consulted, and the patient was offered surgical management, but opted fot medical management. The patient's UTI clinically improved with antibiotics, and renal function returnec to normal. Colovesical fistulous tract occurs secondary to inflammatory, infectious, neoplastic, Iatrogenic or traumatic causes. Diverticular disease is the most common cause and up to 65% of diverticular fistulae are colovesical, with the most common segment being the sigmoid, as observed in our patient. Predisposing factors in our patient include hysterectomy, multiple colonoscopies in the past and advanced age. Establish- ing the diagnosis depends on presentation. CT scan of the abdomen and pelvis is about 90% sensitive Surgical management is the treatment of choice, and in high-risk patients or those who do not want surgery conservative treatment with intermittent antibiotic administration may prevent sepsis and renal failure. Acute Hemorrhagic Rectal Ulcer Syndrome (AHRUS): An Under-recognized Condition S. Bashar Almadani, MD, MPH, Michael Brown, MD, MACM, FACG. Rush University Medical Center, Chicago, IL.

Discussion: This is a rare case of SCC of the rectum in a patient infected with a high-risk HPV subclass. High-risk subclasses have been reported to be 16, 18, 31, and 33. The relationship between SCC of the rectum and HPV in AIDS patients has rarely been described, and in general, the condition presents with advanced stage disease due to the its nonspecific presentation and late symptoms. The probable link between HPV and SCC of the rectum is demonstrated in this case.

Death by Enema: A Rare Case of Rectal Necrosis Following Homemade Enema Administration Edmund Wu, MD, Jason Ferreira, MD, Adam Harris, MD, FACG. Brown University, Providence, RI.

Purpose: Colonic metastases from invasive ductal carcinoma (IDC) of the breast are extremely rare. Based on our literature search using PubMed, Embase, and Scopus, there are only 13 published cases in the literature. We report a rare case of metastasis of IDC to the colon detected on screening colonoscopy. A 73-year-old female underwent left-sided mastectomy followed by adjuvant radiation for breast adeno- carcinoma in 1972. At that time, lymph node sampling was negative. In 2004, she developed right-sided breast cancer found on surveillance mammography and confirmed on biopsy. She underwent right-sided mastectomy, which revealed IDC. Surgical resection had negative margins and axillary lymph nodes. The estrogen and progesterone receptor staining was positive. In 2009, she completed 5 years of anastrazole therapy and had no further evidence of tumor recurrence. This year, she presented for her general medi- cal evaluation. She had also undergone screening colonoscopy 5 years ago, which was unremarkable. She was found to have a hemoglobin of 10.2 mg/dL without any overt signs of gastrointestinal bleeding. Her CEA was 59 ng/mL. She underwent colonoscopy with polypectomy of 4 sessile 6-7 mm polyps in the sigmoid colon, transverse colon, hepatic flexure, and descending colon. The histology revealed poorly differentiated IDC. Immunohistochemistry showed estrogen receptor positivity. Subsequent CT of the chest, abdomen and pelvis demonstrated retroperitoneal lymph nodes and sclerotic spinal metastases. She is currently undergoing treatment with aromatase inhibitor for metastatic disease. IDC is the most common form of breast cancer which accounts for 70-80% of all breast cancer diagnosis. Common sites

[1243B] CT scan: mesenteric lymphadenopathy. Purpose: Gastrointestinal tract lymphomas, although rare, account for about 1% of all colorectal malig- nancies, and colorectal lymphomas account for about 10-20% of all GI lymphomas. We present an atypi- cal case of primary colonic lymphoma incidentally diagnosed on colonoscopy. A 70-year-old man with hypertension and peptic ulcer disease presented with constipation and blood-streaked stools. He denied weight loss, fevers or night sweats. His physical exam was negative for abdominal or pelvic masses and lymphadenopathy. Three years prior, he had a colonoscopy that showed only one reactive non-dysplastic 4-mm ascending colon polyp that was completely resected and retrieved. On repeat colonoscopy, there were multiple patchy areas of circumferential friability, edema and erythema in the colon, most notable in the ileocecal valve (Image 1). Multiple biopsies confirmed diffuse follicular B-cell lymphoma, which was CD-20 positive. Subsequent laboratory tests, including CBC, LDH and B2- microglobulin were nor- mal. Abdominal CT revealed right-sided mesenteric lymphadenopathy suspicious for nodal metastasis (Image 2). A bone marrow aspirate and trephine showed no evidence of bone marrow involvement. The patient was diagnosed with stage IIAE follicular lymphoma on the modified Anne Arbor classification, and was initiated on bendamustine- rituximab chemotherapy. According to Rummel et al, this regimen Case: A 76-year-old white male was initially admitted with a 1-month history of chronic diarrhea, with a negative CDI toxin at an outside hospital. A colonoscopy showed severe pan-colitis with pseudomem- branes, and a subsequent CDI toxin was positive. The colonoscopy was complicated by perforation of the right colon, which required a right hemicolectomy with primary anastomosis (30 cm resected) and

[1242] Sigmoid colon. of metastasis include the lung, liver, bone and brain. Metastasis to the colon is rare. The detection o! metastatic IDC detected in colonoscopy is even more rare. This case underscores another anecdotal ben- efit of screening colonoscopy in a patient with prior non-gastrointestinal malignancy.

{1243A] Colonoscopy: ileocecal valve. resulted in increased progression-free survival and harbored fewer toxic side effects than R-CHOP in patients with indolent colonic lymphoma. In conclusion, although patients with primary colonic lym- phoma usually present with symptoms of abdominal pathology including pain, weight loss or a palpable abdominal mass, our patient only had indolent signs of disease. Therefore, this diagnosis requires a high index of clinical suspicion. Our case also highlights the importance for repeat colonoscopy and further investigation in patients with vague gastrointestinal symptoms.

{1247B] Ulcerated mass with surrounding erythema. [1247A] Lesion in the colon causing partial obstruction.

Background: We report a case of a 66-year-old white male who presented acutely with melena. Past history was significant for hypertension and diabetes, but no previous gastrointestinal pathology was reported. Upper endoscopy was performed after resuscitation and revealed moderate gastropathy and gastritis secondary to Helicobacter pylori infection. The patient was treated with acid suppression and tri- ple antibiotic therapy. Screening colonoscopy and H. pylori breath testing was scheduled in the outpatient setting, but he was lost to follow-up. Seven months later, he presented with symptomatic anemia associ- ated with intermittent hematochezia. Colonoscopy was then performed. Colonoscopy revealed a lesion 50 cm from the anal verge (Figures 1, 2). The mass was ulcerated and partially obstructing. Pathology showed ulcerated neoplasm compatible with epithelioid gastrointestinal stromal tumor (GIST). Cross- sectional imaging revealed marked mass-like adenopathy throughout the mesentery, most severe in the pelvis, suggestive of malignancy. Given his cardiopulmonary comorbidities, he was not a candidate for resection and was placed on oral imatinib. He died of cardiac disease 12 months after starting therapy. Discussion: Gastrointestinal stromal tumors (GISTs) are uncommon tumors of the GI tract. GIST is usually an incidental finding on endoscopy performed for other indications. GISTs can occur throughout the tubular GI tract, but the most common site is stomach (60-70%) followed by small intestine, rectum, and colon (1%). In this particular case, screening colonoscopy at age 50 and subsequent exams may have discovered the lesion earlier, when endoscopic therapy may have been amenable.

[1248] CT Chest showing pneumomediastinum. Discussion: Incidence of colon perforation is common with therapeutic, as compared to diagnostic, colo- noscopy. Subdiaphragmatic free air suggest intraperitoneal perforation, whereas subcutaneous emphysema, pneumoretroperitoneum, and pneumomediatinum suggest extraperitoneal perforation. Extraperitoneal perforation without peritoneal signs can be treated conservatively with bowel rest and antibiotics. Micro- perforation usually close with omental adherence, and symptoms resolve within 24-48 hours.

[1249] Chronic granulomatous colitis post pneumatic balloon dilation. Our case is unique in the chronicity of active inflammation, as well as the presence of foreign body granu- lomata. Coffee enemas have been gaining in popularity, most commonly cited for constipation relief and as a method of “detoxification.” This case highlights the potential harm associated with this unproven therapy. Animal models may help better understand what component of coffee may be responsible for inducing a chronic foreign body granulomatous transmural colitis.

Conclusion: We present the first case of a CeB-associated with RTX therapy. Clinicians should maintain a high degree of vigilance in patients undergoing treatment with RTX who present with non-specific abdominal symptoms. Introduction: Cecal volvuli (CeV) are relatively rare, accounting for 10% of all cases of colonic volvuli. Three types of cecal volvuli (CeV) exist: 80% are type I and II, developing from clockwise and coun- terclockwise axial torsions, respectively, of the cecum (Ce) around its mesentery. A rare type III or Ce bascule (CeB) involves upward folding of the Ce. All three types are dependent on previous existence of abnormally mobile Ce (congenital or acquired). In CeB, folding of the Ce anterior to the ascending colon (AC) causes inflammatory adhesions, fixing the anterior surface of the Ce to the mid-AC. This fixation leads to increased tension on the bowel wall, resulting in gangrene with subsequent perforation. Ritux- imab (RTX) is a chimeric human/mouse monoclonal Ab that binds to a CD20 Ag present on the surface of B lymphocytes, thereby causing lysis of tumor cells. A pooled analysis of clinical trials in patients with CD20-positive non-Hodgkins lymphoma (NHL) has indicated a higher incidence of GI perforations in the RTX plus chemotherapy (CTX) arm, as compared to CTX only arm. Although the mechanism is unclear, aggressive tumor lysis response may be related to the high CD20 expression on tumor cells, lead- ing to perforations in patients with lymphomatous involvement of the GI tract. Ceb as a consequence of RTX therapy, although plausible through the same mechanism, has thus far not been described. Case: A 65-year-old male with NHL treated with RTX presented in acute distress with rigid, distended and severely tender abdomen with hypoactive bowel sounds. A plain film revealed dilated sb with no obvious free air. CT abd/pelvis with PO/IV contrasts showed a markedly dilated Ce with no evidence of BO, volvulus or bowel wall thickening, moderate distention of AC and transverse colon with stool and decompressed descending colon, and rectum with no dilation of SB. Repeat CT with water soluble contrast through the rectal tube showed anteromedial displacement of extensively fecalized and mark- edly dilated Ce in relation to AC, resulting in CeB and possible Ce obstruction. Ultimately, the patient’s symptoms resolved with conservative management, and he was discharged in stable condition. Conclusion: We present the first case of a CeB-associated with RTX therapy. Clinicians should maintain a high degree of vigilance in patients undergoing treatment with RTX who present with non-specific

Conclusion: Despite its rarity in the United States, Strongyloides stercoralis infestation should be consid- ered in the differential diagnosis of immunosuppressed patients with colitis, especially when associated with systemic eosinophilia.

Conclusion: Cap polyposis is a rare and benign disorder characterized by the presence of inflamma- tory polyps, which are covered by a “cap” of granulation tissue. Thirty cases have been reported in the literature, and, similar to our case, were initially misdiagnosed as Crohn's disease or ulcerative colitis. The exact etiology of cap polyposis remains unknown. Treatment regimen is not standardized, but H. pylori eradication has been reported. Review of further cases is necessary to establish a common pathophysiol- ogy and standardize the treatment regimen.

[1256] Hematoxylin and Eosin stain. Discussion: Leiomyomas are benign, smooth muscle tumors and are rarely found in the gastrointestinal tract, with only 3% in the colon. Colonic leiomyomas are mostly found incidentally, and can occur in the sigmoid and transverse colon, and less commonly in the rectum. Most cases are usually asymptomatic and seen in the third decade of life, with a slight female predominance. They arise from the muscularis mucosa, muscularis propria or from vascular smooth muscle. Endoscopically, they present as intramural or pedunculated growths, appearing similar to adenomatous polyps. Immunostain is positive for actin and desmin, and negative for CD34 and CD117 (C-kit), which helps to differentiate them from GISTs. Snare polypectomy is adequate, but for larger tumors or when malignancy is a concern, surgical resection with wide margins is recommended.

non-gastric MALT lymphoma approaches 50%, emphasizing the need for lifelong follow-up in thes patients. 1258

Purpose: Ischemic colitis is the most common type of intestinal ischemia, with a vast clinical spectrum of injury ranging from mild and transient ischemia to acute fulminant colitis. Here is a unique case of ischemic colitis presenting as a cecal mass, then completely resolving 2 months later. A 76-year-old male admitted to the hospital with right lower abdominal pain, non-bloody diarrhea, and a fever of 102 F. Physical exam showed a well-developed male in no distress. He was mildly tachycardic with a tender right lower quadrant on palpation without rebound or guarding. CT scan revealed annular thickening of the cecum, concerning for malignancy. Colonoscopy showed a large, necrotic-appearing mass involy- ing the majority of the cecum. Pathology revealed partially ischemic mucosa with reparative changes, as well as necrotic and fibrinopurulent tissue. His symptoms improved with supportive care, and he was discharged home. A repeat colonoscopy two months later showed complete resolution of the mass. Ischemic colitis is an important disease to recognize, especially in the increasingly elderly population. Endoscopic features are vast, ranging from mild erythema, ulceration, and strictures, to a pseudo-tumor, as seen in this case. The submucosal hemorrhage can create a mass-like appearance when severe. Pathol- ogy features such as mucosal inflammation, along with erosion, granulation hyperplasia, gland atrophy, and macrophages can aid in diagnosis. Generally, conservative management is recommended, as patients who have surgery portent a higher mortality. This case emphasizes that while preliminary imaging may be suggestive for malignancy, colonoscopy is essential to distinguish from carcinoma, to avoid unneces- sary surgery.

[1264A] Figure A. Normal appendiceal orifice and cecum at initial colonoscopy.

[1264B] Figure B. Polypoid lesion noted in the cecum at repeat colonoscopy.

[1266] Figure 1. A) Circumferential Malignant-Appearing Mass in the sigmoid colon. B) Biopsy of mass depicting ulcerative changes with abundant plasma cells. Staining showing C) Lambda protein and D) Kappa protein presence.

Purpose: An 80-year-old female Filipino patient presented with vomiting, right upper quadrant abdominal pain, and constipation for three days. She noted poor oral intake, significant weight loss, and night sweats for one year. The patient was cachectic. Abdomen was mildly-tender and distended. CT abdomen showed bowel wall thickening and obstruction at the level of the ileocecal valve. Colo- noscopy showed a nearly obstructing mass in the ascending colon. Biopsy showed granulation tissue formation, and was negative for malignancy. Given the persistent obstruction, right hemicolectomy was performed. Pathology showed granulomatous enterocolitis, appendicitis, and lymphangitis with mucosal ulceration. Interferon-gamma release assay was positive; however, acid fast stain and TB PCR were negative. There are international case reports and small case studies discussing the diagnostic

[1268] Partially obstructing hematoma in sigmoid colon. prep and technical difficulty, we switched to an adult colonoscope. As a result of continued difficulty, we stiffened the scope, repositioned the patient, applied abdominal pressure, and we were ultimately able to reach the cecum. Upon withdrawal of the colonoscope, a large, nearly obstructing intraluminal hema- toma with no evidence of bleeding was identified in the sigmoid colon. She denied use of NSAIDS, aspi- rin, or other anticoagulation. She was hemodynamically stable throughout the procedure. In the PACU, she never developed abdominal pain or rectal bleeding, and was passing flatus. She was discharged the same day, with instructions to take laxatives and stay on a liquid diet for three days. She remained asymp- tomatic and was having normal bowel movements at day one, three, and seven after colonoscopy. She was referred to hematology to be evaluated for a blood dyscrasia, but none was found. Intramural hematomas of the gastrointestinal tract are unusual. Symptoms are typically non-specific. Patients may present with diminished bowel sounds, obstruction, low grade fever, leukocytosis, and abdominal tenderness, and there can be mild rectal bleeding to hemorrhagic shock. CT scan is diagnostic, although ultrasound and barium enema have been used with success. Little information exists regarding appropriate treatment of intramural hematomas; however, in a stable patient, conservative observation is reasonable.

workup for abdominal TB. Patients present with symptoms similar to our patient. They will commonly have normal chest radiographs, and acid fast staining of the sputum is often negative, as there may not be concurrent pulmonary involvement. Endoscopy shows right sided nodules, polyps, strictures, ulcers, or masses. A majority of lesions will heal completely with treatment. Biopsies show granulomas, but AFB and culture are frequently negative. PCR has 58-79% sensitivity and 68-100% specificity. Diagnosis is confirmed by response to treatment. Abdominal TB does not have a gold standard for diagnosis, and therefore, the clinician must have a high index of suspicion, especially in the United States, where this presentation for TB is rare in an immunocompetent adult.

[1274] Cecal ulcer biopsy. ulcer, and ESRD s/p two failed renal grafts. Current medications include pantoprazole, sevelamer cayexalate, senna, and metoprolol. On admission, the patient was found to be hypotensive with 1emoglobin (Hb) of 9 g/dl (baseline 10-11 g/dl). His blood pressure responded appropriately to fluic esuscitation. Subsequent EGD revealed a single non-bleeding gastric ulcer (3 mm) in the pre-pylori: egion of the stomach with no stigmata of bleeding. The patient continued to have intermittent episode: »f BRBPR, necessitating multiple blood transfusions, and a colonoscopy was done, revealing evidence o' ‘olitis and localized ulcerations in the proximal ascending colon and cecum status post biopsies. Dur. ng the hospitalization, an angiography was also performed, which revealed active bleeding from ceca ranches of ileocolic artery status post embolization with cessation of bleeding. Biopsy results from the ecal ulcers on colonoscopy revealed single particle of crystalline material in the background of an ulce! onsistent with kayexalate-induced ulcers (Image 1). Many drugs can cause non-specific damage in the arge intestine, including solitary hemorrhages, erosions, ulcers, and inflammation. The pathogenesis o he lesions caused by drugs is highly variable, with toxic injury and vascular insufficiency thought to be he most common. Kayexalate-induced intestinal injury reveals rhomboid or triangular basophilic crys. als adherent to surface epithelium. Kayexalate is a cation exchange resin which acts in the large intestin« »y exchanging sodium ions for potassium ions. The mechanism of mucosal damage is not clear, and i: eported to be more common in patients with renal failure. It is speculated to be caused by its osmotic ction and vasospasm of intestinal vasculature. The patient in this case recovered after discontinuation o cayexalate. This case highlights the importance of medication-induced GI tract injury. Physicians shoulc »e aware of colonic ulceration and ischemia in renal failure patients taking kayexalate.

[1278A] Cecal ascending colon wall thickening. Purpose: A 66-year-old male with history of CADs/pCABG presents with sudden onset of diffuse abdominal discomfort. Over time, his abdominal pain became focal, sharp and severe in the right lower quadrant. He denied fever, loss of weight or appetite, nausea, vomiting, rectal bleeding, sick contacts and recent travel. He had a normal colonoscopy three years prior to admission. He is a retired meat cut- ter, married, a non-smoker and consumes alcohol socially. On physical exam, he was afebrile, with HR 81, RR16, BP 110/62 with oxygen saturation 97% RA. Respiratory, neurologic exam and cardiovascular exams were unremarkable. Abdomen was soft, normal bowel sounds with right lower quadrant tender- ness, but no rebound or guarding. Normal digital rectal exam. WBC 13.7 with 76% neutrophils. LFT and BMP were unremarkable. CRP elevated to 23.8. CT abd/ pelvis was notable for asymmetric wall thicken- ing involving a portion of the cecum and ascending colon, with likely involvement of the terminal ileum as well. IV levofloxacin and metronidazole were started on admission, and when he did not improve, colonoscopy was performed. At the ileocecal valve, a nodular ulcerated area, suspicious for ischemic colitis, was biopsied. He was discharged on oral levofloxacin and metronidazole. He was re-admitted for targeted antibiotic therapy when biopsies suggested that the ulcer was the result of infection, rather than ischemia or malignancy. PAS and GMS stains were consistent with Actinomycetes, and Penicillin G 5-m units IV Q6H was started. He was discharged with ceftriaxone for ease of home administration for 12 more weeks. A six-week CT showed interval improvement of the cecal and ileal thickening, fully resolved on a 12-week CT scan.

colonic necrosis remains uncertain. A study in rats showed that sorbitol might be the cause of colonic necrosis via osmotic ischemia or direct intestinal mucosa damage; however, the applicability of the ani- mal model to human beings is unclear. Histologic evidence of angulated, basophilic crystals in areas of ulcerated or necrotic mucosa suggests the diagnosis. In this case, our patient suffered from CKD and received several doses of SPS-sorbitol to treat hyperkalemia. Thus, clinicians need to be aware of colonic necrosis as a rare yet serious adverse effect from this commonly prescribed drug.

eni Verma, MD, Sunjeet Kaur, MD. Internal Medicine, Geisinger Health System, Coal Township, PA.

Abdominal X Ray: Consistent with marked colonic dilation upto 13.5 cm in diameter Computerized Tomography of Abdomen with Oral contrast: Marked colonic gaseous dilation of ascending, transverse and descending colon. Air fluid levels are seen. No bowel wall thickening or pneumatosis [1281B]

Conclusion: The most important step in management of Non Toxic Megacolon is to decide between medical versus surgical management. Timely colonic decompression can be a life saving procedure.

Case: A 24-year-old active duty male deployed in 2011 in support of Operation Enduring Freedom in Afghanistan sustained an improvised explosive device (IED) blast injury complicated by an open left foot fracture and pseudomonas aeruginosa osteomyelitis following internal fixation. He initially had mild ane- mia attributed to polytrauma and osteomyelitis, but, additionally, was noted to have a peripheral eosino- philia of 3706/mcL. A subsequent serologic parasite work-up was negative, as were stool examinations for ova and parasites. He had persistent mild normocytic anemia through 2012 after an elective left below- the-knee amputation for ongoing complications. He re-presented in 2013, complaining of fatigue with vigorous physical therapy. At that time, he had severe iron-deficiency anemia, with hemoglobin 6 g/dL, MCV 66 fL, iron 14 mcg/dL and ferritin 1.8 ng/mL, and ongoing eosinophilia of 2414/mcL. Colonoscopy demonstrated numerous 1.5-cm long worms. Based on exposure in Afghanistan, severity of progressive anemia, gross examination, and four hook-like teeth at the caudal end of the adult worm, Ancylostoma duodenale infection was diagnosed. The patient improved, following treatment with albendazole and iron replacement. While well-described hookworm outbreaks occurred in U.S. forces during the Second World War and, more recently, in Grenada, hookworm infections are rare in contemporary military operations. There are no prior documented cases of Ancylostoma infection in military service members returning from U.S. operational support in the Middle East or central Asia. Comprehensive public health and hygienic practices are necessary to prevent this and other enteric diseases in the deployed setting. [1284] Hookworms visualized during colonoscopy. A worm was removed via biopsy forceps to facilitate identification.

[1286] ICCC criteria for Cowden syndrome Features observed in the case are mentioned in bold.

Multiple Ganglioneuromatous Polyps of the Colon: What Lies Beneath the Surface of Colon? Abhilash Perisetti, MD,’ Dinesh Bande, MD," Sajid Jalil, MD,’ Pamela McGrann, MD”. 1. University 0 North Dakota, Fargo, ND; 2. Sanford Medical Center, Fargo, ND.

[1286] Colonic mucosa with spindle cell proliferation essentially replacing the lamina propria between crypts (200x). demonstrates that this disorder could be more frequent than is currently estimated. A combination of macrocephaly and recurrent gastrointestinal bleeding with skin manifestations should raise suspicions for this disorder. Due to its autosomal inheritance pattern, all family members who have macrocephaly should be evaluated. Screening is important, as there is increased risk for breast (85%), thyroid (35%) and endometrial (28%) cancer. Usual GI manifestations include colorectal hamartomas with esophageal glycogenic acantholysis (seen in this patient), which could be as high as 85%.

Picture 1. Polyps in the sigmoid colon. Purpose: Mastocytosis is characterized by abnormal proliferation and accumulation of mast cells in various organs and tissues. The clinical presentation is variable and can be localized, such as skin rash to systemic symptoms, depending on organ system involvement. 70 to 80% of patients with systemic mastocytosis are found to have gastrointestinal (GI) symptoms, and the GI lesions may involve any part of the digestive tract, from the esophagus to the rectum. We present an interesting case of a 68-year- old asymptomatic female who was found to have multiple polypoid lesions in the sigmoid colon, the descending colon, the ascending colon, and the cecum on routine screening colonoscopy. The histo- pathological examination of the lesion showed mastocytosis with positive markers for CD 25, CD 68, CD 117, and mast cell tryptase. The immunophenotype of the mast cells (CD25) was atypical, and showed many aggregates containing more than 15 mast cells, which fulfills the diagnostic criteria of World Health Organization for systemic mastocytosis. The most common GI symptom in systemic mastocytosis is abdominal pain, followed by diarrhea, nausea, and vomiting. However, in our case, the patient denied having any symptom, skin lesion, or allergic manifestation on the initial --as well as fol- low-up-- visits. Currently, there is no curative treatment for systemic mastocytosis, and no well-accepted

Picture 2. The Hematoxilin and Eosin stained sections of the cecum biopsy show mast cells found in sheets of more than 15 confluent cells consensus or guideline regarding follow-up endoscopy for asymptomatic gastrointestinal mastocytosis, such as in our case. However, close follow-up of the patient to monitor the development of symptoms is very important.

[1296] Table 1. Characteristics of patients and outcome

heart rate of 78 beats/min, and respiratory rate of 14 breaths/min. On physical examination, his abdomen was soft, non-tender, and non-distended, with audible bowel sounds. The remainder of physical exami- nation was unremarkable. Laboratory analyses were within normal limits. Colonoscopy revealed four polyps: A 3-mm sessile polyp in the proximal ascending colon, a 10-mm sessile polyp in the sigmoid, and a 6-mm and 8-mm smooth sessile polyps in the rectum. The polyps were completely removed by hot snare polypectomy, and cold forceps biopsies were performed. Biopsy results were consistent with granular cell tumor (GCT) of the rectum and cecum. Immunohistochemistry analysis was positive for $100, CD68, NSE, and Inhibin. The patient was educated about proper diet and started on omeprazole. At six-week follow-up, he denied any more episodes of blood in the stool. 1297

Purpose: Case 1: A 44-year-old male presented with four days of severe, left lower quadrant abdominal pain, nausea, and constipation. He had no associated fever or diarrhea. The patient was afebrile, and his Purpose: An 80-year-old male was referred to gastroenterology for new onset constipation, colon cancer surveillance, and findings of a thickened sigmoid colon by abdominal CT (Figure 1). Prior to referral, this patient was undergoing extensive work-up for a plasma cell dyscrasia. In addition, he began to demon- strate worsening kidney function and developed diastolic heart failure, which, in combination with his plasma cell dyscrasia, was highly suspicious for systemic amyloidosis. The patient eventually underwent cardiac biopsy for new onset diastolic heart failure, which was positive for amyloidosis. He was eventually referred to GI with subsequent colonoscopy (Figure 2) and microscopic investigation (Figure 3-4), also consistent with amyloidosis. Epiploic Appendagitis: A Rare Entity Easily Misdiagnosed as an Acute Abdomen: Case Series an Review of Literature Stanley Yakubov, MD, Steven Guttmann, MD, Po Cheng Chu, MD, Kadirawel Iswara, MD, FACG, Ira Mayer, MD, FACG, Rabin Rahmani, MD. Maimonides Medical Center, Brooklyn, NY.

abdomen was tense, non-distended, tender in LLQ with positive guarding, but no rebound and normal bowel sounds. Laboratory analysis showed WBC 6.7. He was started on morphine for pain, and broad spectrum antibiotics for presumed diverticulitis with possible abscess formation. CT scan of abdomen/ pelvis showed an oval-shaped fat density in the LLQ anterior to the sigmoid colon characteristic of epi- ploic appendagitis (EA). The patient improved with conservative treatment including NSAIDS. Case 2: A 43-year-old male presented complaining of sharp, right lower quadrant pain associated with nausea, and worsened with coughing for three days. He was afebrile, with RLQ pain and positive guarding, but no rebound. No visible or palpable hernia or tenderness at McBurney’s point was noted. Laboratory tests showed WBC 9.5. CT scan of abdomen/pelvis demonstrated a normal appendix and an area of fatty infil- tration anterior to the cecum consistent with RLQ EA. The patient improved with conservative treatment and NSAIDS. Case 3: A 71-year-old female presented one year after liver transplantation with sharp, right lower quadrant abdominal pain for 10 days, associated with nausea and anorexia. Patient denied vomit- ing, diarrhea, or constipation. She was afebrile with RLQ tenderness, no guarding or rebound noted, and had normal bowel sounds. Laboratory testing was within normal limits. CT scan of abdomen/pelvis showed segmental thickening of small bowel loops in the RLQ, consistent with EA. The patient recovered with supportive care including pain control. 1298

{1300C] Thickening of submucosal blood vessel walls from amyloid deposition .

[1300D] Submucosal blood vessels with thickened walls secondary to amyloid deposition. These vessels have been stained with congo red with resulting apple green birefringence under polarized microscopy.

1303] Multiple small punched-out ulcers seen in the cecum with adherent clot covering one of the ulcers (A). Homeostasis was attempted with placement of two homeostasis ‘lips (B). Case: A 52-year-old female presented for evaluation of abdominal pain. Abdominal CT scan revealed a large polypoid mass in the cecum with heterogeneous enhancement in the center. Multiple enlarged lymph nodes around the mass were noted. CEA level was normal. Colonoscopy showed a lobulated, friable mass arising from cecum. Histopathological evaluation revealed poorly differentiated invasive carcinoma with squamous differentiation. Malignant cells were strongly positive for p63 at the areas of squamous differentiation, scattered malignant cells were positive for CK20 and CDX2. In addition, the malignant cells retained nuclear staining for MLH1, MSH2, MSH6, and PSM2. Surgical exploration confirmed a 12-cm cecal mass infiltrating into the terminal ileum. Open right hemicolectomy with primary ileo-colic anastomosis was performed, and the tumor was staged IIIC with lymph-vascular invasion. Three months after her initial surgery, and before the initiation of the planned adjuvant chemotherapy, the patient underwent repeat surgical exploration for drainage of a fluid collection. At that time, recurrence of the

Recurrent Clostridium difficile Colitis in a Patient with Concurrent Diverticulitis Priya Kathpalia, MD, Stuart Johnson, MD. Loyola University Medical Center, Maywood, II Discussion: Adenosquamous carcinoma (ASC) arising primarily from the colon is extremely rare. The nost common cause for squamous differentiation in a colonic mass is a metastatic lesion. Other poten- ial sources include endometriosis and colocutaneous fistula. All these were ruled out in our case. Clini- ally, ASC has a relatively younger age of presentation, predilection to the right colon, and an overall worse rognosis than colonic adenocarcinoma, given its higher propensity for early metastasis. Hypercalcemia s a presentation has been reported in few cases and is believed to be a paraneoplastic phenomenon. Early letection and surgical resection is usually the best therapeutic option and determines overall prognosis in | particular patient. However, more studies are required to determine the exact role of chemotherapy and adiotherapy in ASC.

[1309B] Spirochetes attached to luminal border of epithelium.

[1309A] Colonic epithelium showing fuzzy blue line of spirochetes. Reference: [1] Junji Umeno et al. Intestinal spirochetosis due to Brachyspira pilosicoli: endoscopic and radiographic features. J Gastroenterol 2007;42:253-256.

{1312] Solitary PGN in rectum. Summary: PGN is not associated with increased risk of colon cancer, and doesn't require any further follow-up. GP and DG can be associated with increased risk of colon and other cancers, and patients may benefit from aggressive surveillance.

[1315] Descending colon polyp and histopathology showing spindle cells and hyperchromatic nuclei. Purpose: Mucosal Schwann cell hamartoma, a rare neural tumor, is rarely found in the colon, yet when seen, it is commonly as a small colorectal polyp, typically on the left side. We report two cases of Schwann ell hamartoma presenting as a polypoid lesion in the proximal colon during routine colonoscopy. Case one: A 78-year-old man with a past medical history of congestive heart failure, hypertension, hyperlipid- >mia, diabetes mellitus type 2, diverticulosis, and peptic ulcer disease presented with hematochezia. His amily history was significant for colorectal cancer in his sister. The patient underwent diagnostic colo- noscopy, which revealed scattered diverticula and a 5-mm sessile polyp at the hepatic flexure. Pathology results from the polypectomy specimen revealed colonic mucosa with stromal proliferation of spindle ells with bland nuclear morphology, consistent with Schwann cell hamartoma. Case two: An 84-year- od man with past medical history of hypertension presented for screening colonoscopy. Colonoscopy revealed hemorrhoids and four polyps. Pathology results revealed that a 10-mm sigmoid polyp was a tubular adenoma, a 5-mm hepatic flexure polyp was a tubular adenoma, and a 5-mm splenic flexure dolyp was inflammatory. The fourth polyp was a 5-mm polyp in the mid ascending colon. The pathol- ogy of this polyp showed colonic mucosa with stromal proliferation of spindle cells with bland nuclear norphology, consistent with Schwann cell hamartoma. Purpose: Malignant melanomas account for 1-3% of all malignant tumors of the gastrointestinal (GI) tract, the majority of which are secondary lesions representing metastatic spread. Primary malignant Vishnu Vandana Palle, MD, Ashutosh Gupta, MD, Victoria Angelova, MD, Asad Rafiq, MD, Bashar Attar, MD, PhD, FACG. John H. Stroger Hospital of Cook County, Chicago, IL.

[1319] Anorectal melanoma detected on flexible sigmoidoscopy. Purpose: A 77-year-old Caucasian female with past medical history of external hemorrhoids presented with a three-month history of anal pain, mucus discharge, and pruritus. She had also experienced inter- mittent anal spasms made worse by bowel movements. The patient was treated symptomatically with hemorrhoid wipes and sitz baths. Her rectal discharge persisted to the point the patient was requiring pads to protect her undergarments. She eventually detected a noticeable lesion near the anus. Flexible sigmoidoscopy revealed a smooth 3x2-cm dark brown nodule at the anal verge. The patient was referred

[1322A] Colonoscopy showing large ulcers at the hepatic flexure. Purpose: Case Report: A 71-year-old man presented to the emergency room about 12 hours after insert- ing a perfume bottle into his rectum. Manual self attempts to remove the perfume bottle resulted in the cap getting stuck and moderate rectal bleeding. Patient reported that he had been drinking and snorting cocaine prior. He also reported abdominal pain, flatulence, distention, and the inability to void urine. The patient’s vital signs were: temperature of 97.8°F (36.6°C), pulse of 101, respiratory rate of 16, and blood pressure of 162/87. Abdominal exam revealed a soft, distended abdomen with lower abdominal tender- Introduction: Cytomegalovirus (CMV) gastrointestinal disease is an uncommon but serious complication of acquired immunedeficiency syndrome (AIDS). Recently, the incidence of CMV gastrointestinal disease has decreased substantially since the advent of highly active anti-retroviral therapy (HAART). Case: A 62-year-old male with history of HIV on HAART was sent from a nursing home for evaluation of respiratory distress with oxygen saturation of 89% on room air. On admission, the patient was noted to have supratherapeutic INR of 4.7. The patient was on warfarin for DVT. He was also found to have an acute drop in hematocrit with no obvious source of bleeding. He received packed red blood cells. He also received vitamin K to reverse coagulopathy. While in the hospital, the patient had recurrent episodes of bright red bleeding per rectum. Despite reversing coagulopathy and multiple packed red blood cell transfusions, he became hypotensive. He was transferred to ICU, where he continued to bleed. Colonos- copy was performed. The bowel preparation was suboptimal. The source of bleeding could not be identi- fied. The patient stopped bleeding spontaneously, and was later transferred to the general medical floor. The patient later had another episode of rectal bleeding. A Bleeding scan showed bleeding originating

Discussion: Rectal foreign bodies are usually a result of deliberate insertion. However, some are a result of assault, iatrogenic, or due to foreign bodies traversing the digestive tract and becoming impacted in the rectum. Presentation usually involves abdominal pain, obstructive symptoms, and rectal bleeding. Per- foration and signs of infection may be evident in complicated cases. Abdominal/pelvic x-rays should be obtained to delineate the foreign body position, shape, size and the presence of pneumoperitoneum. In stable patients without evidence of perforation or peritonitis, digital removal of the foreign body should be attempted first. Low-lying rectal foreign bodies can be removed using one of many clamps and/or instruments. Other methods of removal include endoscopic/fluoroscopic-guided balloon extraction, anal dilation with manual or forceps extraction under anesthesia. Laparotomy is indicated in patients who present with perforation, sepsis, ischemic bowel, or after failed transanal attempts. {1321] Figure. Perfume cap in rectum.

[1322B] Histopathology: colonic mucosa showing giant cells with pleomorphic basophilic inclusion bodies (Owl’s eyes)and inflammatory cells.

[1326A] Figure 1. Image depicts a friable, obstructive mass in the sigmoid colon.

[1326B] Figure 2. Tumor consists of high grade pleomorphic cells arranged in pseudo-papillary clusters within stromal spaces resembling vascular spaces. The tumor cells lack fibrovascular cores and displays reverse cell polarity. Mitotic figures are few and the tumor lacks the “dirty necrosis” seen in conventional adenocarcinoma of the colon.

A Rare Case of Rectal Adenocarcinoma Presenting as Paraneoplastic Chorea lastair Dorreen, MD, Tianyan Chen, MD, Gary Wild, MD. McGill University, Montreal, QC, Canada. Purpose: The presence of paraneoplastic syndromes with unknown primary malignancies should prompt evaluation for colorectal neoplasms in all patients. Both age-appropriate screening and systematic inves- tigation should be employed until a primary malignancy is identified. A rare case of paraneoplastic cho- rea associated with a rectal adenocarcinoma is presented here. A 77-year-old man had been followed by neurology for six years for the presence of anti-CV2 positive paraneoplastic chorea. The patient’s choreiform movements had developed gradually, two years after an episode of Guillain-Barré syndrome. Initial work-up for the choreiform movements in 2006 was unremarkable, with a normal magnetic

[1340] Colonic wall thickening and mucosal ulceration. Purpose: Stercoral colitis is an uncommon inflammatory condition of the colonic wall, related to fecal impaction and resulting in ischemic pressure necrosis and ulceration. It differs from other forms of colitis by the clinical absence of diarrhea. This case highlights the potentially fatal nature of this condition if not diagnosed and treated promptly. A 27-year-old woman was evaluated for a six-week history of constipa- tion, abdominal pain, and distension. She denied vomiting or passage of flatus, and had unsuccessfully tried multiple bowel agents. Her medical history included obstipation and bipolar disorder treated with gabapentin and trazodone. She appeared to be in painful distress with an obese, soft, and diffusely tender abdomen without guarding or rebound. Rectal exam, though limited by patients discomfort, reported a large, firm fecal mass within the anal verge. Basic laboratory testing was unremarkable, and a plain abdominal film showed a large amount of colonic stool. An enhanced computed tomography (CT) of the abdomen and pelvis confirmed a significant amount of colonic stool with marked rectal distension, focal colonic wall thickening, mucosal ulceration, and stranding of pericolonic fat. She underwent aggressive bowel cleansing and colonic disimpaction under sedation. Flexible endoscopy demonstrated a solitary, non-bleeding ulcer on the anterior rectal wall just proximal to the dentate line. Consequently, she was

[1341] Mass in the cecum. Discussion: Very few cases of ischemic colitis resembling colon cancer have been reported. Almost all cases reported were initially misdiagnosed as colon cancer, based on endoscopic findings, but endoscopic biopsy confirmed ischemic colitis. Our case had such severe cellular atypia that this differentiation could not be made. In such circumstances, a high index of suspicion with additional review of biopsy speci- mens might help in confirming the diagnosis and avoiding unnecessary surgery.

eer el Discussion: Cases of complications such as rectal bleeding and pressure necrosis occurring well before the 29-day recommended regimen may be under-reported. We report a case of severe, life-threatening rectal bleeding as a complication of the device, used within the recommended time frame. i at SE ee RE ee ee Nw Se! Case: A 71-year-old man with a medical history of coronary artery disease S/P CABG was admitted for an esophagectomy for esophageal stromal cancer. The patient developed fecal incontinence while in the ICU, and was placed on the Zassi BMS, which was inserted four times during the patient's stay for a mean dura- tion of 5.75 days with an average 10.67 days between each insertion. The first and second insertions and subsequent removal were uneventful. The day after the third insertion of the BMS, the patient developed severe hematochezia, with an initial hemoglobin drop of 2 grams. Anoscopy revealed prolapsed internal hemorrhoids and a rectal ulcer. Nine units of PRBCs were required for resuscitation. An urgent colonos- copy revealed a 3-4 cm bleeding circumferential rectal ulcer, 10 cm from the anal verge (Image 1). Epineph- rine injections and application of bicap cautery were used to attempt hemostasis. Despite these measures, bleeding persisted and the patient underwent IR embolization of a tributary of the right pelvic branch of the internal iliac artery. With no further episodes of bleeding, he was discharged to a long-term care facility. Discussion: Cases of complications such as rectal bleeding and pressure necrosis occurring well before the 29-day recommended regimen may be under-reported. We report a case of severe, life-threatening rectal bleeding as a complication of the device, used within the recommended time frame. Primary intestinal Lymphangiectasia Isolated to the Colon: A Kare Cause of Chylous Ascites Daniel Kroch, MD,' Albert Kim, MD,’ Danielle Marino, MD,’ Arthur DeCross, MD, FACG?. 1. Universit of Rochester Medical Center Division of Internal Medicine, Rochester, NY; 2. University of Rochester Medical Center Division of Gastroenterology and Hepatology, Rochester, NY.

Colonic Schistosomiasis: ‘The Great Masquerade of Inflammatory Bowel Disease Dilhana Badurdeen, MD, Belen Tesfaye, MD, Getachew Mekasha, MD, PhD, Momodu Jack, MD Adeyinka Laiyemo, MD, MPH. Howard University Hospital, Washington, DC. 2.2 gm/dL, and the serum ascites albumin gradient (SAAG) was calculated to be 0.7. A colonoscopy was performed for vancomycin infusion, which revealed severe pseudomembranous colitis. C. diff is the most common cause of healthcare-associated diarrhea with significant morbidity and mortality, with up to 5% of patients requiring surgical intervention for treatment. Approximately 7-15% of patients have been shown to have ascites seen by ultrasound or CT scans. However, an initial presentation with massive ascites is exceedingly rare, and may be found in some patients with fulminant pseudomembranous colitis (PMC). The presence of ascites is not considered to be a well-known characteristic of C. diff-associated disease. Evaluation of PMC-related ascitic fluid reveals a low SAAG. Clinicians must expand their dif- ferential diagnosis to include PMC in patients presenting with low SAAG ascites, even when the initial presentation does not include diarrhea.

[1356] Surgical resection: colonic lipoma at site of intussusception.

Purpose: Disseminated Coccidioides immitis (C.immitis) occurs in ~1% of patients infected with C. immitis, with rare spread to the gastrointestinal (GI) tract. Reports of gastrointestinal involvement

[1367] Langerhans cell histiocytosis in a colonic polyp. Purpose: Langerhans cell histiocytosis (LCH) is a rare disorder of unknown pathogenesis. It is charac- terized by abnormal proliferation and dissemination of Langerhans cells, which are derived from the bone marrow. The disease most commonly affects the bones and the skin. Involvement of the GI tract is extremely rare. We report a case of isolated LCH in a colonic polyp. A 49-year-old woman presented with complaints of constipation, abdominal bloating, and mild change in bowel habits. She denied abdominal pain, early satiety, or weight loss. Family history was positive for colon cancer in her mother and mater- nal aunt. Physical exam was non-revealing. She underwent a diagnostic colonoscopy, which showed three diminutive polyps at the splenic flexure. These were removed by cold biopsy polypectomy. The rest of the colon exam was unremarkable. On histology, one of the polyps showed an ovoid collection of atypical cells within the submucosa. The cells were intermediate in size with eosinophilic cytoplasm and ovoid nuclei. The nuclei were convoluted. No cytoplasmic inclusions were identified. The atypical cells extended into the lamina propria. Immunohistochemical staining showed the cells to be strongly positive for CD1a and $100, which confirmed the diagnosis of LCH. The other polyps were hyperplastic. Sub- sequent extensive clinical work-up showed no evidence of disseminated LCH. Only mild eosinophilia (10.3% eosinophils) was evident. Liver function tests and urinalysis were normal. Chest x-ray showed no acute disease. CT chest showed no pulmonary lesions suggestive of Langerhans cell histiocytosis. There was no mediastinal lymphadenopathy. Review of published literature shows only a handful of cases of colonic involvement with LCH in adults. Most patients are either asymptomatic or have nonspecific GI symptoms. Polyps have usually been found incidentally on screening colonoscopy. The polyps are reported as small (less than 1 cm) and solitary, as in our patient. Only two patients have been reported to have progressed to multisystem disease with skin involvement.

[1370] CT scan of the abdomen without contrast showed mass in the cecal regior eroding through the abdominal wall with gas in the abdominal wall.

Background: Type 2 secondary aortoenteric fistulae (AEF), or para-prosthetic colonic fistulae, accounts for 15-20% of AEF. To our knowledge, there are no documented cases of para-prosthetic colonic fistulae via a Hartmann’s pouch in the current medical literature. Case presentation: A 73-year-old man presented to the VA hospital for evaluation of dizziness. His past history included atrial fibrillation, complicated C. diff colitis in 2009, requiring a Hartmann’s procedure, and an AAA repair in 2009 with aortobifemo- ral graft placement. He denied overt gastrointestinal bleeding from his colostomy and rectum, but did note having an increase in frequency and amount of rectal stools recently. He was initially hypotensive, with a blood pressure of 95/49. Abdominal examination revealed normal stool in his colostomy bag. No guarding, tenderness, or pulsating masses were present. On admission, his Hgb was 5.9 and his INR 9.10. Imaging of his thorax, abdomen, and pelvis showed contrast surrounding the stent in the aortic

[1378A] CMV stain showing CMV in brown. Purpose: A 66-year-old man with HTN was initially admitted for pancolitis and diarrhea, found to have a DVT, was initially discharged on empiric antibiotic therapy, only to return with continued bouts of diarrhea, despite radiographic resolution of pancolitis on a return hospital admission. After ruling common microbial etiologies for diarrhea by medication reconciliation and HIV testing, a colonoscopy revealed ulcerations. Pathology and histological staining of the biopsy confirmed the diagnosis of CMV colitis. Subsequent hospitalization, the patient's condition improved with conservative management and supportive care. CMV is a well-known opportunistic viral infection in immunocompromised patients. However, immunocompetent individuals may occasionally be infected with CMV colitis as well. GI tract

{1378B] CMV infected cells with “Owl Eye” inclusion bodies. (GIT) and CNS are the most frequent sites of CMV infection in immunocompetent adults (1,2,3). The most common site of GIT involvement is the colon. Another well known complication of CMV infectior in the immunocompetent population is the development of DVT (4). CMV can be a secondary pathoger that is superimposed on chronic, pre-existing disease in the gastrointestinal tract. Because of its lov incidence, CMV is not among the primary differentials in patients presenting diarrhea in immunocom. petent patients (5,6,7). However, clinicians should suspect CMV colitis in immunocompetent patient: who have negative stool studies and are refractory to empirical antibiotics therapy. Due to the irritating effects of CMV to the mucosa, as well as the vasculature, it is important clinicians maintain a high inde of suspicion for such a case (5).

Purpose: Gastrointestinal manifestations in HIV patients have a wide differential diagnosis, most frequently due to infectious organisms. We present a case of a 23-year-old HIV patient with chronic diarrhea. He recently relocated to Philadelphia from Georgia three months ago, when his symptoms started. He reports abdominal pain, watery, and non-bloody diarrhea for the past three months, which was occasionally accompanied by rectal bleeding. He remained afebrile and remained functionally well, thus deferring medical consultation. He was diagnosed with HIV five months prior, with a CD4 of 222, viral load 196978, and is in a monogamous homosexual relationship that includes anal sex. He is not on HAART, and takes ibuprofen as needed for pain. Physical exam is unremarkable, revealing a well-devel- oped, normal male. Complete blood count and comprehensive metabolic profile were unremarkable. Colonoscopy showed ileoproctocolitis with diffuse erythema from the rectal mucosa until the terminal ileum. There were multiple erythematous areas with adherent exudates (images attached). Stool cultures were sent. Random biopsy was performed, and pathology revealed small bowell tissue with atypical lym- phoreticular infiltrate and colonic tissue with atypical lymphoreticular infiltrate. No virus isolated. Stool cultures grew Shigella. Treatment with Ciprofloxacin for seven days was initiated, and symptoms resolved after. Shigella diarrhea is a rare cause of chronic diarrhea in an HIV patient. It usually presents as acute diarrhea with or without septicemia. There have been previous case reports on Shigella septicemia in the immunocompromised, including HIV patient. However, they usually have a more dramatic presentation. Our patient is the first documented case of Shigella diarrhea presenting as chronic diarrhea, and this should be included in the differential diagnosis in working up an HIV patient with chronic diarrhea.

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