Abstracts 2396 ACCEPTED: CLINICAL VIGNETTES ...

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2396 Stool Tools: PCR Detection of Astrovirus and Sapovirus Nilima Shet, Vikas Gupta, MD, PhD, David Wan, MD. New York-Presbyterian/Weill Cornell Medical Center, New York, NY FV is an 80 year-old woman with past medical history significant for hypertension, a partial colectomy for ischemic colitis, rheumatoid arthritis, pancreatic insufficiency, and coronary artery disease who had initially presented to her outpatient Gastroenterology follow-up reporting weight loss, constipation, and with continued iron-deficiency anemia. Ultimately, EGD and colonoscopy performed in November 2016 demonstrated only diverticulosis and internal hemorrhoids and pathology results from duodenal and gastric biopsies were unremarkable. In February 2017, she had presented to the Emergency Department complaining of 1 week’s duration of diarrhea that was not initially bloody though did have some blood with her last bowel movements prior to presentation. A CT scan of the abdomen revealed no obstruction and no bowel wall thickening. The PCR pathogen panel resulted detection of both astrovirus and sapovirus and other laboratory values for the patient, apart from her baseline anemia, were unremarkable. Upon treatment with loperamide, the patient’s diarrhea improved and she was discharged soon after presentation. Acute gastroenteritis (AGE) is characterized by the sudden onset of diarrhea, nausea, vomiting, and abdominal pain. Viruses are certainly the most common known agents of AGE and noroviruses, more specifically, have been estimated to cause 19-21 million cases of AGE per year. Viruses including rotavirus, astrovirus, and sapovirus have also been implicated in cases of AGE but more notably, among children. There seems to be little literature on the prevalence of astrovirus and sapovirus among the other AGE-causing viruses. Conventional diagnosis for such viruses has, in the past, been based on direct antigen detection and electron microscopy though enzyme immunoassays appear to be insensitive and not readily available for all relevant pathogens. Now, however, with the advent of single multiplex PCR testing, it has become easier to detect such pathogens. In fact, most laboratories now include real-time PCR testing as the gold standard for norovirus detection given poor performance of EIA and other assays in detecting the virus. Given use of the pathogen PCR panel, we may ultimately have more information surrounding the incidence and prevalence of astrovirus as well as sapovirus infection. Given this we will be able to glean more information surrounding the natural course of such viruses and the clinical significance infection with them bears.

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Am J Gastroenterol 2017; 112:S1305–S1378; doi:10.1038/ajg.2017.325

ACCEPTED: CLINICAL VIGNETTES/CASE REPORTS— SMALL INTESTINE

2397 Severe Bowel Ischemia? Think Again: A Case Report Titilope Olanipekun, MD, MPH, Valery Effoe, MD, MS, Jacquelyn S. Turner, MD, Michael Flood, MD. Morehouse School of Medicine, Atlanta, GA The clinical spectrum of ischemic bowel disease ranges from mild and transient injury, to bowel perforation, peritonitis and septic shock in severe cases. Clinical and radiologic findings are non-specific and seen in other gastrointestinal (GI) conditions such as infectious and inflammatory colitis, creating a diagnosis dilemma. A non-GI pathology mimicking severe ischemic bowel is even more clinically challenging. We present the unique case of a patient with features suggestive of severe ischemic bowel, who was found to have bladder necrosis during surgery. A 57 year old female with risk factors for

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ischemic bowel including hypertension, dyslipidemia, diabetes mellitus and End-Stage Renal Disease on hemodialysis was found unresponsive with a Glasgow Coma Scale of 3 and subsequently intubated. Chart review revealed treatment of Escherichia coli (E.coli) cystitis with bladder wall thickening on imaging (Figure 1) one year prior. On admission, her temperature was 95.5F, heart rate 102 beats per minute and blood pressure 76/55 mmHg. The rest of her physical examination was otherwise unremarkable. Laboratory findings were notable for elevated white blood count (WBC - 15.2K/ mcl), increased serum lactic acid levels (4.5 mmol/l), elevated serum procalcitonin to 112.5 ng/ml and E.coli bacteremia. Abdominopelvic CT scan showed small and large bowel thickening without evidence of obstruction or perforation (Figure 2), thickening and irregularity of the bladder wall with outpouchings (Figure 3), and mild ascites. She was admitted to the Intensive care unit (ICU) for treatment of septic shock from presumed ischemic bowel and E.coli bacteremia. By day 2 of ICU admission, her clinical condition deteriorated as evidenced by persistent hypotension, worsening leukocytosis (WBC - 33.1K/mcl) and severe lactic acidosis (lactic acid - 5.2mmol/l). She had urgent exploratory laparotomy which revealed necrotic bladder. There was no evidence of bowel ischemia as initially suspected. She had partial cystectomy and pathologic analysis of resected bladder tissue confirmed necrosis without malignancy. Our patient had cystitis, likely chronic, from E.coli infection complicated by bladder necrosis and septic shock. Interestingly, her presentation on admission mimicked severe E.coli - associated bowel ischemia. This case demonstrates that even in the presence of strong risk factors for ischemic bowel disease, clinicians should always consider other potential life threatening conditions.

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© 2017 by the American College of Gastroenterology

The American Journal of GASTROENTEROLOGY

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2398 A Rare Presentation of Multiple Lymphomatous Polyposis With Diffuse Metastatic Disease Marvi Rijhwani, MD1, Julien Fahed, MD1, Gerald Smith, MD2, Nizar Hallak, MD1, Aboud Affi, MD1. 1 Aurora Health Care, Milwaukee, WI; 2Aurora Heath Care, Milwaukee, WI

Mantle cell lymphoma (MCL) is a subtype of B-cell non-Hodgkin lymphoma which represents about 6% of all non-Hodgkin lymphomas. Extra-nodal involvement is well described and may be present in the bone marrow, blood, and gastrointestinal (GI) tract. Most GI tract involvement presents as a single lesion. Rarely, multiple polyps may be present throughout the entire GI tract suggesting multiple lymphomatous polyposis (MLP). We present a rare case of MCL with MLP and widespread metastases. Patient is a 75 year old male who presented with melena along with intermittent hematochezia. He reported fatigue but no fever, night sweats, or weight loss. He was noted to have a significant drop in his hemoglobin from 14g/dL to 9g/dL. Patient underwent colonoscopy and esophagogastroduodenoscopy (EGD) to rule out any inflammatory or malignant etiology. EGD revealed duodenal nodularity and the colonoscopy revealed significant nodularity in the rectum, transverse colon, right colon, ileocecal valve, and terminal ileum. Several biopsies were obtained during EGD and colonoscopy. Pathology reports were consistent with mantle cell lymphoma. Immuno-histochemical markers of samples obtained during colonoscopy were positive for CD5, CD20, Cyclin D1 and negative for CD3 and CD 10. Ki-67 was also positive. Patient was referred to an oncologist who ordered a bone marrow

[2398C] Atypical lymphoid infiltrate involving colonic mucosa (H&E stain, 20X).

biopsy and a PET-CT scan. Bone marrow was positive for mantle cell lymphoma involvement. PETCT revealed extensive hypermetabolic lymphomatous adenopathy throughout the neck including the nasopharynx, tonsils, chest, spleen, GI tract, and pelvis. The mantle cell lymphoma international prognostic index score was 3 indicating a poor prognosis. Patient will be undergoing chemotherapy with Bendamustine and Rituximab. Extra-nodal involvement of the GI tract is a well-recognized entity of mantle cell lymphoma. However, multiple lymphomatous polyposis is an uncommon presentation. GI symptoms may include abdominal pain, obstruction, or hematochezia. To confirm the diagnosis detection, either immunohistochemistry (IHC) or fluorescence in situ hybridization (FISH) of chromosomal translocation t[11;14] is necessary. Treatment is based on chemotherapy and is similar to any other mantle cell lymphoma. Chemotherapy regimens include cytarabine, rituximab, and autologous stem cell transplantation as bone marrow infiltration can be seen in up to 66% of the patients. Prognosis remains poor in advanced mantle cell lymphoma.

2399 Pouchitis Caused by Salmonella Braenderup Infection Brett Styskel, MD, Anam Khan, MD, Suneal Agarwal, MD. Baylor College of Medicine, Houston, TX

[2398A] Endoscopic findings revealed multiple nodular lesions in transverse colon.

[2398B] Lymphocytes of atypical lymphoid infiltrate show positive cytoplasmic staining with the immunohistochemical stain for CD20 (a B lymphocyte marker) (Immunohistochemical stain, 20X).


In patients with familial adenomatous polyposis (FAP), medically refractory ulcerative colitis (UC), or UC with dysplasia or cancer, standard treatment includes total proctocolectomy with ileal pouchanal anastomosis (IPAA). The most common complication of this procedure is pouchitis which is more common in patients with UC compared to FAP. Pouchitis can be secondary to infectious causes; commonly cited organisms include cytomegalovirus, Clostridium difficile, and Candida albicans. Pouchitis due to Salmonella species is rarely described, and cases in patients with underlying FAP have not been described. A 21-year-old woman with FAP and total proctocolectomy with a temporary endileostomy that was taken down five months ago with creation of an ileal pouch-anal anastomosis (IPAA) presented with watery diarrhea, abdominal pain and fever. She reported no recent sick con-

[2399A] Proximal limb of J-pouch with patchy ulcers.

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[2399B] Chronic active pouchitis with ulceration. Hematoxylin and Eosin stain. x100. [2400B] Coronal view of an abdominal CT showing “comb sign”. Findings are consistent with a hyper-vascular appearance of the mesentery in an active inflammatory state. tacts, travel or antibiotic use. Her abdomen was soft and non-tender, with no hepatosplenomegaly. Labwork was remarkable for leukocytosis (WBC = 11.4) and abnormal LFTs in a mild hepatocellular pattern (Total Bilirubin = 0.6, Alkaline phosphate = 270, ALT = 71, AST = 60). Stool culture was positive for Salmonella Braenderup. Colonoscopy showed patchy discrete ulcers within the J-pouch (Image 1). Biopsies of the ulcers and pouch wall showed chronic active inflammation with ulceration and abscess formation (Image 2). She was treated with ciprofloxacin and her symptoms resolved. Pouchitis can be caused by infections, ischemia, medications and inflammatory bowel disease. Characteristic endoscopic findings and biopsy aid in diagnosis. The occurrence of pouchitis is thought to be rare in patients who undergo IPAA for FAP compared to UC due to reduced mucosal blood flow in patients with UC compared to FAP. However, recent inquiry suggests pouchitis in FAP may be underecognized and present more mildly. Infectious pouchitis is thought to be secondary to alterations in the fecal microbiota due to fecal stasis within the pouch and broad spectrum antibiotics are usually indicated unless fecal cultures are positive for a specific pathogen. Salmonella has rarely been described to cause pouchitis. Salmonella Braenderup is uncommon in the United States and has been associated with outbreaks of gastroenteritis. The elevation in liver enzymes on presentation may have been a clue to underlying pathogen. Pouchitis secondary to Salmonella Braenderup has not been described previously in literature.

2400 Rare Manifestation of Gastrointestinal Lupus Nha T. Duong, DO1, Brian Moy, DO2, Houman Rezaizadeh, MD2. 1University of Connecticut Health Center, Windsor, CT; 2University of Connecticut Health Center, Farmington, CT Lupus enteritis is defined as inflammation or vasculitis of the small bowel and is a rare complication of systemic lupus erythematous (SLE). Clinical manifestations of this condition can include anorexia, nausea, vomiting, and diarrhea. We herein describe a case of lupus enteritis in a patient with a known

[2400A] Transverse view of an abdominal CT showing “target sign” in small bowel loops.


[2400C] Repeat scan 2 months after treatment showing improved bowel thickening and inflammation in the ascending colon.

history of systemic lupus erythematosus who presented with intractable nausea and vomiting after stopping her lupus medications. A 24-year-old female with history of SLE treated with Mycophenolic acid and Hydroxychloroquine, presented with constipation, nausea, and vomiting associated with a 25-pound weight loss. Symptoms were present during the 6 month time-frame when she was non-compliant with medications. Labs while off of medications were significant for an ANA titer of 1:5120, elevated anti-Sm and anti-RNP antibodies, positive anti-dsDNA antibodies, and a low complement level. Abdominal CT scan showed diffuse mural thickening involving the small and large bowel up to 1.5 cm. After failing conservative therapy, she was treated with IV steroids with near resolution of symptoms. On discharge the patient was continued on Prednisone, Mycophenolic acid, and Hydroxychloroquine. At her two week follow up, the patient reported persistent but improved symptoms. Once her steroids were tapered down, she experienced recurrence of symptoms requiring readmission to the hospital. Due to concerns for poor absorption of oral medications from the degree of her enterocolitis, she was maintained on weekly treatment with IV steroids along with Azathioprine, Hydroxychloroquine, and Rituximab. The importance of early diagnosis and treatment can improve symptoms of lupus enterocolitis. This condition typically presents with abdominal pain, diarrhea, and vomiting. Abdominal CT scan with contrast is key in the diagnosis. Imaging findings include circumferential and symmetric bowel wall thickening (target sign), engorgement of mesenteric vessels (comb sign), and increased attenuation of mesenteric fat. Treatment of this condition includes bowel rest coupled with high dose “pulse" IV steroids. Relapse is common especially in those with extensive bowel thickening greater than 9 mm. Since our patient demonstrated thickening of 1.5 cm, it is likely that she had high risk for relapse, which was reflected by her recurrent admission after stopping IV steroids. Our patient is currently maintained on IV steroids, Hydroxychloroquine, Azathioprine, and Rituximab without symptoms.


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Encountered a Black Swan During ERCP: A Rare Case of IVC Filter Migration to Ampulla

Duodenal Tuberculosis: A Case Report and Review of Literature

Monica Chowdhry, MD, Mustafa Bhaty, MD, Hazem Al Ashhab, MD. West Virginia University Health Sciences Center, Charleston, WV

Hendra Koncoro, MD, Rafael Eddy Setijoso, MD, FACG, Renaningtyas Tambun, MD. Saint Carolus Hospital, Jakarta, Jakarta Raya, Indonesia

Inferior Vena Cava (IVC) filter penetration of the vessel wall into surrounding gastrointestinal (GI) structures is a possible but rare complication. Few cases of IVC filter migration into the duodenum have been reported. We present a case of Greenfield IVC filter penetrating in the ampulla, visualized only during ERCP. To the best of our knowledge, IVC filter migration to ampulla has not been reported in the literature. An 87-year-old female presented to the hospital with melena, and abdominal pain. Her past medical history was significant for Atrial Fibrillation and recurrent DVTs for which she takes coumadin. The patient had a Greenfield IVC filter placed around 20 years ago for her recurrent DVTs as she had contraindication to anticoagulation at that time. She did not follow-up and the filter was not removed. On examination upper abdomen was tender. Lab studies revealed anemia (Hemoglobin 7.5 mg/dl ), supratherapeutic INR and abnormal liver function test suggestive of cholestasis. MRCP showed dilated bile ducts and choledocholithiasis. Upper GI endoscopy was performed but did not reveal any source of bleeding. GI bleeding resolved spontaneously with reversal of anticoagulation and supportive care. ERCP was then performed for management of choledocholithiasis which incidentally revealed a protruding piece of hardware which was consistent with Greenfield filter prawn (Image 1). The protruding prawn was grasped with the biopsy forceps and fluoroscopic images were taken (Image 2). Images confirmed it to be a part of IVC filter while the rest of body was extraluminal, likely in the IVC. It was left undisturbed while choledocholithiasis was treated with sphincterotomy. Patient's abdominal pain resolved.Considering patient’s age, comorbidities and her being asymptomatic, it was decided to manage the perforating filter conservatively. Long standing IVC filter can perforate the duodenal wall and can result in obscure GI bleeding. Generally, filters migrating to the duodenal wall can be seen on endoscopy with forward view scopes. We believe the migrated IVC filter caused GI bleeding in our patient which was missed on EGD. IVC filter strut at the ampulla was visualized only during an ERCP. One of the implications of this rare finding is that if there is high suspicion for IVC filter perforation, then inspection of the ampulla with a duodenoscope should be considered as well. Our case also highlights the importance of timely removal of IVC filters.

Gastrointestinal tuberculosis is rare and difficult in diagnose, as the nonspecific features which may lead to delays in diagnostic and increase complications. Duodenal involvement only affects 2%-2.5% of all gastrointestinal tuberculosis cases. Endoscopic biopsy is important yet usually shows nonspecific changes. We present a case of duodenal tuberculosis found in patient with upper gastrointestinal bleeding. A 27 year old Asian male patient presented with symptoms of hematemesis and anemia. He has neither history of drinking alcohol nor ingestion of analgetics. Vital signs showed tachycardia. Physical examination showed anemic conjunctiva and epigastric pain. The laboratory findings were noted for normocytic anemia and increased erythrocyte sedimentation rate. Immunoassay for fecal occult blood was positive. He underwent EGD for evaluation of overt gastrointestinal bleeding. EGD revealed normal esophagus; hyperemic erosion with signs of bleeding in stomach; duodenal mucosa showed large diverticle with active multiple ulcer and pus in its base in the second part of duodenum. Biopsy of duodenal mucosa was sent for histological examination, Ziehl-Nielsen stain showed AFB with caseosa necrosis of duodenal mucosa and aggregates of epitheloid and histiocytes in lamina propria. Antituberculosis drugs was given to the patient for 6 months and he is doing well on follow up. A review of the literature revealed shared clinical features among reported cases, including presence of epigastric pain and gastric hemorrhage. One of the largest series (Chavhan, et al.) that reviewed 23 adult patients with biopsy-proven gastroduodenal tuberculosis, only 26% had features of upper gastrointestinal bleeding. Puri et al found granulomatous inflammation with or without demonstration of AFB in 92% of the patients by endoscopic biopsy. The definitive diagnosis of tuberculosis in duodenum was made on the basis of pathologic lesions showing the presence of acid-fast bacilli (AFB) on Ziehl-Nielsen staining or tissue polymerase chain reaction positivity for Mycobacterium tuberculosis on endoscopic biopsies and/ or caseating granuloma in the biopsied material. In conclusion, in areas endemic for tuberculosis, duodenal tuberculosis have to be considered as differential diagnosis of upper gastrointestinal bleeding.

[2401A] Leg of IVC filter seen perforating at Ampulla during ERCP.

[2401B] Fluoroscopic image showing IVC filter.



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[2402A] Endoscopy showed large duodenal diverticula with multiple ulcers.

[2402B] Histopathology: duodenal mucosa showed caseosa necrosis and acid-fast bacilli.

2403 Pseudomelanosis Duodeni: A Benign Pigmentation or a Precancerous Condition? Waseem Amjad, MD1, Sadia Malik, MD2, Umair Sohail, MD2. 1Northwell Long Island Jewish Forest Hills Hospital, New York, NY; 2East Texas Medical Center, Tyler, NY Presence of black or brownish spotty pigmentation in mucosal wall of duodenum evident on endoscopy is called pseudomelanosis duodeni (PMD) or melanosis duodeni. Our aim is to present a case of a patient with iron deficiency anemia who had an upper endoscopy and was found to have diffuse pigmentation in duodenum. A 80 year old female with history of hypertension, chronic kidney disease stage 4, iron deficiency anemia who presented for evaluation of anemia. She complained of having dark colored stool for being on iron supplements, but no overt gastrointestinal bleeding. Physical examination was unremarkable. Her laboratory results showed hemoglobin of 11.1 g/dl, hematocrit of 34.6, BUN of 30, creatinine of 2.05. She underwent an EGD and colonoscopy. EGD showed black speckled pigmentation of the duodenal mucosa (Figure 1). Duodenal biopsies showed hemosiderin deposition in the lamina propria of the duodenum, consistent with a diagnosis of pseudomelanosis duodeni. Her colonoscopy was unremarkable. She also underwent capsule endoscopy that showed the pigmentation in the duodenum, with normal appearing remaining small bowel mucosa. PMD is the rare endoscopic appearance of black speckled pigmentation of the duodenum commonly seen in females in the sixth and seventh decades of life. Duodenum is the most common extra colonic gastrointestinal site for pseudomelanosis. While melanosis coli is secondary to accumulation of lipofuscin in the macrophages of the lamina propria, the predominant pigments deposited in PMD are iron sulfide and hemosiderin. The pathogenesis is unclear, it could be secondary to iron deposition as a result of intra-mucosal hemorrhage or impaired iron transport after iron supplementation. Pseudomelanosis duodeni is associated with chronic renal failure, chronic heart failure, gastrointestinal bleeding, hypertension, diabetes mellitus, and the use of certain drugs, such as ferrous sulfate, methyldopa, hydralazine, thiazide, propranolol, digoxin and furosemide. There is no known association with use of laxatives. In conclusion, pseudomelanosis duodeni has unclear diagnostic and prognostic significance and long-term clinical impact of these depositions remains unclear. There is no specific treatment or follow up protocol. Dark mucosal appearance on endoscopy is uncommon and can be a diagnostic challenge for physicians.

[2403] Speckled dark pigmentation of mucosa of duodenal bulb.

2404 An Unusual Case of Acute Pancreatitis With Coexisting Duodenal Diverticulitis Waseem Amjad, MD, Sarah Pervaiz, MBBS, Sayeda Hasan, MBBS, Sophia Jagroop, MD, FACG. Northwell Long Island Jewish Forest Hills Hospital, New York, NY The duodenal diverticulum is mucosal outpouching of the duodenum which can lead to pancreaticobiliary disease due to its anatomical location. We are presenting a case where the patient developed



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2405 Mesenteric Panniculitis: An Unusual Case of Abdominal Pain Due to Undiagnosed Lymphoma Waseem Amjad, MD1, Sadia Malik, MD2, Umair Sohail, MD2. 1Northwell Long Island Jewish Forest Hills Hospital, New York, NY; 2East Texas Medical Center, Tyler, NY

[2404A] Axial view CT abdomen showing duodenal diverticulum (red arrow) with inflammation around duodenal wall and head of pancreas.

Mesenteric panniculitis is a benign fibrosing inflammatory condition of adipose tissue of mesentery. Our aim is to present a case of a patient with abdominal pain who had mesenteric panniculitis on abdominal imaging and was found to have mesenteric follicular lymphoma. A 64 year old male with history of hyperlipidemia presented with severe abdominal pain for 7 days which was located in upper abdomen and associated with vomiting. Examination showed stable vitals and upper abdominal tenderness. The routine laboratory results were normal. Ultrasound abdomen showed gallstones without any biliary obstruction or signs of cholecystitis. CT scan of abdomen revealed severe central mesenteric panniculitis with small peri-aortic nodes. Gallbladder ejection fraction was 20% on HIDA scan. Patient underwent laparoscopic cholecystectomy and mesenteric lymph node biopsy which showed atypical lymphoid infiltrate in adipose tissue suspicious of follicular lymphoma. Inflammation of mesenteric fat tissue characterized by chronic inflammation, fibrosis and necrosis is called mesenteric panniculitis (MP). It is also known as mesenteric lipodystrophy, sclerosing mesenteritis or mesenteric adenitis. Exact etiology is unknown. MP is associated with variety of neoplasms, previous abdominal surgeries or trauma, autoimmune conditions, infections and gastrointestinal conditions (pancreatitis, cirrhosis, peptic ulcer, cholelithiasis and celiac disease). It most commonly involves mesentery of small intestine (found in 90% cases) but it can also involve colonic mesentery. It is asymptomatic in 30-50% cases, it can present as chronic abdominal pain, bloating, diarrhea and infrequently as vomiting, weight loss and constipation. CT scan is imaging modality of choice and shows findings of fat ring sign and tumor pseudo capsule. Biopsy is required for definite diagnosis. MP is usually benign. Symptomatic patients have responded well to steroids. Glucocorticoids in combination with tamoxifen are the preferred first-line therapy while azathioprine or cyclophosphamide may be useful adjuncts. Surgery is recommended for cases where medical therapy is unsuccessful or for patients who develop complications as bowel obstruction or perforation. Mesenteric panniculitis is complex disorder with variable presentation. It may be associated with serious underlying conditions such as neoplasms. Early diagnosis treatment should be individualized based upon symptoms, complications and comorbidities.

2406 Pseudomelanosis Duodeni: Is it Just an Incidental Finding? Ciel Harris, MD1, Asim Shuja, MD2, Jian Guan, MD, PhD3, Ahmad Alkhasawneh, MD1, Miguel Malespin, MD2, Silvio de Melo, Jr., MD2. 1University of Florida College of Medicine, Jacksonville, FL; 2University of Florida College of Medicine Jacksonville, Jacksonville, FL; 3Florida Hospital, Orlando, FL

[2404B] MRI abdomen showing Duodenal diverticula connected to duodenum (red arrow).

Pseudomelanosis duodeni (PD) is a rare condition that when seen on endoscopy can promote apprehension. With the increasing rise of endoscopy on the aging patient population, it is important to be familiar with the characteristics and natural history of this condition. A 67 year old female with history of Diabetes Mellitus and Heart Failure presented with gradual fatigue. She denied abdominal pain, hematemesis, hematochezia or melena. Medication history was notable for ferrous sulphate and hydralazine. Examination was normal. Labs showed a Hb 5 g/dl, MCV 70.7 fl, ferritin 25 ng/ml, serum iron 30 ug/dL, iron saturation 7% and a TIBC 401mcg/dl. The patient received a blood transfusion and GI was consulted. Endoscopy showed diffuse black speckled mucosa in the esophagus, stomach and duodenum (Fig 1&2). Duodenal Biopsies were taken with a cold forceps. Results showed pigment deposition in macrophages of the lamina propria (Fig 3). Staining identified the pigment to be iron and PD was diagnosed. PD is a rare condition of uncertain significance, first described in 1976. Its true incidence and prevalence is yet to be established. PD occurs predominantly in females in the 6th-7th decades of life. The term “pseudomelanosis” was first introduced as initially the pigment was interpreted as melanin. However it has now been demonstrated to be ferrous sulfide. PD is typically found incidentally on endoscopy and does not have any hallmark clinical features. It has been associated with end stage renal disease, diabetes, multiple medications and gastrointestinal bleeding. Our patient was on iron and hydralazine both of which have been linked to PD. The most common site involved is the duodenum with esophageal and stomach involvement even rarer. Typically on endoscopy the proximal duodenal mucosa is speckled

acute pancreatitis and duodenal diverticulitis simultaneously. A 67-year-old female with the history of hypothyroidism, hypertension came with severe and epigastric pain associated with fever and vomiting. Labs showed leukocytosis of 15.1 thousand/ microliter, lipase was 23,100 U/L. Liver function tests were normal. CT abdomen showed marked edema surrounding the head of the pancreas as well as an adjacent 3.9 x 2.3 cm2 duodenal diverticulum. The patient was kept NPO, started on piperacillintazobactam and aggressive IV hydration was given. Ultrasound showed dilated common bile duct measuring 1.1 cm. No gall stones were noticed. Blood cultures grew staphylococcus lugdunensis, the antibiotic was changed to nafcillin based on sensitivity. MRI confirmed the finding of CT scan. Patient symptoms started improving, diet was advanced as tolerated. Repeat blood culture were negative. The patient refused to undergo an endoscopy. She was discharged on day 7 with 1 more week of antibiotics. Duodenal diverticulum within 2-3 cm radius of the ampulla of Vater is called periampullary diverticula (PAD). Advanced age and increased intraluminal pressure can lead to the diverticulum formation. Duodenal diverticulum usually arises from an area of weak points as perivascular connective tissue sheath and site of entry of pancreaticobiliary ducts. The PAD is associated with biliary stones and pancreatitis. Studies have shown pancreatitis in patients with PAD without evidence of gallstones. Duodenal diverticulitis is a rare event which can predispose to an inflammatory process in adjacent organs as pancreas and liver. MRI gives a multiplaner view and better soft tissue contrast and differentiates PAD from cystic lesions and tumors. Duodenal diverticulitis is usually managed conservatively with IV hydration, bowel rest, and broad spectrum antibiotics. Surgical treatment is recommended in cases with complications as gastrointestinal bleeding, gastrointestinal obstruction, bowel perforation, pancreaticobiliary obstruction. A Duodenal diverticulum is usually a benign condition but can lead to serious complications as acute pancreatitis. In elder population before defining the episode as idiopathic pancreatitis, duodenal diverticulum should be considered as possible etiology.

[2406A] Showing PD involvement in the Esophagus.



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with multiple flat, small dark spots. Histologically these lesions will show macrophages laden with a characteristic brown-black granular pigment within the lamina propria of the villi on microscopy. Histochemical stains for iron (Perl’s prussian blue) or melanin (Masson-Fontana) may be positive however this is uneven and unpredictable. Its peculiar appearance can lead to a diagnostic dilemma with differentials including metastatic melanoma, charcoal or hemosiderosis. There is no gold standard therapy, with no particular follow up recommended. Prognosis of PD is yet to be determined however the lack of cytological atypia on histology is reassuring.

2407 Isolated Superior Mesenteric Artery Dissection: An Uncommon Cause of Abdominal Pain Divyesh Nemakayala, MD1, Kirtana Nimmakayala2, Rajit Pahwa, MD1. 1Michigan State University, Lansing, MI; 2Michigan State University, Rochester, MI

[2406B] Showing the hallmark appearance of PD with black speckled appearance in the Duodenum.

Acute abdominal pain secondary to mesenteric ischemia caused by spontaneous superior mesenteric artery (SMA) dissection, with no other abnormality or aortic dissection, is unusual. There have been about 56 cases reported since 1947. However, there have been very few reported cases in literature of accelerated hypertension causing isolated SMA dissection in a female. We report a case of spontaneous, isolated SMA dissection, not involving the aorta or the SMA origin, which was managed conservatively in a female patient. A 51-year-old female with past medical history of cholecystectomy presented with diffuse abdominal pain that radiated to the back. It was associated with nausea, and one episode of vomiting. Patient was noted to have a blood pressure of 226/111 mmHg. On physical exam, patient was inconsolable and writhing in pain. She had decreased bowel sounds, but had a soft, non-tender abdomen to palpation. Patient had lactate level of 0.7 mmol/L. Computed tomography (CT) angiogram of the chest/abdomen/pelvis with contrast showed SMA dissection. Patient was managed with IV narcotics, IV heparin, and IV esmolol with a target systolic blood pressure goal < 120 mmHg. Lactate remained within normal limits. Repeat CT angiogram of chest/abdomen/pelvis on day 3 of hospitalization was ordered which showed no change in size of the dissection. Patient was switched to oral antihypertensives. We chose to stop heparin and start aspirin and clopidogrel. Patient’s abdominal pain had subsided after aggressive blood pressure control. She was discharged with instructions to follow up with subsequent

[2406C] Showing Duodenal Biopsy on H&E stain and Iron Stain, positive for Iron within the Macrophages.

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CT scans if symptoms persist. The pathogenesis behind the case in our patient appears to be that the accelerated hypertension caused high stress on the wall of the superior mesenteric artery at the inferior pancreatic edge causing dissection. The hypothesis from Solis et al states that this type of dissection appears to cause transient mesenteric ischemia causing abdominal pain. Other proposed etiologies of SMA dissection include atherosclerosis, fibrodysplasia, trauma, and connective tissue disorders. Suzuki et al reports that CT angiography is the appropriate imaging modality to investigate SMA dissections. It appears that there is no clear treatment protocol for SMA dissection. There are options for surgery, endovascular stenting, and conservative management. Patients managed conservatively should be followed up closely to look for signs of worsening mesenteric ischemia.

2408 An Uncommon Cause of a Small Bowel Obstruction Ali Zakaria, MD, Bayan Al Share, MD, Issam Turk, MD, Emily Tommolino, MD, Samira Ahsan, MD. Providence Hospital Medical Center, Southfield, MI Introduction: Sarcoidosis is a systemic granulomatous disease of unknown etiology, characterized by the formation of non-caseating granulomas. GI involvement is very rare and can occur in a patient with known sarcoidosis or as the initial manifestation of the disease. Small bowel obstruction secondary to sarcoidosis has been described in few case reports. Case Report: A 67 y/o female with previous history of inactive pulmonary sarcoidosis presented with five-day history of nausea, vomiting, abdominal pain, and constipation. Abdominal X ray and CT scan with contrast demonstrated a high grade small bowel obstruction. She was treated conservatively, but as her symptoms progressively worsened, diagnostic laparoscopy was performed and revealed skin tag appearing lesions on the antimesenteric surface of the mid jejunum causing inflammatory adhesions to the mesentery. The bowel was completely viable with no additional lesions in the liver, stomach or visible parts of the colon. Histopathology of tissue biopsy revealed lymphohistiocytic non-caseating granulomatous inflammation with multinucleated giant cells, consistent with sarcoidosis. The patient was discharged on prednisone taper dose with close follow up. Discussion: GI system involvement that is clinically recognizable occurs in 0.1-0.9% of patients with sarcoidosis, with one study revealed small intestine involvement in 0.03% of the cases. It usually occurs in patients in their fifth or sixth decade of life with evidence of multisystem sarcoidosis in approximately one-half of patients. Establishing a definitive diagnosis of GI sarcoidosis depends on three components: 1) Biopsy evidence of non-caseating granulomas in the "symptomatic organ", 2) Exclusion of other causes of granulomatous disease, particularly mycobacterial, fungal, and parasitic infections, and 3) Clinical, radiographic, and optimally histopathologic evidence of sarcoidosis in at least one other organ system. Treatment of GI sarcoidosis depends on symptomatology. Asymptomatic patients can be monitored without active therapy, while symptomatic patients with organ involvement should be treated with

[2407C] .

[2408B] Intraoperative demonstration of the skin tag appearing lesion at the level of mid jejunum causing inflammatory adhesions.

[2408A] Computed tomography (CT) scan of the abdomen demonstrated early complete bowel obstruction at the level of mid-jejunum (A,B). Gastrografin small bowel followthrough demonstrated failure of contrast to pass into the colon (C).



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[2408C] Histopathology of the resected small bowel lesion (A) H&E stain revealed lymphohistiocytic non-caseating granuloma with multinucleated giant cells (black arrow). (B) Negative for acid fast bacilli (AFB) stain. (C) GMS stain negative for fungal infection.

steroid until a response to therapy is noted followed by gradual taper. The optimal duration of steroid treatment for GI sarcoidosis is not known, but experts recommend treating the initial manifestation for at least one year. Other treatments such as surgical intervention may be necessary in patients with bowel obstruction, perforation, or hemorrhage.

2410 Unlikely Organisms During an Evaluation for Abdominal Pain in an Immunosuppressed Patient Feng Li, MD, Christina A. Arnold, MD, Philip Hart, MD. The Ohio State University Wexner Medical Center, Columbus, OH

2409 Pseudomelanosis Intestini Ali Zakaria, MD1, Bayan Al Share, MD1, Issam Turk, MD1, Mia Manabat, DO2, Kha Ngo, DO3. 1 Providence Hospital Medical Center, Southfield, MI; 2St. John Providence Hospital, Royal Oak, MI; 3 St. John Providence Hospital, Southfield, MI Introduction: Gastrointestinal melanosis is the term used to describe the accumulation of pigment deposits in the intestinal mucosa. Melanosis coli is a well-known condition associated with the use of anthraceneline laxatives, however melanosis of the small intestine is extremely rare. We report a case of pseudomelanosis inestini involving the pylorus, duodenum, and proximal jejunum in a patient presented with GI bleeding. The clinical significance of this condition is unknown, however gastroentero logists should be aware of its existence. Case Report: A 70 y/o female with a past medical history of atrial fibrillation on warfarin therapy, chronic obstructive pulmonary disease, hypertension, congestive heart failure, and chronic kidney disease stage IIIb, presented with recurrent melena. Her initial EGD revealed a non-bleeding gastric ulcer with a clean ulcer base (Forrest Class III) on the lesser curvature of the gastric antrum, and diffuse duodenal melanosis. She had another episode of melena for which repeated EGD showed same non-bleeding ulcer, and melanosis of the gastric antrum and duodenum. She was treated conservatively and was discharged in stable condition. She presented three weeks later with same complain. Double balloon enteroscopy was performed and revealed melanosis of the duodenum and jejunum (280cm distal to the pylorus). The entire colon and examined portion of the ileum were normal with no evidence of melanosis. Histopathology revealed macrophages containing dark pigmented granules within the lamina propria, which were non-reactive to Perl's iron stain. Discussion: Pseudomelanosis intestine is a benign condition refers to the rare endoscopic appearance of dark pigment deposits in the intestinal mucosa. It can be due to the deposition of melanin-like substances, hemosiderin, lipomelanin, lipofuscin or ferrous sulfate. It usually occurs in patients in their sixth and seventh decade of life with a female predominance. It has been mainly described in patients with certain chronic illnesses, such as chronic kidney disease, hypertension, and GI bleeding. Various medications, such as ferrous sulfate, hydralazine, and furosemide, has been associated with this condition as well. However, the etiologic mechanism, clinical significance, and prognostic and long-term impact of this condition remains unknown. Also, there’s no established recommendation regarding the need for therapeutic interventions or regular upper endoscopy survey.

Case Report: A 44 year old man with AIDS (with CD4 count 41 cells per mm3, not on therapy) and a history of chronic hepatitis C presented for evaluation of abdominal pain and odynophagia. The pain was located in the epigastrium and was not associated with radiation. His odynophagia was persistent despite an empiric course of fluconazole. He denied any associated symptoms of nausea, vomiting, or weight loss. He underwent an esophagogastroduodenoscopy (EGD), which demonstrated esophageal ulcers as well as diffusely friable and inflamed mucosa in the duodenum (Figure A). Esophageal and duodenal biopsies demonstrated concurrent opportunistic infections in the esophagus as well as intestinal cryptosporidiosis.Hematoxylin & Eosin (H&E) staining of the esophageal biopsy showed CMV, Candida, and Sarcina, confirming polymicrobial infection of the esophageal muscosa. Sarcina organisms were focally seen in the esophagus, with their characteristic tetrad forms admixed among the ulcer debris (Figure B). Cryptosporidium organisms, seen on duodenum biopsy, are most easily identified along the brush border as small, round bodies on the surface of the epithelium, confined to the apical surfaces of enterocytes (Figure C). Based the presenting symptoms, the patient was treated with oral nitazoxanide for intestinal Cryptosporidiosis as well as fluconazole for the esophageal candida. Due to the uncertain role of antimicrobials, treatment was not recommended for Sarcina. Antiviral therapy was not initiated for CMV due to a low serum PCR level. At two week follow-up, he was tolerating a normal diet without abdominal pain. Cryptosporidium is a parasite that can lead to symptoms in immunocompromised patients, including abdominal pain and a profuse secretory diarrhea. Most with Cryptosporidium infection have normal duodenal villous architecture, and either a normal or moderately increased inflammatory component of the lamina propria. Flattening of the villi and apoptotic bodies in the crypts have been associated with more severe infections. Sarcina organisms are ubiquitous in the environment, however infection and colonization has been described on gastric biopsies in the setting of functional gastric outlet obstruction and delayed gastric emptying. The role of antibiotic treatment for Sarcina (typically with ciprofloxacin and metronidazole) in a clinically stable patient is unproven. (Informed consent was obtained from the patient)

[2409A] Endoscopic image reveals dark pigment deposits in the pylorus.



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[2409B] Endoscopic image reveals dark pigment deposits in the duodenum.

[2410C] Cryptosporidium organisms seen in the duodenum. [2410A] Endoscopic view of duodenum.

2411 Reversal of Superior Mesenteric Artery Syndrome Following Pregnancy Jonathan C. Hillyard, DO1, Sanjeev S. Solomon, MBBS2, Matthew Kaspar, MD1, Eric Chow, MD1, George Smallfield, MD1. 1Virginia Commonwealth University Health System, Richmond, VA; 2Virginia Commonwealth University Medical Center, Richmond, VA

[2410B] Sarcina organisms seen in the esophagus.


Superior mesenteric artery (SMA) syndrome is defined as a compression of the third portion of the duodenum between the superior mesenteric artery and the aorta. When severe, this syndrome usually presents as a gastric outlet obstruction. Reversal of this syndrome after pregnancy is described in this case. A 38-year-old female presented to the emergency department with mid-epigastric pain and intractable vomiting. CT imaging revealed the presence of a massively dilated stomach and compression of the third portion of the duodenum consistent with SMA syndrome (Figure 1 – Arrow pointing to SMA, Star in dilated duodenum). Plans to surgically correct this anomaly were postponed when the patient became pregnant. The patient was followed by a high risk obstetric practice and had difficulty gaining appropriate weight. Despite supportive care, she had a low body mass index, low fetal weight, and worsening symptoms during her pregnancy. The patient was first seen by Gastroenterology when she was 24 weeks gestation. Following initial workup, surgical intervention was proposed due to persistent epigastric pain and inadequate weight gain. Feeding tube placement was also offered as an alternative treatment for weight difficulties however was not necessary as the patient eventually tolerated a sufficient liquid diet. Plans were made to postpone endoscopic evaluation and eventual surgical correction until after successful delivery of the fetus. Supportive care was sufficiently provided in the interim. Following delivery, both abdominal bloating as well as other obstructive symptomatology improved significantly. Repeat imaging showed no evidence of SMA syndrome (Figure 2, Arrow near SMA in the third duodenum). Endoscopy was also performed and supported the resolution of SMA syndrome. There are many complications that are associated with SMA syndrome, especially when it involves patients who are pregnant. Nutritional deficiencies that create difficulties with proper fetal growth and development have been associated with recurrent pregnancy loss. This case demonstrates the first known report of the resolution of SMA syndrome following pregnancy. While the mechanism is not completely known, one may hypothesize that some of the physiologic changes with pregnancy allowing smooth muscle relaxation naturally correct the obstructive angles seen with this syndrome. Additionally, shifting weights due to the growing fetus may also contribute to the resolution.


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[2412A] .

[2411A] Massively dilated stomach caused by gastric outlet obstruction. Red arrow pointing to SMA, star in dilated duodenum.

[2412B] .

[2411B] Red arrow indicates normal caliber duodenum as it crosses midline. The stomach and proximal duodenum are normal in caliber after resolution of the SMA syndrome.

2412 Adalimumab-Inducing Reactivation of Tuberculosis With Previously Negative QuantiFERON Test Rooma Nankani, MD1, Sidney Olefson, MD1, Ameet Kumar, MD2, Houman Rezaizadeh, MD3. 1University of Connecticut School of Medicine, Farmington, CT; 2Queens Hospital Center, New York, NY; 3University of Connecticut Health Center, Farmington, CT Intestinal tuberculosis (TB) is a very rare disease in the 21st Century. This case highlights the necessity of including TB enteritis as a differential diagnosis in patients who had previously negative interferon-


gamma release assay (Quantiferron) who presents with non-specific abdominal symptoms while on immunosuppressive therapy. A 37 year old Bangladeshi male with a remote history of treated pulmonary TB and Psoriasis, presented with fever and loose stools for one month. Fever was intermittent, associated with night sweats and mild RLQ discomfort. He denied sick contacts or recent travel history. Three months prior to admission, dermatology had initiated Adalimumab (ADA) for refractory Psoriasis. Prior to starting ADA, sputum and interferon-gamma release assay was negative. Physical exam was notable for temperature of 103 degrees F and mild RLQ tenderness without a discrete mass. CBC, serum transaminases, lipase, viral hepatitis panel, and HIV assay were all negative. ESR was elevated at 110 and CRP at 220. Sputum culture for AFB, stool culture and blood culture were negative. Chest x-ray and CT chest was unremarkable. CT abdomen and pelvis showed short segment mural thickening of the terminal ileum with bowel distention, right retroperitoneal lymphadenopathy and 4.2 cm right retroperitoneal lymph node conglomerate. Pt underwent CT guided biopsy of mesenteric lymph node which showed patchy necrosis, multinucleated giant cells, few granulomas and rare acid fast bacilli. Pt was started on TB therapy with improvement in symptoms. Extra-pulmonary TB (EPTB) is found in approximately 20% of the patients with TB in the U.S. The 6th most common extra pulmonary site is the ileocecal region. Clinical and radiological findings of GI TB often mimic diseases such as Crohn's disease and malignancy. Therefore, this can lead to delays in accurate diagnosis and treatment. This is particularly true for a case like ours, where a prior negative Quantiferron may ‘rule-out’ TB as a diagnostic possibility. Our case points out that under circumstances where a high index of suspicion for EPTB exists, particularly in patients with negative PPD, Quantiferron, and sputum, lymph node biopsy can be a very impor-


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tant supplement to our diagnostic armamentarium. An algorithm of these diagnostic methods leads to considerably higher precision in the diagnosis of this insidious disease which primarily necessitates a clinical awareness of this serious health problem.

2413 Chylous Ascites: A Rare Association With Metastatic Carcinoid Laith Al Momani, MD, Lindsey Crosnoe-Shipley, BS, Jennifer Phemister, MD, James Allen Swenson, MD, Mark Young, MD. East Tennessee State University, Johnson City, TN Carcinoid tumors are a type of neuroendocrine tumors derived from enterochromaffin cells. Rarely, it can lead to ascites. Even fewer cases in the literature report an even less common type of ascites, chylous ascites, which is a milky-appearing peritoneal fluid rich in triglycerides due to the presence of lymph. Here we present a patient who developed recurrent chylous ascites as a result of his metastatic carcinoid tumor. His condition was effectively managed with monthly octreotide injections. A 66 year old male patient referred to the Gastroenterology clinic with recurrent increasing ascites. He was diagnosed with metastatic carcinoid three years prior to presentation and had been followed by Oncology. He started complaining of abdominal distention and increased girth of a few months duration. The diagnosis of chylous ascites was made necessitating multiple diagnostic and therapeutic paracentesis. He had no symptomatic complaints with regards to his metastatic disease. In addition, the patient denied any history of alcohol, tobacco or illicit drug use. His physical exam was benign and his laboratory work up was within normal limits, including his liver function test. Review of cytologic examination of the ascitic fluid was negative for neoplastic cells. A screening colonoscopy performed five years prior was unremarkable. Subsequently, monthly octreotide injections were continued, and not only did that aid in alleviating his symptoms of carcinoid syndrome, but also his ascites significantly improved as he has not required a paracentesis since then. Chylous ascites is an extremely rare complication to develop in patients with known metastatic carcinoid tumor. Review of the literature suggests it may be caused by serotonin induced fibrosis of the mesentery either in the lymph nodes themselves or within the lymphatic ducts causing secondary lymphangiectasia. Hence why the presence of chylous ascites is thought to be a predictor of a poor outcome. Paracentesis should be performed in carcinoid patients with new onset ascites for ascitic fluid testing and analysis to rule out other more common etiologies. In addition, the use of chromogranin-A quantitative assay from both serum and ascetic fluid may be considered in the evaluation. Although chylous ascites is a predictor of a poor outcome in patients with carcinoid tumors, if diagnosed, Octreotide can aid in the management of both carcinoid syndrome symptoms and chylous ascites as observed in this particular patient.

[2414A] CT Abdomen and pelvis showing ileocolic and jejunojejunal intussusceptions (white arrows) along with filling defects suggestive of ileal polyps (red arrows).

2414 Undiagnosed Peutz-Jeghers Syndrome Presenting With Multiple, Simultaneous Small Bowel Intussusceptions: A Case Report Syed R. Shah, MD1, Syed Abdul Basit, MD2. 1University of Nevada School of Medicine Las Vegas, Las Vegas, NV; 2University of Nevada School of Medicine, Las Vegas, NV INTRODUCTION: Peutz-Jeghers Syndrome (PJS) is a rare genetic disorder, characterized by autosomal dominant inheritance (ADI), abnormal mucocutaneous pigmentation, multiple gastrointestinal (GI) hamartomatous polyps (HP) and increased risk of both intra and extraintestinal malignancies. The presenting symptoms include nausea, vomiting, abdominal pain, gastrointestinal bleeding, and anemia. Complications such as recurrent episodes of polyp induced bowel obstruction often need surgical intervention. We present a case of a young, Hispanic post-partum woman with multiple simultaneous small bowel intussusceptions secondary to PJS. CASE REPORT: A 20-year-old, 3 weeks postpartum female with no significant past medical history was admitted for recurrent episodes of flank pain. She was treated with antibiotics for possible urinary tract infection without any improvement.Physical exam revealed dark spots on lips, buccal mucosa, and finger-tips.She denied any previous history of (GI) disorders and had no other family members with similar skin findings. CT scan of the abdomen showed multiple sites of intussusceptions and polyps in the GI tract, as shown in figure 1 and 2. Patient had surgical exploration with the goal of relieving intussusceptions and pathological diagnosis of small bowel masses. During surgery, multiple intussusceptions were reduced and partial small bowel resection was performed. Histopathology of three specimens showed characteristic HP consistent with PJS, as shown in fig 3.Genetic counseling and cancer screening was recommended. DISCUSSION: PJS has ADI pattern, caused by mutation of STK11(LKB1)gene. Familial disorders are responsible for 70-80% of cases.. The distinct clinical feature is melanin pigmentation which is present in more than 90% of patients of PJS involving lips and buccal mucosa. GI HP have been reported throughout the GI tract, however,most commonly involve jejunum . The diagnosis of PJS is based on histopathological determination of HP and at least two of the following clinical features i-e positive family history , small intestine polyps and mucosal hyperpigmentation..

[2414B] CT Abdomen and pelvis showing jejunojejunal intussusception (white arrow).

[2414C] (a,b) Histologic sections demonstrate benign small bowel containing polyp composed of small bowel epithelial hyperplasia with an arborizing smooth muscle core with no evidence of high grade dysplasia or malignancy consistent with a hamartomatous polyp. The American Journal of GASTROENTEROLOGY


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CONCLUSION: Intussusception should always be considered in the differential diagnosis of acute onset abdominal pain in subjects with a known history or clinical features of PJS. Cross sectional imaging of GI tract is the investigation of choice and should be considered early to confirm the suspicion of intussusception.

2415 Concurrent Findings of a GIST Tumor and Carcinoid Tumor in an Elderly Female Alexa Sasson, MD1, Jonathan Weinberger, MD2, Seth Lapin, MD1, Rabin Rahmani, MD1. 1Maimonides Medical Center, Brooklyn, NY; 2Maimonides Medical Center, New York, NY Gastrointestinal stromal tumors (GIST) are sporadic growths that account for less than 1% of GI tumors. They are the most common group of mesenchymal neoplasms and can occur in any portion of the alimentary tract. Carcinoid tumors are relatively rare tumors that are well-differentiated neuroendocrine growths, the majority of which arise in the GI tract. Both GIST and carcinoid tumors are potentially malignant and the pathogenesis of concurrent findings in a patient remains unclear. We are presenting a rare case of a patient who had concomitant findings of a GIST and carcinoid tumor. A 70-year-old woman presented with 2 months of progressively worsening abdominal pain associated with early satiety. She also noted increasing abdominal fullness over a period of 2 years. Physical exam revealed a distended abdomen with a lower abdominal central mass that was palpable up to the umbilicus with moderate tenderness to palpation. CT scan of the abdomen and pelvis revealed a large irregular enhancing mass within the pelvis which extended into the lower abdomen, measuring approximately 14.0 x 14.0 x 15.0 cm which may be arising from the right adnexa and was suspicious for a large heterogeneous ovarian mass. A portion of the mass appeared to erode into the wall of the adjacent cecum. MRI of the pelvis revealed mostly necrosis and blood in the center of the mass with a circumferential ring of solid nodules. Colonoscopy and exploratory laparotomy were performed. Colonoscopy revealed 1 cm rectosigmoid polyp and a 2.5 cm ascending colon polyp that were not removed, and no erosion of the mass into the cecum. Laparotomy revealed a large mass originating from the small bowel and adherent to the sigmoid colon. Patient underwent small bowel resection with enterostomy, sigmoid resection with end-to-end anastomosis and bilateral salpingo-oophorectomy. Pathological analysis of the pelvic mass with immunohistochemical staining revealed GIST tumor. Analysis of tissue from the distal colon donut revealed a carcinoid tumor. The patient tolerated the procedure well and continues to follow up at the specialty clinics. Our case represents a rare finding of coexisting small bowel GIST and carcinoid tumor. To our knowledge, there has been only one reported case of a concomitant gastric GIST and carcinoid tumor. As few cases have been reported in literature, future studies may be used to evaluate a link between the occurrence of a GIST and carcinoid tumor in a single patient.

umbilical region and migrates to the right lower quadrant region due to localized inflammation of surrounding peritoneum. We present a case of painless appendicitis in an immunocompromised patient. 54-year-old male with a history of chronic steroid use presented with complaints of fever and weakness for one day. The patient’s medications included: Prednisone 60 mg, for possible vasculitis, Isoniazid and pyridoxine for latent TB, and Trimethoprim/Sulfamethoxazole for PJP prophylaxis. Initially, the patient was found to be tachycardic to 135, febrile to 102F, and tachypneic to 32 bpm. The rest of his physical exam was unremarkable. The only remarkable lab data was a positive rapid flu test for influenza A. Despite adequate fluid resuscitation and Oseltamivir, he continued to be febrile with tachycardia. After 24 hours of admission, blood cultures showed gram-negative bacteremia, which prompted a CT scan of the abdomen to look for a gastrointestinal or genitourinary source of infection. CT abdomen revealed mural thickening of the distended appendix; measuring 11mm in diameter with stranding in the periappendiceal fat. Patient underwent a laparoscopic appendectomy and surgical findings included an acutely inflamed appendix with yellow purulent fluid within the right pericolic gutter. Cultures from the purulent fluid grew the same pan sensitive E. coli as the blood cultures. The patient was later discharged with oral antibiotics. This case highlights an atypical presentation of acute appendicitis in an immunocompromised patient. Due to chronic steroid use, there was limited inflammation in the peri-appendicular region, resulting in a clinically silent abdomen. This case demonstrates the significance of early CT imaging in an immunocompromised patient presenting with a fever of unknown origin.

2417 Celiac Crisis: An Unusual Presentation of Celiac Disease in the Elderly Ghulam Mustafa Aftab, MBBS, MD1, Muhammad Riaz, MBBS, MD1, Hasan Zahid, MBBS, MD1, Butt Mujtaba, MD2, Shahdi Malakooti, MS, MD2. 1Orange Park Medical Center, Orange Park, FL; 2Orange Park Medical Center, Jacksonville, FL Celiac Disease is an autoimmune disorder, affecting genetically susceptible people, due to intake of gluten containing products. The prevelance of celiac disease in United States of America is 1%. Celiac crisis is an unusual manifestation of celiac disease. A 64 year old woman with past medical history of cholecystectomy and hypothyroidism, presented to the emergency department with complaints of intractable diarrhea for six weeks. She had large volume, watery, nonbloody diarrhea with 15-20 episodes per day. She denied abdominal pain, fever, or chills. She was placed on atropine/diphenoxylate and metronidazole for empiric treatment prior to hospital admission which did not abate her symptoms. Physical examination was benign. Patient was hemodynamically stable. Initial labs showed hypokalemia (2.8 mmol/l), hypocalcemia (6.5 mg/dl), hypomagnesemia (0.9 mg/dl), acidosis with bicarbonate of 18 mmol/l and hypoalbuminemia (1.9 g/dl). Computed Tomography imaging of the abdomen with intravenous contrast was unremarkable. Stool cultures and studies for clostridium difficile, giardia and cryptosporidium were negative. Gross examination via esophagoduodenoscopy revealed blunting of the villi with partial scalloping of the duodenal folds suggesting celiac disease. Gross visulaization via colonoscopy showed normal colonic mucuosa. Celiac serologies were sent. Anti endomysial antibodies, tissue transglutaminase and anti gliadin antibodies were elevated. Duodenal biopsy revealed severe complete villous atrophy and intravillous lymphocytosis. Colonic biopsy showed intraepithelial lymphocytosis and lymphoid aggregrates. It was negative for dysplasia and malignancy. Patient was diagnosied with celiac disease and lymphocytic colitis. Her electrolytes were replenished. She was started on a gluten free diet and prescribed budesonide. This illustrates a case of celiac disease presenting as celiac crisis. Celiac crisis is a life threatening condition primarily affecting children. The most common presentation of celiac disease in adults is diarrhea with abdominal pain. Celiac crisis is manifested by severe diarrhea, hypoproteinemia, electrolyte and metabolic abnormality. Our case showed the patient had associated microscopic colitis which has around 10% association with celiac disease. Patients with microscopic colitis and celiac disease have more severe diarrhea. Management of celiac crisis is gluten withdrawal and treatment with budesonide maybe considered.

2418 Abdominal Pain and Weight Loss Masquerading in the Outpatient Setting Veronica Nguyen, MD, Elizabeth Selden. MedStar Georgetown University Hospital, Washington, DC

[2415] .

2416 Silent Appendicitis in an Immunocompromised Patient: A Diagnostic Dilemma Fnu Anshul, MD1, Jeffery M. Naids, BS2, Kshitij Thakur, MD3. 1Crozer Chester Medical Center, Upland, PA; 2Temple University School of Medicine, Philadelphia, PA; 3Crozer Chester Medical Center, Chester, PA

Abdominal pain with weight loss is a common outpatient complaint. Internal hernias are an infrequent cause of unintentional weight loss and abdominal pain and thus not commonly diagnosed. The overall incidence of internal hernias is less than 1%. However, they account for 5.8% of small bowel obstructions and can lead to significant morbidity if not diagnosed promptly and corrected. 56-year-old male with chronic gastrointestinal reflux disease presented to clinic for evaluation of worsening abdominal discomfort for 3 months. Eight weeks prior, he went to another hospital and underwent a volvulus correctional surgery however without relief of his symptoms. He had lost 25kg since surgery and a total of 43kg since the onset of the original symptoms. Additionally, he reported multiple unrevealing upper endoscopies and colonoscopies. He had a normal CA 19-9 and CEA. He reported flatus with regular bowel movements without visible blood. He also denied any nausea or vomiting. Review of systems was otherwise negative. On exam, his BMI was noted at 17.8 with cachexia, temporal wasting and mild epigastric tenderness. Laboratory results were unrevealing. Attempts of conservative treatments failed. After a third visit he was started on empiric antibiotics for small intestinal bacterial overgrowth with marked improvement. However symptoms recurred after 4 weeks and abdominal CT showed a high-grade bowel obstruction. He underwent an exploratory laparotomy where an internal hernia in the transmesenteric area was identified and corrected. Complete resolution of symptoms was achieved and the patient's BMI is now 22. The diagnosis of an internal hernia causing obstruction is heavily reliant on a complete history and imaging studies. Locations and frequency of internal hernias are as listed: paraduodenal, 53%; pericecal, 13%; foramen of Winslow, 8%; transmesenteric and transmesocolic, 8%; pelvic and supravesical, 6%; sigmoid mesocolon, 6%; and transomental, 1%–4%. Internal hernias are difficult to diagnose as it can mask as other abdominal pathologies especially when causing intermittent symptoms over a prolonged period of time. Bowel obstruction may be chronic and patients should have prompt referrals to Gastroenterology and Surgery for a multidisciplinary evaluation. There should be a low threshold to image patients with recurrent symptoms given that internal hernias may intermittently reduce causing a complex constellation of symptoms.

Acute appendicitis is the most common abdominal surgical emergency in the US. Traditionally, diagnosis is based on history and physical exam findings. Appendicitis pain usually starts in the peri-



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[2416] Mural thickening in distended appendix, measuring 11 mm in diameter with stranding in periappendiceal fat.

2419 Sclerosing Mesenteritis: An Uncommon Cause of Chronic Abdominal Pain Santosh Sharma, MBBS, MD1, Denzil Etienne, MD1, Lenar Latypov, MD2, Emmanuel Ofori, MD2, Madhavi Reddy, MD, FACG3. 1The Brooklyn Hospital Center, Brooklyn, NY; 2Brooklyn Hospital Center, Brooklyn, NY; 3The Brooklyn Hospital Center, New York, NY Sclerosing mesenteritis (SM), also known as mesenteric panniculitis or mesenteric lipodystrophy, is a rare disease affecting the mesentery of the small intestine. It is characterized by fat degeneration, necrosis, chronic inflammation, scarring and eventually fibrosis of the fatty tissue within the mesentery. Although the exact cause remains unknown, sclerosing mesenteritis has been associated with certain paraneoplastic syndromes, autoimmune diseases, infections, ischemic injury and abdominal trauma. A 58 year old male with a past medical history of gastroesophageal reflux disease and umbilical hernia was referred by his primary care physician for evaluation of chronic right lower quadrant abdominal pain. He denied change in bowel habits, weight loss or blood in stools. Physical exam was unremarkable with the exception of mild tenderness in the right low quadrant. Basic laboratory investigation was essentially normal. CT abdomen/pelvis with contrast revealed increased mesenteric attenuation with associated lymphadenopathy within the inferior midline abdomen. Lymph nodes demonstrated a halo of spared fat (Figure 1) consistent with sclerosing mesenteritis. The patient subsequently underwent elective hernia repair with mesenteric specimen pathology also consistent with nonspecific chronic inflammation. Repeat CT abdomen/pelvis one year later showed increased density of the fat at the root of the mesentery which was essentially unchanged from the initial imaging study. Sclerosing mesenteritis is a rare condition that typically affects white males in the fifth to seventh decade of life. It is typically a benign condition that usually is diagnosed incidentally. Clinical symptoms can include chronic low grade abdominal pain, nausea/vomiting, bloating, early satiety, loss of appetite and diarrhea or constipation. Physical exam can sometimes reveal a deep seated and poorly defined mass usually in the upper quadrant or epigastrium. CT abdomen may demonstrate thickening of the mesentery with the presence of enlarged lymph nodes. A ‘halo of spared fat’ can also be characteristically seen surrounding nodes and vessels as was demonstrated in our patient. Mesentery tissue biopsy usually shows fibrous tissue and chronic inflammation. Asymp-


[2419] ‘Halo’ of spared fat surrounding multiple mesenteric lymph nodes.


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tomatic patients typically require no treatment, while refractory cases have shown some symptomatic improvement with immunosuppressive therapy such as steroids, azathioprine, colchicine or hormonal therapy (eg. tamoxifen).

2420 Small Bowel Villous Atrophy Isn’t Always Sprue Benjamin R. Niland, MD1, Jack A. Di Palma, MD, MACG2, Brooks D. Cash, MD, AGAF, FACG, FASGE2. 1 University of South Alabama, Moblie, AL; 2University of South Alabama, Mobile, AL A 52-year-old Caucasian female was admitted for generalized weakness, progressive weight loss, malnutrition, and chronic diarrhea. A previous EGD revealed duodenitis with histologically severe villous blunting. TTG and gliadin peptide IgA and IgG antibodies were undetectable. Progressive symptoms did not respond to gluten restriction. She also reported diffuse arthralgias and cognitive changes. On admission, she weighed 90 lbs. with a BMI of 16. Examination revealed a cachectic, chronically ill-appearing female with diffuse muscle wasting and anasarca. Laboratory evaluation revealed multiple electrolyte deficiencies, malnutrition, and water and fat-soluble vitamin and mineral deficiencies. QuantiFERONTB Gold was negative. TTG and gliadin IgG and IgA antibodies were repeated and negative as were HLA DQ2 and DQ8, stool bacterial cultures, ova and parasites, and Clostridum difficle stool PCR. CT showed an abnormal appearance of the small bowel with cavitated appearing mesenteric lymph nodes “suspicious for celiac disease.” Flexible sigmoidoscopy revealed normal mucosa, however, rectosigmoid biopsies revealed mild focal active colitis. EGD demonstrated diffuse erythematous mucosa of the gastric body and antrum and duodenal scalloping. Gastric biopsies showed moderate chronic and active gastritis with scattered intracytoplasmic organisms within macrophages as well as Helicobacter pylorilike organisms. Duodenal biopsies revealed foamy macrophages within the lamina propria containing PAS-positive and AFP-negative rod-shaped bacilli and granules. PCR of duodenal tissue was positive for Tropheryma whipplei, confirming Whipple’s disease. Echocardiogram showed no vegetations and CSF analysis was negative for T. whipplei PCR. Bactrim DS BID was started and electrolytes, vitamins,

[2420C] PAS positive organisms and granules within macrophages in lamina propria.

and minerals were replaced. After three months, she reported feeling well other than mild joint pains without swelling. Her diarrhea was resolved, her mentation had returned to normal, and her weight was 174 lbs. with a BMI of 30. Bactrim DS was advised for at least 1 year. Whipple’s disease is a rare entity and is considered when there are progressive symptoms of weight loss, diarrhea, and arthropathy. It can also involve multiple extraintestinal organ systems including cardiac, pulmonary, and the CNS. This case illustrates the value of further evaluation of villous atrophy when encountering progressive symptoms and a negative serologic evaluation for celiac sprue.

2421 Postpartum Abdominal Pain, With a Twist Boskey Patel, DO, Mark O'Connor, MD. University of Massachusetts Medical Center, Worcester, MA

[2420A] Gastropathy due to T. whipplei.

Introduction: Intestinal malrotation classically presents in the neonatal period as acute obstruction due to intestinal, or midgut, volvulus. Midgut volvulus due to intestinal malrotation is rare in adults, with an estimated incidence of 0.2-0.6%. We present a case of a young, post-partum woman who presented with two months of abdominal pain and was found to have a midgut volvulus from intestinal malrotation. To our knowledge, this is one of the first cases of intestinal malrotation presenting as midgut volvulus after uterine involution. Case Report: A 22-year-old female with no history presented with progressively worsening post-prandial epigastric pain that started after she gave birth 2 months prior. She had an uncomplicated pregnancy and normal vaginal delivery. Over the past week, the pain had became more severe and persistent, and was

[2420B] Duodenal scalloping due to T. whipplei.

[2421A] Sonographic evidence of SMV and SMA twisting.



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accompanied by nausea and bilious vomiting. She denied weight loss and had no other constitutional symptoms. She did note constipation over the past few days but was still passing flatus. Exam revealed tenderness to palpation over the epigastrium without evidence of an acute abdomen. Labs were signifi-

cant for a blood urea nitrogen of 33, hemoglobin of 16.3, and hematocrit of 50. Hepatic function panel revealed an elevated total bilirubin level of 3.5. A RUQ ultrasound done to rule out biliary obstruction showed a twisting of the proximal superior mesenteric artery (SMA) and vein (SMV) with patent flow. A CT angiography of the abdomen and pelvis showed the classic “whirlpool sign,: confirming a midgut volvulus with intestinal malrotation, with resultant duodenal obstruction. There was no evidence of bowel ischemia or perforation. An emergent surgical consultation was placed and the patient was taken down for an exploratory laparotomy with detorsion of volvulus, lysis of Ladd’s bands, broadening of the mesentery, and an appendectomy. Discussion: Total small intestinal volvulus with malrotation classically (64-80% of the time) presents in neonates, typically within the first month of life. Symptomatic intestinal malrotation is rare in adults. This is often an incidental finding, although symptoms can range from those associated with obstruction or reflux to those found in acute intestinal infarction. CT findings can be pathognomonic if the whirlpool sign is seen. CT also allows for rapid diagnosis and surgical treatment, which is important as delayed diagnosis or treatment can result in bowel necrosis and death.

2422 A Rare Cause of Small Bowel Obstruction Anish V. Patel, MD1, Pooja M. Jotwani, MBBS1, Keith Sultan, MD, FACG2. 1North Shore-LIJ Health System, New Hyde Park, NY; 2Northwell Health, Great Neck, NY

[2421B] Classic "whirlpool" sign seen on CT angiography of abdomen/pelvis.

BRIEF INTRODUCTION: Sclerosing Encapsulating Peritonitis (SP) is a rare benign cause of acute or subacute small bowel obstruction and pseudo-obstruction. It is characterized by total or partial encasement of the small bowel within a thick fibro-collagenous membrane. It can be idiopathic or secondary to chronic peritoneal dialysis (occurring in 0.5%), ventriculo-peritoneal shunts, drugs or infectious peritonitis. The disease carries a high mortality rate between 44 and 71%. There is no expert agreement on medical or surgical management. CASE DESCRIPTION: We present an 80 year old African American male with end stage renal disease. He had been receiving peritoneal dialysis (PD) for 8 years, and over the past year had two episodes of bacterial peritonitis with an infected PD catheter that was replaced. He was admitted to the hospital for nausea, vomiting and inability to tolerate oral intake for 4 days. Admission laboratory studies showed - WBC 8.1, sodium 136, BUN 28, creatinine 6.48, total bilirubin 0.4, lipase 40 and amylase 26. CT abdomen and pelvis with oral & IV contrast revealed diffuse peritoneal calcifications and several moderately thickened & distended loops of small bowel with serosal calcifications (no transition point) - see figure 1. The radiologic findings supported a diagnosis of sclerosing encapsulating peritonitis (SP). He was managed with bowel rest and IV hydration. However he was unable to tolerate oral intake and was discharged on total parenteral nutrition (TPN). He was subsequently re-hospitalized twice over the next 3 months for recurrent symptoms of nausea and vomiting, with similar findings on CT imaging and unfortunately passed away from a small intestinal perforation and septic shock. DISCUSSION: We present a case of SP resulting in recurrent obstructive bowel symptoms in a patient with PD. PD related risk factors such as history of peritonitis and duration of PD are involved in the development of this disease. Hence patients undergoing PD who develop recurrent peritonitis as with our patient should have a discussion regarding possible discontinuation of PD with initiation of hemodialysis to prevent development and/or progression of peritoneal sclerosis and SP. Although a rare complication, bowel obstruction or pseudo-obstruction resulting from SP should be considered in the differential diagnosis of any patient undergoing long term PD with recurrent abdominal pain, unexplained malnutrition and intestinal obstruction.

2423 An Unusual Cause of Diarrhea: Losartan-Induced Sprue-Like Enteropathy Areej Mazhar, DO, Jelena Arnautovic, DO. Henry Ford Macomb Hospital, Clinton Township, MI

[2421C] Anatomic deviation of congenital malrotation; appendix seen in left upper quadrant.

Losartan is a commonly prescribed anti-hypertensive. Severe, chronic diarrhea with substantial weight loss can occur after long term Losartan use. However, the infrequency with which this occurs makes the diagnosis challenging. The mechanism of action is still being studied, although, it has been hypothesized that cell mediated immunity plays a role.The importance of considering drug induced enteropathy in the differential of chronic diarrhea is highlighted in this case, as prompt diagnosis results in less unnecessary testing and better outcomes.

[2422] CT Abdomen showing diffusely thickened and dilated loops of small bowel, with peritoneal and serosal calcifications.



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A 67-year-old male with a history of hypertension on Losartan 50 mg twice a day for more than three years presented to the hospital with loose stools for the a week and unintentional weight loss of 20 pounds. Bowel movements were loose and 10-12 liters daily. He had tried antimotility agents, Ciprofloxacin and Metronidazole without change in symptoms. Extensive workup was completed to rule out infectious, inflammatory, absorptive and autoimmune causes. Enteroscopy with biopsies revealed marked villous blunting of the duodenum and lymphocytosis. The patient’s diarrhea resolved after 2 weeks of supportive treatment and discontinuation of Losartan. Follow up enteroscopy after 3 months showed complete resolution of villous blunting and atrophy. An increasing number of cases of sartan induced enteropathy are being recognized in patients with chronic diarrhea. There have been reports of enteropathy associated with Olmesartan and Valsartan. The first known case of Losartan induced enteropathy was reported in 2015 in the Journal of Clinical Gastroenterology.1 Cessation of Losartan resulted in resolution of symptoms and reconstruction of the intestinal villae on follow up enteroscopy.2 This case highlights the importance of including sartan induced enteropathy as a differential in those with chronic diarrhea and weight loss. It is one of the reversible causes of enteropathy with features suggestive of infectious or autoimmune conditions yet negative serology. One should maintain a high index of suspicion in the right clinical context to ensure timely treatment and prevent several unnecessary tests. 1. Burbure, Nina et al.Olmesartan-associated sprue-like enteropathy: a systematic review with emphasis on histopathology. Human Pathology. 2016. 50: 127-134. 2. Choi, E.K., McKenna, B.J. Olmesartan-Associated Enteropathy: A Review of Clinical and Histological Findings. Archives Of Pathology Lab Medicine. 2015;139:1242-1247.

2424 A Rare Case of Periampullary Tumor Peter C. Johnson, MD, Ryan Cho, MD, Kelly Haeusler, MD, Katherine M. Cebe, MD, Angelo H. Paredes, MD. San Antonio Uniformed Services Health Education Consortium, San Antonio, TX Gangliocytic paraganglioma is a rare tumor that can affect anywhere in the gastrointestinal tract, though it is most frequently found in the second portion of the duodenum. They commonly present with abdominal pain, gastrointestinal bleeding, or rarely with obstructive jaundice. This is a case of an asymptomatic periampullary gangliocytic paraganglioma. A 45 year old male with a history gastroesophageal reflux well controlled on a PPI was referred for iron deficiency anemia with no overt bleeding. He underwent an upper endoscopy that revealed a submucosal nodule involving the ampulla. The endoscopic ultrasound subsequently revealed a 2.3x1.5cm hypoechoic heterogeneous mass of the periampullary region. Fine needle aspiration showed a neoplasm with neuroendocrine differentiation. The immunohistochemical stain was strongly positive for synaptophysin and negative chromogranin, S-100, CD-117, and DOG-1. The periampullary mass was resected using endoscopic mucosal resection, with the final pathology consistent with gangliocytic paraganglioma. The patient had further testing with negative urine metanephrines and catecholamines. There was no radiographic evidence of distal metastatic disease. Gangliocytic paraganglioma (GP) is a rare neuroendocrine tumor, with only around 200 cases reported. It consists of three distinct cellular elements: spindle cells, epithelial cells, and ganglion cells. In spindle-cell predominant tumors, the differential diagnosis includes schwannomas and GIST. When visualized endoscopically, GPs are difficult to distinguish from other submucosal tumors and may appear as a pedunculated or sessile polypoid mass that may be smooth or ulcerated. Endoscopic biopsies are frequently negative since the tumor is submucosal. An EUS is frequently necessary to obtain a fine-needle aspiration as well as evaluate for local spread of the tumor and detect metastatic lymph nodes. The majority of GPs are benign without local or distant spread. However, lymph nodes metastases and distant metastases to other organs have been reported. Treatment is dependent on the size of the tumor and the presence of any metastatic lymph nodes or other metastatic sites. Case reports have shown that overall the prognosis is good but there have been reported deaths from metastatic tumors. In conclusion, we present the case of an incidental periampullary gangliocytic paraganglioma.

[2424B] Endoscopic image of the periampullary mass.

[2424C] Endoscopic ultrasound image of the periampullary mass.

2425 Rare Case of Ectopic Pancreatic Cancer of the Jejunum Neal Sharma, MD1, Jay Anderson, DO2, David Y. Lo, MD, FACG, FASGE3, Lance Shoemaker, MD1. 1 OhioHealth Riverside Methodist Hospital, Columbus, OH; 2Riverside Methodist Hospital, Columbus, OH; 3 Ohio Gastroenterology Group, Inc., Columbus, OH

[2424A] Ganglion cells have abundant cytoplasm, round nuclei, and prominent nucleoli (small arrows). Spindle cells are arranged in fascicles (large arrows).Epithelioid endocrine cells are arranged in trabeculae (arrowheads).


Ectopic pancreatic cancer is exceedingly rare. We present a case of ectopic pancreatic cancer of the jejunum. A 75-year-old female presented with severe acute abdominal pain and nausea for a few days. Abdominal CT showed a 3.7x4.7x4.2 cm mesenteric mass encasing the superior mesenteric artery (SMA). CT-guided biopsy demonstrated adenocarcinoma of unknown primary. She was initiated on fluorouracil and oxaliplatin, but with only transient response. Surveillance CT scans did not show any evidence of metastases. She then underwent exploratory laparotomy with resection of the mass and 3rd/4th portions of the duodenum and proximal jejunum, along with vascular reconstruction of the SMA. Final pathology results demonstrated adenocarcinoma in the jejunum arising from an ectopic pancreas with tumor invading the SMA. Ectopic pancreatic tissue is estimated to be present in the gastrointestinal tract in approximately 2-15% of the population. It is thought to develop during through metaplasia of the intestinal mucosa or congenitally. Rarely does ectopic pancreas degenerate into adenocarcinoma (0.7-1.8%). It also rarely invades the mesentery, in which case the jejunum is the most commonly found location. Masses invading the mesentery typically measure 3-5 cm. Heterotopic pancreas can lead to other uncommon complications such as ulceration of mucosa, gastrointestinal bleed, intestinal obstruction, and pancreatitis. The differential diagnosis also includes gastrointestinal stromal tumors, lymphomas, and carcinoid tumors. Vitiello et al. (2017) described 29 surgical cases of ectopic pancreas, with only 37.9% of patients


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symptomatic prior to surgery. Only 1 of these 29 cases demonstrated pancreatic cancer. Other therapies include chemotherapy, with less information available in the literature. However, Fukino et al. (2015) did report a case of gemcitabine being effective in treating duodenal ectopic pancreatic cancer. There was also one case by Ogawa et al. (2015) which utilized tegafur/gimeracil/oteracil potassium (S-1) and particle beam therapy yielding partial remission. Overall prognosis of jejunal ectopic pancreatic cancer is unclear, however, a literature review by Yamaoka et al. (2015) noted that survival for those with distant metastases appears to range from 5-9 months.

2426 To the O.R. and Back Again: A Case of Recurrent Jejunal Diverticulitis David Snell, MD1, Gaurav Ghosh, MD2, Vikas Gupta, MD, PhD1, Aleksey Novikov, MD1, Patrick McIntire, MD1, Rasa Zarnegar, MD3, David Wan, MD1. 1New York-Presbyterian/Weill Cornell Medical Center, New York, NY; 2New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY; 3Weill Cornell Medical College, New York, NY A 43-year-old healthy man presented in 2015 with abdominal pain, nausea and vomiting in the context of multiple prior self-resolving episodes of abdominal pain over a four-month period. He had an acute abdomen with CT imaging remarkable for acute perforated jejunal diverticulitis. In the operating room, he was found to have a loop of bowel 55 cm from the ligament of Treitz with a perforated diverticulum. Scattered jejunal diverticula were noted. Approximately 12 cm of small bowel was resected with primary anastomosis. Pathology revealed diverticulitis, serositis, and mural abscess (Figs. 1, 2). In 2016, the patient again presented with an acute abdomen and E. coli sepsis. CT imaging was notable for recurrent jejunal diverticulitis with microperforation and non-occlusive thrombi of the superior mesenteric and portal veins. Intraoperatively, there was chronic inflammation around the previous anastomosis. He was anticoagulated for the portal vein and superior mesenteric vein thrombi for six months. In the next year, he was admitted twice with recurrent diverticulitis that was medically managed. MR enterography was

[2426C] Gross specimen of resected small bowel with diffuse diverticular disease.

done to determine if the distribution of diverticula would be amenable to a limited small bowel resection, but imaging was unable to provide accurate characterization. Ultimately, he underwent elective resection of 43 cm of small bowel with diffuse diverticular disease (Fig. 3). Jejunal diverticula are reported in 0.06-1.3% of patients in autopsy series1. They are usually multiple, localized to the proximal jejunum, and associated with disorders of motility such as systemic sclerosis, visceral neuropathies, and myopathies2. The risk of complications is higher in jejunoileal diverticula compared to duodenal diverticula, including obstruction, diverticulitis, and bleeding2. Jejunal diverticula typically present with complications requiring surgical intervention in 8-30% of cases2. If perforation, abscesses, or mechanical obstruction are seen intraoperatively, resection of the diseased bowel is the most appropriate intervention3. (1) Miller RE, et al. Surgical complications of small bowel diverticula exclusive of Meckel's. Ann Surg 1970;171:202–210. (2) Kassahun WT, et al. Complicated small-bowel diverticulosis: A case report and review of the literature. World J Gastroenterol 2007;13(15):2240-2242. (3) Macari M, et al. CT of jejunal diverticulitis: imaging findings, differential diagnosis, and clinical management. Clin Radiol. 2007 Jan;62(1):73-7.

2427 Granulomas in Small Bowel Crohn’s Masking Whipple’s Disease Omar Y. Mousa, MD1, Yazan S. Mousa, MD2, Sarah M. Nimri, MD3. 1Mayo Clinic, Jacksonville, FL; 2 Jordan University of Science and Technology, Amman, Amman, Jordan; 3Jordan University of Science and Technology, Amman, Jordan

[2426A] Representative small intestinal diverticulum located in peri-intestinal fat.

[2426B] Peri-diverticular fibrosis and chronic inflammatory infiltrate consistent with remote small intestinal diverticulitis.


Introduction: Since the first description of Whipple’s disease in 1907, only about 1000 cases have been reported. Such a rare disease with variable clinical features at presentation makes its diagnosis easily missed in the clinical setting. Although uncommon, granulomas in the proximal small bowel have been rarely reported in patients with Whipple’s disease. Case presentation: We present a case of a 78 year old female with chronic diarrhea (3 to 5 non-bloody loose stools daily), intermittent abdominal pain and weight loss for 3 years, and worsening peripheral

[2427A] .


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of cocaine use causing small bowel mucosal ulceration, which presented with acute GI bleed has been reported (World J Pediatr. 2009;5(2):149-51). Aim: The aim of this case report is to show that chronic cocaine abuse can result in mucosal ulceration of the small bowel presenting with chronic abdominal pain and diarrhea. Case Presentation: A 50y/o man with Hepatitis C, HTN, polysubstance abuse and cocaine-induced NSTEMI, presented multiple times with chronic abdominal pain over 18 months, unrelated to meals, without improvement on defecation, and associated with watery, non-bloody diarrhea 2-3 times daily. He had weight loss of 20kg in 2 months. CT abdomen/pelvis with IV contrast revealed non-specific small bowel wall thickening, especially in the TI concerning for possible IBD or mesenteric ischemia, with CT angiogram not showing stenosis. CT enterography again showed small bowel wall thickening and mucosal enhancement without stricture. Colonoscopy with terminal ileal intubation was unremarkable with random TI biopsies revealing inactive chronic nonspecific ileitis with mild architectural distortion. Capsule endoscopy was initiated for further mucosal evaluation, revealing multiple areas of deep ulcerations with denuded mucosa with loss of villi throughout the entirety of the small bowel, with increased size and circumferential involvement more distally, likely secondary to chronic ischemic insults form cocaine (Figure 1). The capsule did not pass the ileocecal valve on video. He had recurrent pain, and KUB revealed a retained capsule with an area of proximal dilatation indicating stricture. He was treated conservatively for small bowel obstruction initially, left the hospital AMA, and upon return had no evidence of capsule retention on imaging. Discussion: Cocaine is known to induce transient vasospasm; however, the chronic effects of cocaine abuse on the small bowel are not well described. This is the first case describing cocaine induced enteritis with deep mucosal ulcerations with extensive loss of villi visualized on capsule endoscopy presenting with chronic abdominal pain and diarrhea. Cocaine induced enteritis should be included in the differential diagnosis of those with cocaine abuse and chronic abdominal pain with diarrhea.

[2427B] .

2429 Lupus Enteritis: An Uncommon Cause of Abdominal Pain

edema for 3 weeks. She had a previous presumptive diagnosis of Crohn’s disease. Diagnosis was based on the finding of patchy erythematous mucosa in the jejunum found during capsule endoscopy, but otherwise normal colonoscopy. She was treated at an outside clinic with multiple regimens over the past 3 years, including prednisone, adalimumab, certolizumab pegol, or 6-mercaptopurine with no improvement. On exam she was malnourished with 2+ pitting edema in her legs. Labs revealed normocytic anemia (Hgb 11.9 g/dL), leukocytosis 13.4x109/L and hypoalbuminemia 1.4 g/dL. Workup for chronic diarrhea showed negative infectious (including CMV and TB), thyroid and vascular workup. Autoimmune workup ruled out autoimmune enteropathy and combined variable immunodeficiency. We repeated an upper endoscopy which showed diffusely scalloped mucosa from the duodenum to the proximal jejunum, with biopsies from the jejunum showing active chronic enteritis with rare granulomas (Figures A and B). Tropheryma whipplei PCR was positive. He was treated with IV ceftriaxone for 2 weeks then trimethoprim sulfamethoxazole for 1 year with clinical and endoscopic improvement. Discussion: It is imperative to have a high index of suspicion for Whipple’s disease among Gastroenterologists, especially in a patient presenting with chronic diarrhea and endoscopic findings of duodenojejunal inflammation with granulomas. Whipple’s disease can have a nonclassic presentation and the clinical and endoscopic findings can be suggestive of Crohn’s disease. This can lead to a potentially life threatening outcome especially when exposing the patient to significant immunosuppressive therapies with serious adverse events. Early diagnosis is crucial to avoid the unnecessary side effects of an inflammatory bowel disease treatment regimen, and begin simple therapy with antibiotics which are readily available.

Karthik Ragunathan1, Swati Kumar, MD2, Lilly Gonzalez, MD3, Richard Ferstenberg, MD4. 1SUNY Downstate Medical Center, New York, NY; 2SUNY Downstate Medical School, Brooklyn, NY; 3State University of New York Downstate Medical Center, Brooklyn, NY; 4Kings County Hospital Center, Brooklyn, NY Background Lupus enteritis an uncommon complication of systemic lupus erythematosus(SLE) that could present like acute mesenteric ischemia(AMI) due to vasculitis of mesenteric arteries. Here we present an unusual cause of acute abdominal pain due to lupus enteritis. Case Presentation A 50-year-old female with a history of congestive heart failure(10-15%), Coronary artery disease, SLE who presented to the ER with acute onset abdominal pain for 3 days. Patient described the pain as epigastric, sharp pain, rating 10/10 and non radiating. This was associated with

2428 Cocaine-Induced Enteritis as a Cause of Chronic Abdominal Pain and Diarrhea Morgan A. Sendzischew Shane, MD, Jodie A. Barkin, MD, Jamie S. Barkin, MD, MACG, MACP, AGAF, FASGE. University of Miami Miller School of Medicine, Miami, FL Introduction: Cocaine causes transient ischemia of the bowel due to vasospasm. Patients can present with non-specific complaints including abdominal pain, chest pain, nausea, ileus, and diarrhea. One case

[2429A] Target sign.

[2428] Capsule endoscopy images of small bowel deep mucosal ulcerations secondary to cocaine abuse.



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Clostridium difficile PCR and HIV antibodies were negative. Gastrin level, celiac panel, and a 72 hour fecal fat collection were within normal limits. A CT scan chest/abdomen/pelvis showed reactive mesenteric lymph nodes and multiple small pulmonary nodules. A colonoscopy was unremarkable with normal biopsies. Upper endoscopy revealed moderate esophagitis, chronic gastritis, and duodenitis. Gastric biopsies were positive for H. pylori. Duodenal biopsies revealed increased eosinophils, suggestive of eosinophilic enteritis. The patient was treated for H. pylori. The diagnosis of eosinophilic gastroenteritis was entertained, though ultimately a Strongyloidies IgG ELISA test resulted positive. She was treated with a two-day course of Ivermectin, which led to a resolution of both her symptoms and eosiniophilia. Concomitant elevation of peripheral eosinophils may be seen in eosinophilic gastroenteritis. However, it is critical that patients with strongyloidiasis not receive steroids due to the risk of hyperinfection syndrome and death. Isolation of the parasite may be missed on routine O&P samples due to intermittent shedding. It is imperative that serology be sent if there is clinical suspicion, as it has both high sensitivity and specificity in immunocompetent patients.

2432 [2429B] Comb sign.

nausea and non-bloody emesis with fever and chills. Patient had prior admission to an outside hospital with similar complaints 2 months ago and was treated with prednisone with improvement in her symptoms. Patient's medications include enalapril, metoprolol, hydroxychloroquine, prednisone 20mg. Patients abdomen was soft, mildly tender in epigastric area without guarding. Lab work was significant for WBC was 10050/mcL, Lactate of 3.0 mg/dL and Lipase 28 U/L. C-reactive protein(CRP) of 180 mg/L. CT abdomen/pelvis showed bowel wall edema and hyperenchancement of the proximal jejunum with moderate distention along with minimal right paracolic ascites. Patient had a previous CT scan done 2 months earlier which showed duodenal wall thickening. Differential diagnosis included infectious vs inflammatory vs ischemic bowel. Her C4 complement levels were low at 4, which in addition to high CRP was suggestive of lupus flare, causing enteritis. Patient had routine infectious workup including blood and urine cultures which were negative . Patient was given prednisone 20 mg with dramatic improvement of her symptoms and she was discharged home. Discussion Lupus enteritis an uncommon complication of SLE caused due to vasculitis of the small bowel. Lupus enteritis typically affects the jejunum and ileum and presents with acute abdominal pain, out of proportion to exam. This can be confused with acute mesenteric ischemia which has similar presentation. Diagnosis is made with CT which shows thickening of the bowel wall, enhancement of the bowel known as target sign, enlargement of the mesenteric vessels with discernable vessels known as Comb’s sign. Other differential diagnosis includes inflammatory bowel disease, mechanical bowel obstruction, peritonitis and pancreatitis. Main stay of treatment is with prednisone for acute control of inflammation, which is usually associated with dramatic improvement of abdomen pain.

Rare Presentation of Small Intestinal Angiosarcoma in an Elderly Gentleman Umar Darr, MD, Stella Pak, MD, Zubair Khan, MD, Khaled Srour, MD, Ali Nawras, MD, FACP, FACG, FASGE. University of Toledo Medical Center, Toledo, OH Introduction: Angiosarcomas are uncommon, aggressive mesenchymal sarcomas of endothelial cell origin with high mortality. These tumors can arise from any location in the body due to the ubiquity of blood vessels and lymphatics, but are most commonly found in the skin and subcutaneous tissues. Angiosarcomas have been reported in the breast, heart, lung, liver, spleen, adrenal glands, and ovaries. Presence in the gastrointestinal tract especially in the small intestine is possible, however rare. Here we report a case of angiosarcoma in the small bowel. Case Presentation: A 73-year-old male presented to the emergency room with complaints of chest pain, dyspnea, melena, weakness, and fatigue for three days. Single balloon enteroscopy revealed a nonbleeding superficial bulbar ulcer, one large actively bleeding cratered D3 ulcer too large for endoscopic treatment, two bleeding proximal jejuna superficial ulcers, and three bleeding mid jejunal superficial ulcers treated with cauterization. Repeated enteroscopy three days later revealed one angioectasia in D3 that was cauterized and a 2 cm bleeding ulcer with irregular surface and necrotic area which was biopsied. Biopsy reports revealed poorly differentiated malignant neoplasm consistent with high grade sarcoma. During repeat enteroscopy, the D3 mass was tattooed, and a non-bleeding small superficial duodenal mass with the largest diameter of 6 mm was noted. Pyloric sparing Whipple procedure was performed. Surgical pathology demonstrated multiple ulcerated mucosal and submucosal nodules of high grade angiosarcoma involving the duodenum and jejunum measuring up to 1 cm, and metastatic angiosarcoma in 10 out of the 14 peri-pancreatic and mesenteric lymph nodes. Surgical pathology showed positivity for CD34, Vimentin, Wilms tumor 1 (WT1), and vWF, supporting the diagnosis of angiosarcoma. After the surgery, the patient survived 16 days on mechanical ventilation until the family decided to terminate the treatment. Conclusion: Angiosarcoma of the duodenum and jujenum is a rare and unique manifestation that must be considered when managing such malignancy.

2430 Mycobacterium avium Mimicking Whipple’s Disease in the Small Intestine

2433

Keri Lee Pinnock, MD, Yousef Nassar, MD, Seth Richter, MD, FACG. Albany Medical Center, Albany, NY

Chemotherapy-Induced Small Bowel Perforation

Whipple’s disease is a rare systemic illness caused by a bacterial infection with the bacteria Tropheryma whipplei. It is diagnosed by biopsy, that may be taken from the small intestine that appears as positive for Periodic acid-Schiff stain. Tropheryma whipplei does not stain with acid fast stain. Mycobacterium avium complex is a mycobacterial species that may lead to systemic infection, particularly in patients with AIDS and may lead to infection of the small intestine. A 42 year old HIV positive woman presented to our hospital complaining of watery diarrhea for the past 3 weeks, associated with abdominal pain, anorexia as well as intractable vomiting. She has had significant weight loss over the last 3 weeks. She did not have any fever. Physical examination on presentation revealed tenderness to abdominal palpation but was otherwise normal. Laboratory values on presentation revealed a white blood cell count of 800 with a CD4 count of 0. A CT scan of the abdomen with contrast was performed which revealed wall thickening and hyper-enhancement of nearly the entire small intestine. Stool analysis was negative for parasites and stool cultures were negative for any infectious etiologies including Clostridium Difficile. An endoscopy was performed which appeared grossly normal. Biopsies were taken from the small intestine that revealed periodic acid shiff stain positive as well as acid fast bacilli stain positive. Further testing for Trophyrema whipplei PCR was tested in order to differentiate Mycobacterium avium infection and Whipple’s disease and this test was negative. Conclusion: In this case of severe diarrhea and malabsorption leading to severe malnutrition in a patient with HIV. Endoscopic biopsy of the small intestine was positive for Periodic acid Schiff (PAS) which can be seen in both MAI as well as Tropheryma whipplei. Further testing must be done to exclude MAI. In our patient the acid fast bacilli was also positive and therefore our patient likely had MAI. Additional testing done revealed negative PCR for Trophyrema wipplei.

2431 Eosinophilic Enteritis and Diarrhea Caused by Strongyloides stercoralis in the Immunocompetent Patient: A Diagnosis Hidden Beneath our Feet Filley Howe, MD, Krista Edelman, MD. Duke University Medical Center, Durham, NC Strongyloides stercoralis infection can cause eosinophilic enteritis and diarrhea. Providers should be aware that strongyloidiasis can infect immunocompetent patients and is endemic to many portions of the United States. A 47-year-old African American female with a history of vitiligo and hypertension was admitted to the hospital for evaluation of nausea, vomiting and profuse diarrhea with laboratory evidence of hypokalemia. She endorsed copious non-bloody diarrhea intermittently over the preceding four months. Review of systems was notable for ten pound weight loss, sore throat and headaches, though she denied any pulmonary or dermatologic complaints. She resides in North Carolina, denied international travel aside from a trip to Japan a decade prior, and had only been to Ohio in the past year. Laboratory studies were notable for marked eosinophilia (43.7 %, normal range 0 - 7.0 %) for the preceding four months. Of note, absolute eosinophil count was normal the year prior. Evaluation included negative ova and parasite testing on two separate occasions and negative stool culture.


Mohamad Al Kateb, MD1, Rasha Haykal, MD1, Muhannad Bahrami, MD1, Hale Z. Toklu, PhD2, Lucio N. Gordan3. 1University of Central Florida College of Medicine, Gainesville, FL; 2North Florida Regional Medical Center, Gainesville, FL; 3Florida Cancer Specialists, Gainesville, FL Gastrointestinal perforation is an infrequent but potentially fatal condition that may be seen during chemotherapy. The pathogenesis of bowel perforation is unknown, but suggested mechanisms include ischemia with thrombosis of intestinal mesenteric vessels, necrosis of primary tumor or cancers involving the bowel serosa with weakening of the intestinal wall, and predisposing bowel conditions such as diverticulitis, prior surgery, or radiation enteritis (1). Here, we present a case that caused small bowel perforation during chemotherapy with multiple agents including cyclophosphamide,, vincristine, prednisone and rituximab. A 68- year- old female with previous history of low-grade Non-Hodgkin lymphoma presented to emergency department due to worsening sharp constant non-radiating epigastric pain accompanied with nausea, vomiting and generalized weakness. Patient denied fever, chills, diarrhea, dysuria or hematuria. Other elements of review of systems were negative. Patient’s vital signs were stable and physical exam was unremarkable except for mild epigastric tenderness on palpation, presence of a mass at the location of left hepatic lobe. Abdominal CT scan, large masses in the left lobe of the liver, fundus of the stomach and the hilum of the spleen with splenic infarct were found. The patient was admitted for Hematology/ Oncology consultation. She underwent a biopsy of the mass adjacent to the left hepatic lobe, which demonstrated a Marginal zone B-Cell Lymphoma (mucosa-associated lymphoid tissue, MALT). Because of abdominal pain, she was also seen by gastroenterology, and underwent esophagogastroduodenoscopy where multiple gastric ulcers noted. Biopsy of these ulcers demonstrated more aggressive histology, i.e., diffuse B-cell lymphoma. During hospitalization, the patient had undergone a course of chemotherapy (R-CVP), which included cyclophosphamide 750 mg/m2, vincristine 2 mg single dose, prednisone 100 mg 5 doses, and monoclonal antibody rituximab 375mg/m2. Four days after chemotherapy, the patient developed severe abdominal pain with tenderness on palpation. Repeating CT imaging demonstrated large amount of free air which indicated perforated viscus. She was evaluated by the General Surgery team and was immediately operated to repair perforated viscus. Afterwards, she was sent to the ICU and intubated. While in the ICU, patient developed pancytopenia. She was treated with multiple antibiotics (vancomycin 1.5 gm q12h IV, cefepime 2 gm q12h IV, Levofloxacin 750 mg q24h IV and metronidazole 500 mg q8h IV) plus, Micafungin 100 mg IV q24h. The patient was treated in the ICU for several days, but no significant improvement achieved. After multiple discussions with the patient and family, she was extubated and admitted into hospice service. A few reports were presented earlier in literature to point out the occurrence of gastrointestinal perforation during chemotherapy (1, 2). Above case also illustrates this lethal and rare side of effect of chemotherapy in a patient treated with multiple agents including cyclophosphamide;, vincristine, prednisone, and rituximab. Even though the incidence is rare, patients on chemotherapy also need to be monitored in terms of gastrointestinal toxicity. References 1. Torrisi JM, Schwartz LH, Gollub MJ, Ginsberg MS, Bosl GJ, Hricak H. CT findings of chemotherapy-induced toxicity: what radiologists need to know about the clinical and radiologic manifestations of chemotherapy toxicity. Radiology. 2011;258(1):41-56. doi: 10.1148/radiol.10092129. PubMed PMID: 21183492. 2. Qi WX, Sun YJ, Tang LN, Shen Z, Yao Y. Risk of gastrointestinal perforation in cancer patients treated with vascular endothelial growth factor receptor tyrosine kinase inhibitors: a systematic review and meta-analysis. Crit Rev Oncol Hematol. 2014;89(3):394-403. doi: 10.1016/j. critrevonc.2013.10.002. PubMed PMID: 24182420.


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2434 Celiac Crisis in an Adult Presenting With Severe Coagulopathy: Recognition of a Life-Threatening Condition Juan Gonzalez, MD1, Shikha Mishra, MD2, Orimisan Adekolujo, MD2, Susan Smith, MD2. 1McLaren Regional Medical Center, Grand Blanc, MI; 2McLaren Regional Medical Center, Flint, MI Introduction: Celiac crisis is a rare, life-threatening condition manifesting with profuse diarrhea and severe metabolic disturbances typically in patients with undiagnosed celiac disease (CD). This case highlights that acute, severe coagulopathy can be a rare presentation of celiac crisis in a patient previously diagnosed with CD. Case Summary: A 76 year old Caucasian male presented with intermittent steatorrhea for two months, worsening 4 days before presentation. He had abdominal pain, vomiting, bloody diarrhea 5-6 times per day, dizziness and generalized weakness. CD had been diagnosed 4 years earlier by duodenal biopsies. He became non–adherent to his gluten-free diet 5 months prior to presentation. On exam he was cachectic, dehydrated and hypotensive with generalized abdominal tenderness and hyperactive bowel sounds. He had metabolic acidosis, hypoalbuminemia, acute renal failure and severe coagulopathy with INR >10.10. He was treated with intravenous fluids, sodium bicarbonate, electrolyte supplementation, fresh frozen plasma and emergent hemodialysis. Stool culture, Clostridium difficile toxin, leukocytes, ova and parasites were negative. Colonoscopy showed unremarkable colonic and rectal mucosa. Esophagogastroduodenoscopy revealed flattened mucosa of the second part of the duodenum and areas of mucosal nodularity. Duodenal biopsies exhibited severe villous atrophy and intraepithelial lymphocytosis. A diagnosis of celiac crisis was made and parenteral nutrition, vitamin K and corticosteroids were given. Gluten-free diet was restarted with complete symptom resolution. Discussion: Celiac crisis is a rare, life-threating complication described in fewer than 30 adults to date, typically in those with undiagnosed CD. To our knowledge, there are only two reported cases of celiac crisis in adult patients previously diagnosed with CD and only one initially presenting with severe coagulopathy. Proposed diagnostic criteria includes acute onset or rapid progression of severe gastrointestinal symptoms attributable to CD requiring hospitalization and/or parenteral nutrition, along with at least two of the following: severe dehydration, neurological and/or renal dysfunction, metabolic acidosis, albumin 10lbs. Although coagulopathy is a rare manifestation of celiac crisis, it is important to consider this diagnosis when confronted with a patient with bleeding diathesis and a history of steatorrhea.

[2435B] - PGA removed with saline lift and hot snare.

2435 Duodenal Pyloric Gland Adenoma in a 59-year-old Asian Male: A Case Report Mia Manabat, DO1, Matthew Jackson, DO2, Kha Ngo, DO3, Laurence E. Stawick, MD, AGAF4. 1St. John Providence Hospital, Royal Oak, MI; 2St. John Providence Hospital, Warren, MI; 3St. John Providence Hospital, Southfield, MI; 4Providence Hospital, Novi, MI Pyloric gland adenomas (PGAs) are rare precancerous tumors typically arising from the stomach. They account for about 2.7% of all gastric polyps. Even more rarely do they arise in extragastric sites. The identification of these lesions is important because they possess a risk of developing into invasive adenocarcinoma. In past studies, the transition of PGAs to adenocarcinoma is noted to be as high as 28%. As of yet, there are no long term studies following these lesions and there are no recommendations regarding long-term surveillance. This case report is of a 59-year-old Asian male who presented to office for a follow up of a known 1.3 cm duodenal polypoid lesion in the 2nd portion of the duodenum. Pathology revealed polypoid gastric metaplastic mucosa with focal epithelial atypic and chronic gastritis with benign focal metaplasia. Endoscopic ultrasound revealed a 13 mm pedunculated and sessile polyp on the lateral wall opposite the major papilla in the 2nd portion of

[2435C] - High power view of the PGA arising from the duodenum with normal villous mucosa.

the duodenum. The polyp was completely removed using a hot snare following a 4 mL saline lift and placement of 2 hemostatic clips. Pathology revealed pyloric gland adenoma with predominantly low grade dysplasia with an area of focal high grade dysplasia. PGAs are typically found in the stomach but can also originate from the duodenum, gallbladder, bile duct, pancreas, rectum, and heterotopic gastric mucosa in Barrett’s esophagus. Although these lesions are generally rare, there has been an increase in the number of PGAs diagnosed. According to the Chen study, 36% of patients diagnosed with PGA had no dysplasia, 12% had low grade dysplasia, 39% had high-grade dysplasia, and 12% had invasive carcinoma. In the Vieth, 30% of pyloric gland adenomas were found to have invasive carcinoma. Although there is a discrepancy in the rate of transformation into carcinoma, it has been established that there is a significant risk of becoming cancerous. There are currently no specific guidelines for the removal and surveillance of pyloric gland adenomas. However the ASGE GI Endoscopy Guidelines from 2006 recommend that adenomatous gastric polyps be resected and surveillance endoscopy be performed at 3-5 year intervals. Until more studies are done describing the long-term behavior of pyloric gland adenomas, we believe it is important to recommend that all pyloric gland adenomas be completely removed and that surveillance endoscopy be performed on these lesions every 3-5 years.

[2435A] - PGA located in the second portion of the duodenum opposite the ampulla.



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2436 A Case of Brunner Gland Adenoma, Which Exhibited Dramatic Macroscopic Metamorphosis in 2 Years Without Canceration Kenji Sasaki, MD, PhD1, Nobuo Takano, MD, PhD2, Noriyuki Iwama, MD, PhD3, Takayuki Masuda, MD, PhD4. 1Home Medical Care Supporting Clinic, Sendai, Miyagi, Japan; 2Shiogama City Hospital, Shiogama, Miyagi, Japan; 3Tohoku Rosai Hospital, Sendai, Miyagi, Japan; 4Miyagi Cancer Society, Sendai, Miyagi, Japan Brunner gland (BG) nodule greater than 5 mm in diameter, a rare lesion, is regarded as BG hyperplasia (BGH) regardless of coexistence of other tissues. It is only the nodule whose epithelium is dysplastic that deserves the term BG adenoma (BGA), which is still less common. Though two extremely rare cases of cancerating BGA have been reported, which proved a definite association of macroscopic transformation of the lesion with canceration, we present a case, which casts doubt upon it. A spherical semipedunculated submucosal tumor with a small central depression was incidentally located opposite the inferior duodenal angle of a 68-year-old Japanese diabetic male with noncontributory past and

[2436C] The oral J-shaped excavation extended anally to merge with the inverted V-shaped one another 2 months later.

[2436A] Endoscopic picture demonstrating a spherical semipedunculated SMT with a small central depression located opposite the inferior duodenal angle.

family histories. Laboratory data were unremarkable. He was followed up under the diagnosis of BGH by biopsy. The tumor was found to have turned bowl-shaped with a wide central depression occupying almost all the top of it 2 years later. The disrupted surface was uneven, more reddened and lobuated by the groove-like excavations, in and around which the mucosal pattern was obscured and abnormal vessels were observed. As the glandular epithelium showed dysplastic, it was interpreted as BGA. An imminent risk of complicating cancer got it treated with endoscopic mucosal resection, when the central depression more deepened and the excavations coalesced into a wider deeper one. Measuring 17x12x10 mm, it was proven to be composed of nothing but BGs with dysplastic, cystically dilatated epithelium. It demonstrated papillary growth with the large round nuclei having the larger nuclear-cellular ratio but no conspicuous nuclear crowding with stratification. No fibrous septa existed separating the lobules. Relatively larger proportion of the cells was Ki 67-positive in the superficial part but only few p53-positive ones were strewn. Though diffusely immunolabeled with MUC6 but not with MUC2, the lesion, in contrast to the normal BG, had the foci positive for MUC5AC not only in the superficial but in the deeper part, where no regenerative impact extended, reflecting the neoplastic trait. Showing positivity for PAS but not for AB, pepsinogen1 or H+K+-ATPase, it was differentiated from pyloric gland adenoma and definitely diagnosed as BGA without cancer. The present case explicitly proclaims that macroscopic transformation of BGA in a natural history, though omens possible canceration through the neoplastic features, does not necessarily herald such degeneration within.

2437 A Rare Case of Primary Gastrointestinal Follicular Lymphoma With Exclusive Involvement of the Mucosal Layer of Duodenum Amr Dokmak, MD1, Evangelos Tsipotis, MD1, Claudia Paba-Prada, MD2, Joshua Goldman, MD3, Sandeep Krishnan, MD1. 1Steward St. Elizabeth's Medical Center, Boston, MA; 2Dana Farber Cancer Institute, Boston, MA; 3Steward St. Elizabeth's Medical Center, Brockton, MA

[2436B] The SMT turned from spherical to inverted dome-shaped with a wide central depression in 23 months.


58-year-old woman with a past medical history of GERD presented with indigestion and bloating. Vital signs, physical exam, and routine labs were unremarkable. She underwent an EGD which revealed a 15-mm frond-like lesion in the second portion of the duodenum along the lateral wall. Biopsy was obtained and pathology showed a lymphoid infiltrate with prominent germinal centers concerning for a lymphoproliferative disorder. However the specimen was inadequate. She therefore underwent an EGD/EUS which revealed a 15-mm sessile polypoid lesion in the same location. The lesion was noted to be limited to the mucosa with normal appearance of all the other duodenal wall layers. No abnormal appearing lymph nodes were seen surrounding the examined portion of the duodenum. The lesion was resected by endoscopic mucosal resection (EMR). Pathology showed frequent intramucosal follicular aggregates of lymphocytes. Immunostains showed the follicles to be positive for pan B-cell antigens CD20 and CD79a. Numerous associated T cells were positive for CD3 and CD5. Cyclin D1 was negative and CD10 was positive consistent with follicular center cells and follicles were positive for BCL-2 consistent with neoplastic follicles. Diagnosis was consistent with indolent grade 1-2 follicular lymphoma stage IE. A body CT scan showed heterogenous attenuation pattern within the vertebral bodies. No lymphadenopathy or splenomegaly were present. She is scheduled to undergo a spine MRI with plans for a bone marrow biopsy if bone marrow replacement is detected. Primary GI FL accounts for only 1-3% of the GI lymphomas. It predominantly affects middle-aged females. The duodenum accounts for the majority of small intestinal FL. Endoscopic findings include isolated follicles, single or multiple polyps, plaques and nodularity of mucosa. Histopathologic features include predominant involvement of lamina propria and to a lesser extent, submucosa. Isolated mucosal involvement such as in our case is extremely rare. EUS can assess the size and depth of the lesion as well as detect locoregional spread. Endoscopic biopsies may not always provide adequate diagnostic material. In such situations, EMR could be considered to enhance the diagnostic yield as well as to diagnose the infiltrative type of lymphoma. We hereby report a rare presentation of primary GI FL that exclusively involved the mucosal layer, using a combination of advanced endoscopic techniques.


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2439 Rare Case of Recurrent Jejunal Cancer Seme Tabassum, MD, Mehandar Kumar, MD, Michael Maroules, MD, Walid Baddoura, MD. St. Joseph's Regional Medical Center, Paterson, NJ

[2437A] EGD showing polypoid lesion within the duodenum.

[2437B] EUS showing no lesion within the deeper duodenum layer.

Small bowel obstructions can often be caused by abdominal tumors. Obstructions due to rare primary tumors of the small bowel, however, seldom reoccur at the same site after initial treatment. We present an atypical case of persistent jejunal obstruction over the course of several years due to the recurrence of the same primary cancer. A 35 year old Male with no past medical or surgical history presented with complaints of severe periumbilical pain that developed one day prior to admission, constant, nonradiating, with no aggravating or alleviating factors. He had no associated symptoms, took no home medications, denied alcohol or illicit drug use, and had no family history of cancers. His abdomen was soft, non-distended, with normoactive bowel sounds, and mild tenderness to palpation of periumbilical region with no rigidity, rebound or guarding. Rectal exam was unrevealing, and lab analysis was also unremarkable. CT Abdomen/Pelvis with contrast showed distended loops of small bowel at the level of the proximal ileum, suspicious for a closed loop obstruction (Figure1). He underwent an exploratory laparotomy with resection of a distal jejunal mass versus stricture with anastomosis. Pathology and Immunohistochemical stains revealed Stage 1 primary MALT Lymphoma of the jejunum with negative margins. He also had an EGD and an Enteroscopy which showed minimal gastritis and no evidence of villous atrophy or residual lymphoproliferative neoplasm. Biopsy for H. pylori, as well as HIV and Hepatitis panels were also negative. His symptoms resolved and he was managed as an outpatient for the next year; subsequently, however, he had persistent similar abdominal pain on several occasions, and was managed conservatively for partial small bowel obstruction of distal jejunum and clinically improved(Figure2). Four years after the initial presentation, he underwent a repeat laparotomy due to persistent symptoms. Biopsy of the distal jejunum, which had previously been resected of the cancer, was once again, consistent with primary jejunal MALT Lymphoma. He was treated with Rituximab, and has had resolution of symptoms with no cancer recurrence. Primary MALT Lym-

[2439A] Initial CT Abdomen/Pelvis with contrast: -Contrast visible up to the small bowel. -Wall thickening present (yellow arrow) -Fecalization of the small bowel indicating small bowel stasis.

2438 Anchored Down: Diagnostic Pitfalls in the Evaluation of Chronic Nausea and Vomiting Christopher Velez, MD1, Aaron Tokayer, MD2. 1Montefiore Medical Center, Bronx, NY; 2Montefiore Medical Center Albert Einstein College of Medicine, Bronx, NY A 20-year-old man with no significant history presented with 2 months of sudden onset but progressively worsening epigastric pain followed by nausea and vomiting. Initially, symptoms occurred only at night, with vomitus containing slightly digested food; they then occurred after small meals as well. There was accelerating weight loss. Physical exam noted fullness of the right abdominal wall. Laboratory testing was unremarkable including hemoglobin A1c. Computed tomography and ultrasound were normal. As esophagogastroduodenoscopy (EGD) revealed retained food, a gastric emptying scan (GES) was performed showing delayed gastric emptying. After an initial diagnosis of gastroparesis, he was managed unsuccessfully by multiple other clinicians. Consequently, alternative diagnoses, including median arcuate ligament syndrome (MALS), were entertained; initial angiography and duplex ultrasound, though, identified no celiac impingement. Given continued suspicion for MALS, celiac ganglion injection was performed with immediate (but temporary) symptom relief. Therefore, definitive surgical decompression was considered. Repeat pre-operative duplex sonography showed celiac artery velocity increasing by 200% with expiration, consistent with MALS. His symptoms completely resolved after his operation. MALS has unclear prevalence given variable presenting symptoms usually associated with other disorders. Confusingly, patients with significant celiac artery stenosis may be asymptomatic. A neuropathic component has also been posited, explaining the patient’s improvement with celiac ganglion injection. Operative decompression is generally recommended, at times paired with vascular intervention. Elements of this patient’s clinical course reflect common pitfalls of diagnostic testing. Namely, EGD and GES findings caused anchoring bias after the constellation of symptoms was incorrectly interpreted as gastroparesis. Prior clinicians should have found the diagnosis inadequate given the atypical symptom progression and relatively rapid clinical deterioration. Only by recognizing the limitations of routine evaluation for chronic nausea and vomiting was further testing and intervention considered that ultimately yielded the correct diagnosis. This case demonstrates the importance of interpreting diagnostic testing within the patient-specific context. It also reminds us to consider MALS despite its non-specific symptoms given how quality of life can be improved once it is identified.


[2439B] Last CT Abdomen/Pelvis with contrast Performed before 2nd Exploratory Laparotomy: -Thickening of the small bowel along with sutures at the anastomosis site.


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phoma of the jejunum is uncommon. Furthermore, Stage 1 cancer has good prognosis after radiation or surgical resection. Recurrent marginal zone B-cell lymphoma of the jejunum, at the same exact location, is an extremely rare occurrence, and we believe that this is the first case reported in literature of such an instance.

2440 A Rare Case of Rapidly Progressive Metastatic Melanoma Presenting as Upper GI Bleed Matthew Fasullo, DO1, Prashanth Rau, MD2, Abbas Rupawala, MD3, Christopher Marshall, MD3. 1UMass Memorial Medical Center, Shrewsbury, MA; 2UMass Memorial Medical Center, Hingham, MA; 3UMass Memorial Medical Center, Worcester, MA Malignant melanoma (MM) involvement in the GI tract is rare and varies markedly with regards to its presentation. We present the case of a 66 year-old male with known metastatic melanoma to the brain presenting with an upper GI bleed found to have biopsy proven MM of the jejunum. A 66 year-old male with MM to the brain on active Pembrolizumab (27th cycle) presented to clinic with complaints of melena and fatigue for three weeks duration without any other associated symptoms.

The patient underwent outpatient EGD with biopsy, both of which was unremarkable. The patient presented a month later with similar complaints requiring transfusion and underwent video capsule endoscopy, which revealed duodenal and jejunal ulcers (Fig. 1). At this time decision was made to repeat EGD, which revealed a single non-bleeding jejunal ulcer with biopsy proven MM staining positive for S100, Melan A, and SOX10 (Fig. 2). At this time, a decision was made to switch the patient to Ipilimumab. While metastatic malignant melanoma to the GI tract can be found in up to 60% of autopsies, it has been cited to present with symptomatic GI complaints in only 0.8% to 4.7% of patients. The majority of melanoma involvement in the GI tract is considered to be metastatic. The most common primary location of melanoma with GI metastasis tends to be the extremities (30%), followed by the trunk (25%), head and neck (18%), and unknown primary (12%). Our case shows rapid progression (less than 1 month) of metastasis from unknown primary to the GI tract in the setting of active systemic treatment. We hope this case demonstrates that although MM metastasis to the small bowel is uncommon, it can occur rapidly, and that any vague and persistent GI symptoms warrants further investigation, regardless of recent endoscopic studies. We believe patients who are at high risk for GI metastasis, such as those with melanoma, may benefit from small bowel surveillance. That modality may be VCE given its economic feasibility, its ability to review the entire GI tract, and its ease of administration.

2441 Metastatic Melanoma Presenting as an Acute Gastrointestinal Bleed: An Intriguing Diagnosis Ankush Sharma, MD1, Brian Dinh, MD2, Sangeeta Agrawal, MD2. 1Wright State University Boonshoft School of Medicine, Beavercreek, OH; 2Wright State University Boonshoft School of Medicine/Dayton VA Medical Center, Dayton, OH Malignant melanoma is known to metastasize to the gastrointestinal (GI) tract. However, clinical detection of GI metastatses occurs in only 2-4% of cases antemortem and is usually recognized at a higher rate postmortem (40-50%). We describe a case of metastatic melanoma presenting as an acute obscure GI bleed. A 91-year-old male previously in good health presented to the hospital with new onset weakness and melanotic stools. His past medical history included hypertension, atrial fibrillation, and melanoma of the right suprapubic area treated with wide local excision eight years prior. He was not on any anticoagulants and was recently placed on iron supplementation for his anemia. He denied any weight loss, bright red blood in his stool, significant NSAID use, or prior endoscopy. On exam he was pale, tachycardic and hypotensive, with rectal exam showing melena. Lab analysis showed a hemoglobin of 5.5 g/dl, BUN 48 mg/dl, and creatinine of 1.5 mg/dl. The patient was adequately resuscitated, and an esophogastroduodenoscopy (EGD) and colonoscopy did not reveal any source of bleed. Interestingly, video capsule endoscopy (VCE) was performed which was became lodged in the distal small bowel, demonstrated a large ulcerated lesion. Computed tomography of the abdomen and PET imaging both showed a large mass concerning for malignancy, with no lymph node involvement. The patient was referred to surgery for a laparotomy with small bowel resection and anastomosis performed. Surgical exploration revealed a 6 x 9 and a 2 x 2 cm mass within the proximal and mid-jejunum, pathology confirming metastatic malignant melanoma. The patient recovered well and his anemia subsequently improved. This case illustrates an interesting etiology for an acute GI bleed, highlighting the need for keeping small bowel etiologies in mind. While it is not uncommon for melanoma to metastasize to the small bowel, diagnosis is only made in 1-5% of cases. Small intestine metastasis usually is only discovered when complications such as obstruction, perforation, intussusception, or bleeding arise. The disparity between clinical and postmortem diagnosis emphasizes that GI tract metastatic melanoma is under detected. With less than one-year survival when melanoma metastasizes to the GI tract, early recognition and consideration of this diagnosis is paramount. Utilization of capsule endoscopy is crucial for all obscure GI bleeds, but may even lead to prolonged survival for these types of cases.

[2440A] Video Capsule Endoscopy demonstrating ulcerative lesions in the jejunum.

[2441A] Capsule Endoscopy image of an ulcerated mass occupying up to one-third of the lumen in the distal small bowel. [2440B] EGD demonstrating a non-bleeding jejunal ulcer.



| OCTOBER 2017

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2442 Ulcerative Jejunoileitis Presenting as Protein-losing Enteropathy: A Diagnostic and Therapeutic Dilemma Tasleem Katchi, MD, Benjamin Barbash, MD, George P. Jolly, MD, Eric Wold, MD, Brad Dworkin, MD. New York Medical College at Westchester Medical Center, Valhalla, NY

[2441B] Coronal image of a large small bowel mass (arrow). Pathology confirmed metastatic melanoma.

[2441C] PET imaging with increased uptake at left lower quadrant of the abdomen and no other apparent sites of metastasis.

Ulcerative jejunoileitis (UJ) is a rare condition that is difficult to diagnose and treat. We present a case of steroid-responsive UJ. A 62-year-old female presented with 3.5 months of diarrhea, abdominal pain, and pedal edema. Prior workup included an unremarkable EGD and colonoscopy (with unremarkable biopsies), and non-diagnostic MR enterography. Symptoms did not respond to a glutenfree diet. Physical examination revealed bibasilar crackles and anasarca. Laboratory results revealed a serum albumin of 1.4 g/dl and low immunoglobulin levels. Stool studies showed negative bacterial and acid-fast cultures, ova and parasites, helicobacter pylori antigen and C. Difficile toxin. Stool alpha1-antitrypsin was elevated at 960mg/dl. Serum studies were negative for ESR, CRP, HIV, ANA, ANCA, tTG, CMV, Anti-Saccharomyces Cerevisiae IgA and IgG. Serum and urine protein electrophoresis was normal. Small bowel capsule endoscopy showed small bowel erosions and denuded villi. Push enteroscopy revealed patchy jejunal erythema, erosions and absent or mosaic-appearing villi. Jejunal biopsies showed focal partial villous blunting with loss of brush border without granulomas or dysplasia. T. whipplei PCR was negative. Prednisone 60mg by mouth daily was started, which led to resolution of her symptoms and improvement of her albumin. UJ is likely T-cell mediated and characterized by small bowel ulcerations and villous atrophy. Patients present with non-specific gastrointestinal complaints and signs of malabsorption or protein-losing enteropathy. It is highly associated with Celiac disease. Differential diagnosis includes Celiac and tropical sprue, Crohn’s disease, lymphoma, infections, and infiltrative and rheumatologic disorders. Laboratory tests and biopsies ruled out these conditions in

[2442B] Image demonstrating jejunal mucosa with erythema and erosions, seen on push enteroscopy.

[2442A] Image demonstrating normal esophagus, gastroesophageal (GE) junction and stomach on push enteroscopy.



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pattern with features of chronicity, active inflammation and scattered apoptotic cells-strongly suggestive of a drug-induced lesion, likely nivolumab-related autoimmune enteritis.The patient’s earlier dose of 40mg prednisone PO was changed to 100mg IV q8h hydrocortisone with resolution of the diarrhea. Nivolumab is an anti PDL-1 monoclonal antibody that blocks the interaction of PD-1 and PDL-1 to prevent T-cell activation.The rate of grade 3 or 4 diarrhea, requiring corticosteroids in patients treated with PDL-1 patients is low (0-3% in nivolumab).This is therefore a rare case of a patient developing enteritis as an adverse event of nivolumab requiring systemic steroids.There are no proven treatments to prevent the occurrence of diarrhea.Further immunosuppression through systemic steroids is often useful in their management, as in our patient.Other more severe cases have required anti-tumor necrosis factor alpha agents,such as infliximab, or mycophenolate mofetil.While the diarrhea is reversible in most cases, temporary immunosuppression through corticosteroids and other agents is only warranted in the case of severe grade diarrhea.Therefore,early recognition of diarrhea as an irAE is helpful in reducing patient morbidity.

2444 Eosinophilic Enteritis: A Delayed Diagnosis Ankita Munjal, MD1, Abdulhameed Al-Sabban, MD2, Kathy Bull-Henry, MD, FACG1. 1Georgetown University Hospital, Washington, DC; 2Georgetown University Hospital and Washington Hospital Center, Washington, DC

[2442C] Microscopic examination of the small intestine demonstrating blunting of villi. Eosinophilic Gastrointestinal Disorders (EGID) are a rare and complex group of disorders that are characterized by eosinophilic infiltration of the gastrointestinal tract. Eosinophilic esophagitis (EoE) is limited to the esophagus while eosinophilic gastroenteritis (EGE) can involve any portion of the GI tract. Patients often present with a wide range of signs and symptoms including abdominal pain, our patient. All imaging was negative prior to capsule endoscopy. Literature on UJ is scarce and limited to case series and reports. UJ is typically refractory to treatments including prednisone, azathioprine, cyclosporine, biologic agents and chemotherapy. Even after initial treatment success, the relapse rate is high- 90% in one case series. Prognosis is poor with up to 33% mortality rate within three years. Our patient represents a rare diagnosis of UJ and a rare case of steroid-responsiveness. Further research into the pathophysiology and treatment of this poorly understood and difficult-to-treat condition is warranted.

2443 PD-L1 Inhibitor-Associated Diarrhea in a Patient With Stage IV NSLC Tushar Khanna, MD1, Vikas Gupta, MD, PhD2, Russell Rosenblatt, MD2, David Wan, MD2. 1Jill Roberts Center for Inflammatory Bowel Disease, Weill Cornell Medical College, New York, NY; 2New York-Presbyterian/Weill Cornell Medical Center, New York, NY We present a case of immune-mediated diarrhea in a patient with stage IV chemotherapy-resistant non squamous cell lung adenocarcinoma (NSLC) on palliative nivolumab.This highlights a rare but known immune-related adverse event (irAE) of PDL-1 inhibitors such as nivolumab. A 60-yearold female with a past medical history significant for HTN,HLD,Hypothyroidism,OA and stage IV chemo resistant NSLC on palliative nivolumab and on chronic steroids for chemotherapy-related pneumonitis,presented with recurrent diarrhea and periumbilical abdominal cramping associated with nausea and vomiting to the ER.She reported having bowel movements at night unprompted by food around 3-4 weeks ago. The stool was lately more watery,numerous and associated with cramps.Physical exam revealed somewhat distended abdomen that was tender to palpation periumbilically.Multiplex PCR tests for identifying GI pathogens and C.Diff PCR were negative and other infectious causes were ruled out.CT Abdomen revealed long segment enteritis, most prominently in the duodenum, without any evidence of colitis.An upper endoscopy and colonoscopy revealed mild inflammation in the duodenum and spasm in the colon with some semi-solid stool throughout.Pathology showed a regenerative

[2444A] Endoscopy showing erythematous gastric nodules in the antrum of the stomach.

[2444B] Endoscopy showing erythema, scalloping, and villous blunting throughout portions of gastrointestinal tract.



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nausea, vomiting, dysphagia, diarrhea, and even more serious manifestations such as intestinal obstruction or perforation as any length or layer of the GI tract can be involved such as mucosal, muscular, or serosal 1,4,10. As a part of the work-up, patients frequently undergo CT scans and multiple endoscopies before the diagnosis is finally made as was true in our case of a 59 year-old male patient presenting with 2 months of nausea, abdominal pain and weight loss. He underwent EGDs, colonoscopies, a video capsule study and balloon enteroscopy before the diagnosis was confirmed histologically. Endoscopic findings can be variable and often include mucosal erythema, edema, strictures, polypoid lesions and ulcerations8. Radiographic findings are also unpredictable and may include mural thickening, nodularity, luminal narrowing, and perienteric inflammation suggestive of an acute inflammatory condition2,3,8. The diagnosis is confirmed on histopathological examination of biopsies that must show >15-50 eosinophils/high power field based on the location in the GI tract. In our patient, erythema, scalloping, whitish exudate, and patches of villous blunting with a flat pink appearance were noted in the duodenum to proximal ileum endoscopically with >50 eosinophils/hfu confirming the diagnosis of eosinophilic enteritis. This class of diseases is often found in patients with a history of allergic disorders including asthma, eczema, seasonal allergies and food allergies suggestive of hypersensitivity in the etiology of the disease although our patient had no such known history4. Elimination diets and steroids are the mainstay of therapy and often lead to complete resolution of symptoms as well as endoscopic and radiographic findings in up to 90% of patients as was seen in our patient, although some patients have a chronic remitting course8.

2445 Duodenal Ulceration as a Complication of Yttrium-90 Microsphere Radioembolization of Intrahepatic Cholangiocarcinoma

This case highlights a potential complication associated with radioactive microsphere embolization. Given the increasing use of this treatment modality, gastroenterologists should recognize this entity, and its delayed occurrence in particular. New-onset, or change in abdominal discomfort or pain should prompt endoscopic evaluation in patients with prior Y-90 RE. We suggest high dose PPI therapy as initial management, but the optimal treatment strategy to treat gastrointestinal ulceration as a complication of RE should be further investigated. 1. Mouli S, Memon K, Baker T, et al. Yttrium-90 radioembolization for intrahepatic cholangiocarcinoma: safety, response, and survival analysis. J Vasc Interv Radiol. 2013;24(8):1227-34. 2. South CD, Meyer MM, Meis G, et al. Yttrium-90 microsphere induced gastrointestinal tract ulceration. World J Surg Oncol. 2008;6:93.

2446 Eosinophilic Gastroenteritis With Eosinophilic Ascites and Eosinophilic Pleural Effusion: A Case Report Santi Kulpatcharapong, MD1, Roongruedee Chaiteerakij, MD, PhD2. 1King Chulalongkorn Memorial Hospital, Bangkok, Krung Thep, Thailand; 2Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Krung Thep, Thailand A 51-year-old healthy female presents with periumbilical colicky pain and watery diarrhea for 2 weeks, followed by progressive abdominal distension for 1 week. On examination, she was alert with stable vital

Derek J. Estes, MD1, Andrew R. Scheinberg, MD2, Mai Sedki, MD1, Morgan A. Sendzischew, MD1, Shree R. Venkat, MD3, Daniel A. Sussman, MD, MSPH3. 1Jackson Memorial Hospital / University of Miami Miller School of Medicine, Miami, FL; 2Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL; 3University of Miami Miller School of Medicine, Miami, FL Yttrium-90 (Y-90) microsphere radioembolization (RE) can be an effective regional treatment for primary hepatobiliary malignancies. RE with Y-90 has been described as safe for patients with intrahepatic cholangiocarcinoma (ICC)1. However, gastrointestinal ulceration is a rarely reported complication of Y-90 microsphere RE2. Given the increasing incidence of primary hepatobiliary tumors and an expected rise in use of Y-90 RE, we present a case of Y-90 RE-associated duodenal ulceration. A 76-year-old woman presented to the hospital with lower abdominal pain and was evaluated with a CT scan which revealed an ill-defined liver mass adjacent to the gallbladder which was diagnosed as stage IV intrahepatic cholangiocarcinoma involving segment 4 of the liver. She was treated with Y-90 RE with the intent of tumor down-sizing prior to resection. As part of the treatment application, the gastroduodenal artery was densely packed with coils with complete stasis of flow achieved. Through the medial branch of the left hepatic artery, the Y-90 spheres were super-selectively deployed through a micro-catheter. Two months after the radioembolization, she experienced mid-epigastric abdominal pain, not responsive to proton pump inhibitor. Upper endoscopy revealed two non-bleeding superficial duodenal ulcers with no stigmata of bleeding in the duodenal bulb. Pathology from biopsies of the ulcer bed revealed the presence of Y-90 beads in the lamina propria, consistent with radiation-induced duodenitis. She is currently being treated with high dose proton pump inhibitor (PPI) therapy by mouth twice daily, with good response.

[2446A] Slightly turbid yellow asictes fluid, wright stain showed cluster of eosinophils.

[2446B] EGD showed distal esophageal furrows (a), atrophic mucosa at gastric antrum (b), swelling duodenal and jejunal mucosa with whitish pustule (black arrow) (c and d).



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[2446C] Histopathology showed eosinophils infiltration at mucosa through submucosal layer at mid-esophagus (a), gastric antrum (b), duodenum (c), and eosinophilic abscess at jejunum (d).

signs. There was no stigmata of chronic liver disease nor skin rash. She had decreased breath sound with dullness on percussion at right lower lung area. Abdomen was distended, with a fluid thrill. Her legs showed no edema. Lab results were as follows: WBC count 17,850/μ L (neutrophil 38%, lymphocyte 13%, eosinophil 49% with absolute eosinophil count 8,750/μ L), total protein 6.2 g/dL, serum albumin 3.6 g/ dL, others – unremarkable. The peripheral blood smear showed increased eosinophil without abnormal lymphoid cell. Chest x-ray showed bilateral pleural effusion. Abdominal ultrasound showed moderate amount of ascites with normal liver parenchyma. Abdominal fluid analysis found slightly turbid yellow fluid, WBC count 4,084 cells/mm3, eosinophils 92% (Fig 1), total protein 4.1 g/dL, albumin 2.5 g/dL, and negative for gram and AFB stain. Pleural fluid was slightly turbid yellowish, with WBC count of 2,192 cells/mm3 (eosinophils 85%), with total protein of 3.75 g/dL. Provisional diagnosis of eosinophilic gastroenteritis (EGE) was made. Esophagogastroduodenoscopy showed mucosal edema from first part duodenum to proximal jejunum (Fig 2). Histopathology exam found eosinophil infiltration through stroma of esophagus, stomach, duodenum and jejunum, confirming the diagnosis of EGE (Fig 3). On day 3 after treatment with oral prednisolone 40 mg/d, she had rapid response with reduced ascites. Blood eosinophil count was decreased to 120/μ L. EGE is a rare gastrointestinal (GI) tract disease, characterized by eosinophils infiltrate in the gut wall. It is diagnosed by a combination of GI symptoms, presence of tissue eosinophil in at least one area of GI tract, and exclusion of other causes of tissue eosinophilia. EGE is classified into 3 types as mucosal, muscular, and serosal type. Each type has different manifestation. Our patient had diarrhea due to mucosal involvement, the most common form, followed by ascites, reflecting serosal involvement. Eosinophilic pleural effusion can also found in EGE patients with ascites and can be massive causing respiratory compromise. Prednisolone 20-40 mg/day is the mainstay of treatment. Most patients had rapid improvement, usually within 2 weeks. Due to rarity of disease, data on other treatments are limited.

2447 Drug-Induced Flu-Like Enteropathy Adnan Malik, MD, GCPHP1, Hassan Alsabbak, MD2, Asma Samreen, MD3, Khaleeq Siddiqui, MD, MRCP, MRCPI4, Heba Ashraf, MD5, Kais Zakharia, MD6, Muhammad Azrak, MD, MPH6. 1William Beaumont Hospital, Dearborn, MI; 2Beaumont Hospital, Dearborn Heights, MI; 3Jackson Park Hospital and Medical Center, Chicago, IL; 4Calderdale and Huddersfield NHS Foundation Trust, Halifax, United Kingdom; 5 Beaumont Health, Dearborn, MI; 6Beaumont Hospital, Dearborn, MI Introduction: Refractory diarrhea, weight loss and villous atrophy are usually associated with celiac disease and a diagnosis can be confirmed with positive IgA anti-TGA and EGD. Irrespective of the diagnostic tests results if patient does not respond to gluten free diet alternative diagnosis like common variable immunodeficiency, autoimmune enteropathy, microscopic colitis, pancreatic exocrine insufficiency, bacterial overgrowth, GI infections, intestinal cancers, irritable bowel disease, small-bowel strictures, collagenous sprue, Crohn’s disease and tropical sprue should be considered. Case: 75 y/o female with PMH of HTN, DM, asthma and hypothyroidism presented with c/o frequent nocturnal loose stools associated with nausea, vomiting and weight loss for past 14 months. Medication history: Albuterol, Pulmi-cort, Flonase, levothyroxine, Lantus, Benicar, potassium fiber capsules, and vitamin B12. Vitals: BP:80/59 and HR:100 . Exam: Scaphoid abdomen otherwise insignificant Diagnostics: Celiac panel was negative. CT abdomen showed mesenteric lymphadenopathy, EGD showed scalloping of folds mosaic pattern to the mucosa (cracked mud appearance), and prominence of a nodular pattern to the mucosa with similar changes in colon and terminal ileum. Chronic gastritis, duodenal villous atrophy with gastroduodenal increased sub-epithelial collagen deposition and chronic ascending/


descending colitis with focally increased collagenous deposits were noted on biopsy. Repeat endoscopy after 6 months of stopping omlesartan showed normalization of villi and sub-epithelial collagen table. Discussion: Omlesartan possibly induces a cell-mediated immune response hence causing sprue like enteropathy months to years after its initiation which after activation of transformation growth factor damages intestinal mucosa causing villous blunting and thickened sub-epithelial collagen table. Only omlesartan among its class is associated with this side effect and hence it’s cessation would terminate immune process and resolve symptoms. Conclusion: Omlesartan is the only ARB found to be associated with sprue like enteropathy with clinical and histological improvement noticed after cessation of the medication.

2448 Autoimmune Enteropathy: Oh Goody Noor Ali, MD1, Eugenia Tsai, MD2, Robin Staudinger, MD2, Nicholas Verne, MD1. 1Tulane University Health Sciences Center, New Orleans, LA; 2Tulane University School of Medicine, New Orleans, LA A 75-year old man with thymoma status-post resection and Good Syndrome presents with chronic diarrhea for 30 years. The diarrhea is non-bloody, malodorous and occurs several times weekly with-

[2448_A] Laboratory Work Up for Celiac Disease Lab

Value

Anti-transglutaminase

Within normal

IgA

Low

HLA-DQ2

Positive

HLA-DQ8

Negative

[2448_B] Mayo Clinic Proposed Diagnostic Criteria for Adult AIE Adult-onset chronic diarrhea (>6 weeks duration) Malabsorption Specific Small Bowel Histology: partial/complete villous blunting, deep crypt lymphocytosis, increased crypt apoptotic bodies, minimal intraepithelial lymphocytosis Exclusion of other causes of villous atrophy including celiac disease, refractory sprue, intestinal lymphoma, and/ or AG antibodies


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[2448A] .

[2448B] .

out nighttime awakenings. He notes associated 60-lb unintentional weight loss, fatigue and decreased appetite. Medication history is notable for atorvastatin and candesartan. Lactose-free and dietary modifications have not provided symptomatic relief. His abdominal exam is benign and labs are significant for low albumin (3.3gm/dL), and elevated AST and ALT (89 units/L and 139 units/L). Chronic diarrhea workup, including infectious stool studies are negative; serum labs for celiac disease evaluation were equivocal (Table 1.) CT imaging showed thickened ascending colon and distal ileum. Upper and lower endoscopies were performed which only revealed small erosions in the stomach but diffusely erythematous colonic mucosa. Duodenal biopsies showed villous blunting without increased number of intraepithelial lymphocytes; colon biopsies showed focal cryptitis, crypt apoptosis and architectural distortion. A follow up video capsule endoscopy showed inflammation and exudate with ulcerations throughout the small bowel. Autoimmune enteropathy (AIE) is a rare disease characterized by intractable diarrhea, villous atrophy of the small intestine, sometimes the presence of autoantibodies, and usually the need for immunosuppressive therapy. Although more commonly seen in infants, AIE is increasingly recognized in adults. Non-infectious diarrhea has been described in 50% of patients with Good syndrome, and there have been several reports of AIE as the cause of diarrhea. Diagnosing AIE is difficult given nonspecific symptoms. Proposed diagnostic criteria are listed in Table 2. In our patient, more common disease processes were considered including Celiac disease and lymphoma but were less likely given persistence of symptoms despite a gluten-free diet, lack of intraepithelial lymphocytes, and the diffuse nature of bowel involvement. First-line therapy for AIE is commonly corticosteroids. Our patient required both budesonide therapy and immunosuppressive therapy with rituximab. Chronic diarrhea in immunocompromised patients requires a thorough workup along with recognition and consideration of rare etiologies so that appropriate treatment can be provided.

2449 Air on the Side of Caution: An Uncommon Colonoscopy Complication John P. Haydek, MD, Max L. Goldman, BA, Furheen Baig, MD, Christopher O'Donnell, MD, Willie H. Smith, Jr., MD. Emory University School of Medicine, Atlanta, GA A 70-year old woman with history of hypertension was admitted for a 9-day history of nausea and vomiting. She was in a normal state of health until undergoing screening colonoscopy. One day after


the procedure, she developed non-bloody, non-bilious emesis and diffuse, episodic abdominal pain. Her vital signs were all normal. Her admission exam was pertinent for a soft, non-tender, non-distended abdomen. Her admission labs were notable for a blood urea nitrogen of 58 mg/dL, creatinine of 2.07 mg/dL, lipase of 150 units/L, and white cell count 10.4 cells/mcL. Abdominal CT scan identified a highgrade, partial small bowel obstruction with closed loop physiology and left adnexal mass. She underwent surgery, which identified adhesions along the bowel in the left lower quadrant but no evidence of adjacent malignancy. She additionally underwent left oophorectomy, which revealed a high grade serous carcinoma. She recovered well and was discharged on post-operative day 3. Colonoscopy is widely used as a screening, diagnostic, and therapeutic tool in clinical practice. While generally considered a low-risk procedure, serious complications occur in approximately 1% of cases. Bowel obstruction is an extremely rare complication and usually occurs secondary to direct mechanical forces or barotrauma. At least seven cases of small bowel obstruction (SBO) following colonoscopy have been reported. Most SBOs secondary to colonoscopy present at least 24 hours after the procedure and have occurred almost exclusively in male patients with a history of intraabdominal procedures. The proposed mechanism involves reflux of air through the ileocecal valve due to excessive insufflation or anatomical abnormalities. We report a rare case of SBO, with onset 24 hours after colonoscopy, in a woman with no history of prior abdominal instrumentation. Exploratory laparotomy identified serosal adhesions of the small bowel without evidence of adjacent malignancy. To our knowledge, this is the first case of SBO after colonoscopy secondary to non-surgical adhesions that has been reported. In the setting of a de novo ovarian malignancy, the resulting serosal adhesions likely predisposed the patient to obstruction after unintentional small bowel insufflation. While rare, SBO can be a serious complication of colonoscopy, and care should be taken to avoid excessive insufflation and manipulation in individuals with a history of abdominal instrumentation or ongoing malignancy.

2450 A Case of Severe Enteropathy in a Seropositive Patient Following Exposure to Olmesartan Anila Kumar1, Kevin Louie2, Kutner Donald3, Kutner Matthew4, Beth Schrope5, Stephen Lagana, MD6. 1 Rowan University School of Osteopathic Medicine, Martinsville, NJ; 2Rowan University School of Osteopathic Medicine, Robbinsville, NJ; 3Valley Hospital, Fair Lawn, NJ; 4Valley Hospital, Hoboken, NJ; 5 Columbia University College of Physicians and Surgeons, New York, NY; 6New York-Presbyterian/ Columbia University Medical Center, New York, NY Celiac disease is a chronic, immune-mediated enteropathy precipitated by dietary gluten in genetically predisposed individuals. Clinical manifestations include diarrhea, abdominal pain, and weight loss [1]. Olmesartan has been associated with severe sprue-like enteropathy in patients seronegative for celiac disease [2]. We present an interesting case of a patient with chronic diarrhea and total villous atrophy following olmesartan exposure. A 71 year-old Caucasian male with a history of hypertension, anemia and diabetes mellitus presented to a community hospital after a mechanical fall. Blood work showed pre-renal azotemia and concomitant metabolic derangements. The patient reported experiencing voluminous diarrhea, weight loss and abdominal distention for three weeks prior to his presentation. Home medications included olmesartan, allopurinol, furosemide, glimepiride and spironolactone. An upper endoscopy revealed diffuse mucosal congestion, edema and erythema of the duodenal bulb and second portion. Duodenal biopsies showed total villous atrophy, chronic active inflammation and diffuse intraepithelial lymphocytosis. Laboratory studies revealed Anti-Endomysial Ab titer > 1:320, Tissue Transglutamin IgG >100, TTGA >100, Gliadin IgG > 125, Gliadin IgA >150 and HLA DQ 05:01,05, HLA DBQ1 02;01,03;01. The patient’s symptoms resolved with discontinuation of olmesartan and initiation of a gluten free diet. Olmesartan, an ARB, has been identified in the literature as a common cause of sprue-like enteropathy. Other ARBs have been reported to cause sprue-like enteropathy, suggesting a class effect [5]. Symptoms of diarrhea and weight loss tend to persist despite a gluten-free diet [2]. Histopathological findings consist of severe intestinal villous atrophy, intraepithelial lymphocytosis, subepithelial collagen deposition and inflammation of the lamina propria [3]. Discontinuation of olmesartan results in improvement of symptoms and histology [4]. Interestingly, our patient had serological evidence of celiac disease yet no prior episodes of clinical enteropathy. Repeat laboratory analysis and duodenal biopsies, while off olmesartan, will be required to differentiate between olmesartan-asscociated enteropathy and seropositive celiac disease. As mentioned in previous reports, this case highlights the importance of communication between gastroenterologist and pathologist, as discontinuation of a medication can have a profound effect.


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2451 Use of Volumetric Laser Endomicroscopy to Characterize a Duodenal Neuroendocrine Tumor 2017 Presidential Poster Award Amrit K. Kamboj, MD, Prasuna Muppa, MBBS, Kenneth K. Wang, MD, FACG, Cadman L. Leggett, MD. Mayo Clinic, Rochester, MN Volumetric laser endomicroscopy (VLE) is a novel technology that provides real-time, high-resolution images of human tissue microstructure. Presently, VLE is primarily used for detection of dysplasia in Barrett’s esophagus (BE). The use of VLE for imaging of other areas of the gastrointestinal tract remains limited. While the differential for submucosal lesions in the small bowel is broad and includes carcinoid tumors, gastrointestinal stromal tumors, and leiomyomas, VLE may help differentiate such lesions. Here, we present a case where VLE was used for imaging of a duodenal neuroendocrine tumor (NET). A 75-year-old male enrolled in an active surveillance program for BE with low-grade dysplasia presented with a recurrence of a duodenal NET. He was first diagnosed with a duodenal NET 7 years prior and was treated with endoscopic mucosal resection (EMR). At presentation, an upper endoscopy demonstrated a nodule in the duodenal bulb with normal appearing overlaying mucosa (Figure 1A). The patient underwent EMR of the lesion using the cap and snare technique. VLE imaging of the EMR specimen revealed an asymmetric submucosal mass with septated regions of high and low signal intensity (Figure 1B). At low power (2X), matching histopathology demonstrated a well-circumscribed mass with multiple lobules of small blue cells separated by fibrous septa (Figure 1C). A high power view (40X) revealed a moderately differentiated submucosal NET, composed of uniform polygonal cells with finely granular chromatin, inconspicuous nucleoli, and moderate eosinophilic cytoplasm. The final diagnosis of NET was confirmed with immunohistochemical stains positive for keratin AE1/AE3, synaptophysin, and chromogranin. To our knowledge, this is the first case describing VLE features of a duodenal NET, a common type of small bowel malignancy. This case highlights the potential use of VLE for small bowel imaging. Additional VLE studies characterizing different types of small bowel lesions may be helpful in distinguishing benign from malignant tumors. In-vivo studies are necessary to determine the true utility of VLE in the diagnosis of NETs.

obstruction or chronic intestinal obstruction whereas our patient presented with profuse diarrhea and malabsorption, which is mostly seen in AA Amyloidosis and not AL. Case Report: A 51 year old African American female presented with 3 weeks of progressive lower extremity weakness, swelling and chronic diarrhea. Past medical history significant for AL amyloidosis s/p ASCT with BEAM conditioning. On physical examination, vital signs included temperature of 36.7, pulse of 80, and blood pressure of 98/66 mm Hg. Patient had 2+ pedal edema to the thighs along with pressure ulcers on lower back, right heel and right calf.Work up for her chronic diarrhea included stool PCR studies for Clostridium Difficile, Cytomegalovirus, Herpes Simplex Virus, Giardia and Cryptosporidium Antigen, all of which were negative. Fecal Fat and Stool Alpha 1 antitrypsin studies were within normal limits. Relevant labs included ALP of 172 mIU/ml (40-175) and Albumin of 1.1 g/dl (3.4 - 5.0). EGD with biopsies of the small bowel mucosa showed significant microscopic involvement of AL amyloid deposition within vessel walls and smooth muscle tissues which was visible using congo red stain (Figure1). During admission, she was started on Psyllium as a bulking agent and Octreotide 100 mcg daily which resolved her diarrhea. She also received daily diuresis with albumin which improved peripheral edema significantly. Discussion: As mentioned above, this is a very unique case because most patients with AL amyloid deposition in the GI tract present with constipation, mechanical obstruction or chronic intestinal obstruction whereas our patient presented with profuse diarrhea and malabsorption, which is mostly seen in AA Amyloidosis and not AL. Furthermore a course of steroids are a mainstay of treatment for these patients but there was no utility for steroids in our patient as as there was no inflammation on biopsy and patient had a good clinical response to octreotide 100 mcg daily.

[2452] The presence of amyloid fibrils can be confirmed by their characteristic appearance on electron microscopy and by their ability to bind Congo red leading to green birefringence.

2453 Acute Abdominal Pain in Systemic Lupus Erythematosus: A Broad Differential

[2451] An upper endoscopy demonstrated a nodule (red arrows) in the duodenal bulb with normal appearing overlaying mucosa. 1B) VLE imaging revealed an asymmetric submucosal mass. 1C) Matching histopathology (letters) exhibited a wellcircumscribed, lobulated submucosal NET (2X magnification).

2452 A Case of Chronic Diarrhea and Malabsorption Treated With Octreotide in a Patient With AL (Lambda Type) Amyloidosis Status Post-Autologous Stem Cell Transplant KumKum Patel, MD1, Sanmeet Singh, MD1, Sima Patel, MS2. 1University of Illinois at Chicago, Chicago, IL; University of South Florida, Lutz, FL

2

Introduction: The following case report describes a patient with known medical history of AL Amyloidosis previously treated with Autologous Stem Cell Transplant (ASCT) presenting with chronic diarrhea, weakness and progressively worsening lower extremity swelling. Workup revealed a protein losing enteropathy secondary to GI Amyloidosis found via EGD with duodenal biopsy. This case is unique because most patients with AL amyloid deposition in the GI tract present with constipation, mechanical


Nabil D. Baddour, DO, MPH1, Jane Andrews, MD, MPH2. 1Tulane University Health Sciences Center, New Orleans, LA; 2Yale University, New Haven, CT Presentation: A 49 year-old woman with Systemic Lupus Erythematosus (SLE) complicated by multiple thromboembolic events presented with four days of abdominal pain. The pain localized to the periumbilical region with radiation to perineum, and was associated with 3 days of non-bloody diarrhea and anorexia. Laboratory analysis revealed a leukocytosis of 16,300 cells/mm3. Lactic acid was 4.4 mmol/L. Serum lipase, liver function tests and urinalysis were all within normal limits. A CT scan of her abdomen and pelvis noted thickening of multiple ileal segments (Figure 1) and a large thrombus within the superior mesenteric artery (Figure 2, Figure 3). She subsequently underwent embolectomy and ileal resection due to intestinal ischemia and necrosis. Discussion: Abdominal pain in patients with SLE represents a unique diagnostic challenge. Given the life-threatening complications of bowel ischemia, lupus mesenteric vasculitis (LMV) and mesenteric thrombus are two particularly important considerations. However, the high incidence of corticosteroid use can mask the more explicit findings of peritonitis, and long term use of immunosuppressant and NSAID therapies elevates consideration of infectious colitis and peptic ulcer disease. Few clinical indicators confer diagnostic support in differentiating between lupus mesenteric vasculitis and ischemia due to thrombosis. Computed tomography typically yields non-specific findings of bowel wall thickening, edema and fat stranding common to both ischemic and infectious processes. In rare instances, radiological surveys may reveal important distinctions in distribution of effected bowel. In the present case however, CT imaging was able to provide confirmation of a superior mesenteric artery (SMA) thrombus.Elsewhere, evidence exists for the utilization of the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) as a diagnostic tool, with the vast majority of ischemic events due to LMV or thrombus occurring in patients with an elevated SLEDAI (> 6) at presentation.


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Conclusion: LMV and thromboembolic disease are life-threatening gastrointestinal manifestations of SLE with similar presentations. While the mechanisms and management of each condition are unique, diagnostic differentiation is problematic, creating a challenge for the clinician. Assessing SLE disease activity is advisable as an initial consideration when there is concern for SLE-related ischemia. Characteristic CT findings can be an additional diagnostic tool.

[2453C] Multiple vessels of the ileal wall occluded by thrombus.

[2453A] Computer tomography showing thickened segments of ileum.

2454 The Hidden Colors Within Nicolas Mungo, MD1, Diego F. Hidalgo, MD2, Jennifer Phemister, MD2, Puneet Goenka, MD2, Mark Young, MD2. 1East Tennessee State University, Jonesborough, TN; 2East Tennessee State University, Johnson City, TN A 60-year-old female presented with worsening shortness of breath. Her past medical history consists of coronary arteriosclerosis, heart failure, diabetes mellitus, dyslipidemia, hypertension, paroxysmal atrial fibrillation, Factor V Leiden mutation, and resection of ascending colon, cecum, and

[2453B] Thrombus in the proximal superior mesenteric artery seen narrowing the proximal take-off.


[2454A]


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attain large size and produce various manifestations like duodenal obstruction or upper gastrointestinal bleeding. CASE REPORT A 55 yr female presented to the outpatient with complaints of fatigue, weakness and recurrent melena. She had previous history of epigastric discomfort and melena for which she used to take iron infusion. There was pallor but no other remarkable finding on examination. Her investigations showed Hb 8.8 gm/dl (11.0 -17.0). Upper G I endoscopy was done and showed a large pedunculated polypoidal mass in D1 extending till D2 occupying the whole lumen(figure 1). Subsequently CT Abdomen was done and showed a large pedunculated polyp with smooth margins arising from D1 and prolapsing into the second part, measuring 5.3 x 1.8 x1.5 cm(figure 2). Local excision of the lesion was done by endoscopic snare cautery technique after applying endoloop. Histological examination showed hyperplastic brunner,s gland in the submucosa and in the lamina propria with overlying intact mucosa. The nests of brunner,s gland were separated by smooth muscle and vascular septae with chronic inflammatory infiltrate and occasional cystic change.Patient remained asymptomatic on regular follow up visits. Discussion Brunner’s gland hamartoma is a rare benign tumor of the duodenum accounting for about 10.6% of benign duodenal tumors and occurred in about 0.008% of individuals in a single series of 215,000 autopsies. Since its first description by Cruveilhier in 1835 and Salvioli in 1876, less than 200 cases have been reported in the literature. The differential diagnosis includes gastrointestinal stromal tumor, benign or malignant (previously known as gastrointestinal leiomyoma or leiomyosarcoma), lipoma, endocrine cell tumor (carcinoid tumor), lymphoma, vascular tumor, aberrant pancreatic tissue, adenocarcinoma, adenomyomatous polyp, prolapsed pyloric mucosa, ampullary neoplasm and even a foreign object. At present, the most accredited pathogenetic hypothesis remains that BGA is a duodenal dysembryoplastic lesion or hamartoma.

[2454B]

partial small bowel due to ovarian cancer metastasis. She is a smoker but denies drug and alcohol use. Home medications included aspirin, statin, gabapentin, hydralazine, insulin, isosorbide mononitrate, labetalol, warfarin and torsemide. Upon admission, laboratory findings were low hemoglobin and iron deficiency. She received 2 units of packed red blood cells. Gastroenterology was consulted for further investigation. She denied any change in stool and fecal occult blood test was negative. No epigastric pain, NSAID use, nausea or vomiting. There was no history of celiac disease, atrophic gastritis or H. pylori. She had undergone the intestinal resection mentioned above but no bariatric surgery which would possibly affect the iron absorption. No erythropoietin use or renal failure. Colonoscopy revealed rectal varices and a tortuous colon. Esophagogastroduodenoscopy demonstrated portal gastropathy, small esophageal varices with red wale signs and pigmentation throughout the duodeni not found on colonoscopy. This endoscopic appearance is called pseudomelanosis duodeni (PD) a rare, thought to be benign, condition first described in 1976 by Bisordi and Kleinma. In literature to date there are few cases described. Originally named melanosis duodeni, it was thought the deposits were composed of melanin but later found to be composed of ferrous sulfide and hemosiderin within macrophages in the lamina propia. It has female predominance and occurs mostly in the sixth and seventh decades of life. The cause of this condition has not been confirmed to date though strong associations with hypertension, diabetes mellitus, end-stage renal disease, and folic acid deficiency have been suggested. PD is asymptomatic and unlike iron or other metals in the body which can cause an inflammatory reaction, it has not been associated to cause strictures, fibrosis or duodenitis. Our patient is consistent with other cases being that she is female, in her sixth decade of life and suffers from hypertension and diabetes. Therefore, our case provides further support to unveiling the definitive cause of this rare endoscopic finding.

2455 Brunner Gland Hamartoma Presenting as Recurrent Melena Varun Mehta, MBBS, MD, DM1, Charanpreet Grewal, MBBS, MD1, Saurabh Singh, Sr., MBBS, MD2, Ramit Mahajan, MBBS, MD, DM1, Ajit Sood, MBBS, MD, DM1. 1Dayanand Medical College and Hospital, Ludhiana, Punjab, India; 2DMC and Hospital, Ludhiana, Punjab, India INTRODUCTION Benign small bowel neoplasms are rare, among them brunner gland hamartoma is uncommon benign tumour of duodenum. Most of them are asymptomatic and small but very few

[2455B] CT abdomen showing polypoidal mass in duodenum.

[2455A] endoscopic image of brunner,s gland polyp.



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2456 Successful Endoscopic Resection of a Rare Minor Ampullary Duodenal Gangliocytic Paraganglioma: A Case Report Tanuj Sharma, MD1, Mohammed Albugeaey, MD2, Nadim G. Haddad, MD2. 1MedStar Washington Hospital Center, Washington, DC; 2MedStar Georgetown University Hospital, Washington, DC Duodenal gangliocytic paragangliomas (DGP) are extremely rare neuroendocrine tumors. We present a case of a successful endoscopic resection of an incidental DGP. A 61-year-old Caucasian male with a history of cholecystectomy, iron deficiency anemia and GERD was incidentally found to have a 1.3cm periampullary duodenal polyp without any lymphadenopathy on a routine CT scan. The findings were confirmed with an abdominal MRI. He denied abdominal pain, early satiety, nausea, diarrhea, constipation, flushing, wheezing, weight loss, melena or any family history of gastrointestinal malignancies. An EUS examination showed markedly enlarged minor papilla with a hypoechoic mass and intact muscularis propria. A prominent pancreatic duct (PD) was also visualized. The EUS was followed by an ERCP to resect the polyp and a 5Fx4cm stent was placed in the PD due to high suspicion of pancreatic divisum. The specimen was a tan-colored, well-circumscribed 1.3x0.8x1cm soft, polypoid mass. Histologically, it was mostly a submucosal mass with a focal mucosal component. It exhibited a triple cellular differentiation with the epithelioid tumor cells arranged in nests along with occasional ganglion-like cells and surrounding scant spindle cells without atypia. The margins were clean. The epithelioid cells stained strongly positive for synaptophysin and chromogranin, and weakly positive for keratin. They were negative for S100, gastrin and somatostatin. The spindle cells stained positive for S100, synaptophysin and were negative for keratin. The mitotic active was low with a Mib-1 proliferative index of 3%. A 6-month follow up EGD with minor ampullary biopsy showed no signs of dysplasia or malignancy. DGPs are extremely rare and non-functional neuroendocrine tumors. They are twice more prevalent in males and usually found in the 6th to 7th decades of life. They are mostly benign tumors with excellent prognosis post resection. However, there have been about 20 case reports with lymph node metastasis and 1 report of fatal metastatic DGP. Traditionally, pancreaticoduodenectomy has been the treatment of choice when lymph nodes are involved. However, endoscopic resection, as in this case, remains a safe alternative for a localized DGP. In the lack of official guidelines, more studies are required to understand the nature of the disease, optimal treatment and follow up duration.

[2456C] The ampulla post resection.

2457 A Rare Case of Acute Ischemic Duodenal Ulcer With Near Complete Resolution Post-High Dose Proton Pump Inhibitor Therapy Tanuj Sharma, MD1, Katherine Hahn, MD, MPh2, Mitesh Patel, MD1, Zone-En Lee, MD1. 1MedStar Washington Hospital Center, Washington, DC; 2MedStar Georgetown University Hospital, Washington, DC

[2456A] Duodenal Gangliocytic Paraganglioma, ultrasound view.

[2456B] Duodenal Gangliocytic Paraganlioma, endoscopic view.


Ischemia is an uncommon cause of duodenal ulcers due to its rich vascular supply. We present a case of severe aortic stenosis leading to vascular slow-flow induced multiple ischemic duodenal ulcers with near-complete resolution after high dose proton-pump inhibitor therapy. A 74-year-old Caucasian male with a history of severe bicuspid aortic stenosis and diverticulosis was admitted for an elective surgical aortic valve replacement. After an uncomplicated procedure, patient complained of acute onset right upper quadrant abdominal pain, nausea, bloating, loss of appetite and melena. His hemoglobin decreased from 13gm/dL to 7.4gm/dL over 3 days and responded appropriately to blood transfusions. Patient denied hematemesis, post-prandial abdominal pain, diarrhea, constipation, prior episodes of melena, and chronic NSAID use. An EGD showed LA grade B esophagitis, patchy erythematous changes and shallow ulcerations in gastric antrum, and multiple ulcers in the duodenal bulb and second segment of duodenum. The largest duodenal ulcer measuring 3.5cm had a deep necrotic base and a pigmented protuberance without signs of active bleeding. Epinephrine was injected in the surrounding mucosa. However, given the size and the depth of ulceration further interventions were deferred. Patient was started on high dose proton-pump inhibitors. H. pylori serologies were negative, and gastrin and tryptase levels were normal. A repeat EGD, 5 days later, showed remarkable improvement with multiple clean-base healed duodenal ulcers and no signs of necrosis. H.pylori and chronic NSAID use are the most common causes of duodenal ulcers. In the absence of such risk factors, presence of multiple duodenal ulcers raises suspicion of less frequent hypergastrinemia, radiation injury or systemic mastocytosis. Ischemic injury is a rare cause of duodenal ulceration due to the rich vascularization of the gastroduodenal mucosa. Given the paucity of data, there are no official guidelines for ischemic gastroduodenal ulcers. Surgical resection of the necrotic bowel with non-healing ulcers remains the treatment of choice in most cases. In patients with severe cardiovascular co-morbidities, as in our case, ischemic injury must be consid-

[2457A] Necrotic 3.5 cm ulcer at second segment of duodenum. Pre-PPI therapy.


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ered because of its potential to cause severe damage to the duodenal mucosa. Besides cardiovascular optimization, high dose proton-pump therapy can lead to remarkable recovery. More studies are indicated to understand the optimal treatment and follow-up duration for such pathology.

2458 A Rare Case of Gastrointestinal Histoplasmosis in an Immunocompromised Host Frank Lopez, DO1, Amulya Reddy, DO1, Thomas Birris, MD2. 1Lakeland HealthCare, St. Joseph, MI; 2Great Lakes Gastroenterology, St. Joseph, MI Introduction: Histoplasmosis capsulatum (HC) is a dimorphic fungus common to the Ohio and Mississippi River valleys and is found mainly in soil enriched by avian or bat droppings. It typically presents as an asymptomatic pulmonary infection. Gastrointestinal (GI) involvement is usually unrecognized due to nonspecific symptoms and is thought to be symptomatic in only 3 to 12% of patients. The majority of GI histoplasmosis involves patients with HIV/AIDS. The most common site of GI involvement is the ileocecal region due to the presence of abundant lymphoid tissue. Case Presentation: A 64-year-old man with paroxysmal atrial fibrillation (on warfarin), end stage renal disease on hemodialysis, status post failed transplanted kidney and on chronic immunosuppression presented with a one day history of hematochezia and hematemesis and six weeks of worsening left lower quadrant abdominal pain. CT thorax with intravenous contrast revealed a right lower lobe cavitary mass and a spiculated left upper lobe nodule (Figure 1). Esophagogastroduodenoscopy with enteroscopy revealed old blood in stomach and the endoscope was advanced into the jejunum revealing multiple ulcers (Figure 2). Histopathology from jejunal biopsies was consistent with HC (Figure 3). Histoplasmosis antibodies by complement fixation for yeast and mycelia were positive as was fungal immunodiffusion for Histoplasma M antigen. Histoplasmosis serum antigen was negative. The patient was treated with intravenous amphotericin for presumed disseminated histoplasmosis. He improved clinically with resolution of symptoms and was discharged on oral itraconazole and remains therapeutic five months later. Discussion: Histoplasmosis capsulatum is generally seen in immunocompromised hosts. While common at autopsy, gastrointestinal histoplasmosis (GIH) goes unrecognized during life as the symptoms are nonspecific. Patients with GIH most commonly present with abdominal pain and diarrhea, but may also have dysphagia, odynophagia, bowel obstruction or perforation. In this case, the patient presented with clinically significant gastrointestinal bleeding. Upper endoscopy with jejunal biopsies revealed HC. Both the presence of symptomatic GIH and the jejunal location are atypical. This observation in a patient without HIV is exceedingly rare.

[2457B] Giant ischemic ulcer at second-segment of duodenum. Pre-PPI therapy.

2459 Cervical Cancer Presenting in an Extremely Unexpected Location Talha Qureshi, MD, Mazen Shobassy, MD, Stephen C. Pappas, MD, JD. Baylor College of Medicine, Houston, TX Malignancy within the duodenum is an infrequent encounter accounting for less than 0.4% of all cancers. Metastatic lesions from malignant melanoma and adenocarcinomas of the pancreas, lung, stomach, and colon are most common. Carcinoma of the cervix most typically spreads via direct extension, but nodal metastases are not uncommon. This case reports an extremely rare location of cervical cancer within the duodenum. A 54 year old female from Honduras presented with anorexia, early satiety, and weight loss for several months. She was reportedly treated for cervical cancer with hysterectomy and total salpingo-oophorectomy. She also received chemotherapy and radiation two years ago but dosage and duration were unknown. On examination, she was a frail appearing woman with conjunctival pallor. Rectal and pelvic examinations were unremarkable. Labs were significant for iron deficiency anemia. Further investigation included computed tomography (CT) scan of the abdomen and pelvis revealing circumferential wall thickening in the second and third portions of the duodenum with an exophytic necrotic 5.0x3.1 cm mass between the duodenum and pancreas. Esophagogastroduodenoscopy showed a friable mass near the ampulla extending to the second and third parts of the duodenum. Pathology of the endoscopic biopsies demonstrated duodenal mucosa with neoplastic proliferation of squamoid tumor nests with lymphovascular invasion. Immunostains were positive for P16 and P40; while, negative for CK7, PAX8, and CDX2. Findings were consistent with metastatic squamous cell carcinoma originating from the cervix. Given the extent of tumor burden, palliative chemotherapy was offered, but unfortunately, patient declined further treatment with wishes to return to Honduras for treatment. In the developing world, cervical cancer accounts for the second most common type of cancer and the third most common cause of cancer mortality in women. Extra-pelvic spread of cervical squamous cell carcinoma to the small bowel has only been reported six times in the English literature. Cervical cancer has been reported to metastasize through the lymphatic system, and this case emphasizes the ability of cervical cancer to spread via the para-aortic lymph nodes affecting the small bowel. This case raises awareness for an infrequent location of metastatic cervical cancer, particularly in patients with barriers to adequate cervical cancer surveillance.

[2457C] Near-complete resolution of ulcer. Post-PPI therapy.

[2458A] CT thorax with intravenous contrast showing (A) 21mm right lower lobe cavitary mass (B) and 19mm left upper lobe spiculated nodule.



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[2458B] Ulcerations of proximal (A) and mid-jejunum (B).

[2458C] Gomori methenamine silver (GMS) stain of jejunal biopsy specimen showing budding yeast form of histoplasmosis capsulatum. [2459B] Friable mass in the second and third portions of the duodenum.

[2459A] CT Abdomen with contrast showing an exophytic, necrotic mass between the duodenum and pancreas.


[2459C] Hematoxylin and eosin staining showing duodenal mucosa with neoplastic proliferation of squamoid tumor nests predominantly in the submucosa.


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2460 An Unusual Case of Late Metastasis to Jejunum From Previously Resected Colon Cancer Mass Harika Balagoni, MD, Laith Al Momani, MD, Dhara Chaudhari, MD, Chakradhar Reddy, MD, Mark Young, MD. East Tennessee State University, Johnson City, TN Distant metastasis of colorectal cancer (CRC) to unusual sites, like small bowel, kidney, thyroid many years after resection of the primary tumor is rare but has been reported. A 71-year old female with a history of Stage IIIb CRC status post resection 2 years ago presented with worsening dyspnea, fatigue and post-prandial lower abdominal pain for 2 weeks. Her other medical conditions include coronary artery disease, pulmonary hypertension and atrial fibrillation on anticoagulation therapy. She denied any nausea, vomiting, bright red blood per rectum, NSAID’s use or epigastric pain. Her abdominal exam was benign except for dark stool on rectal exam. Labs showed iron deficiency anemia and positive fecal occult blood. She underwent capsule endoscopy which showed a ulcerated area in the proximal small bowel with oozing blood and irregular mucosa. Eventually, she underwent single balloon enteroscopy which showed an ulcerated, friable mass in the mid-distal jejunum. Biopsies showed moderately differentiated adenocarcinoma and positive anti-CK 20, similar to her primary sigmoid lesion, confirming the diagnosis of metastasis from CRC. The incidence of CRC metastases to the small bowel is relatively rare, about 2.8–8.2%. The most common site is ileum, followed by jejunum. A significant lag time of 1.3-7 years, from the initial diagnosis of colorectal cancer to the onset of symptomatic small bowel metastasis, has been reported. The routes of metastasis to the small intestine include hematogenous, peritoneal or intestinal metastasis. The major route from CRC is, disseminated metastasis associated with peritonitis carcinomatosa. Patients may present with symptoms such as occult bleeding, intestinal obstruction, or perforation. The diagnosis is often made on a small bowel series or CT. However, neither can differentiate a primary from a metastatic small bowel cancer. Radical surgical resection of such late metastasis is reportedly associated with a good quality of life but postoperative complication rates are high, about 80% and survival is short (2–15 months), although survival up to 11 years has been reported. Our case highlights the late occurrence of CRC metastases at unusual sites like small bowel, several years after the resection of the primary. It should be suspected in any patient with occult GI bleeding and history of CRC. Diagnosis is based on capsule endoscopy for tumor localization and balloon-assisted enteroscopy for confirmation.

lesions, but terminal ileal intubation during colonoscopy demonstrated creamy-white, discrete, punctate mucosal lesions in the terminal ileum, characterteristic of lymphangiectasia. Standard EGD with intubation to the mid-descending duodenum did not reveal any significant lesions, but subsequent enteroscopy demonstrated similarly appearing lesions in the distal duodenum/proximal jejunum. Histopathologic analysis of the lesions of the terminal ileum and proximal jejunum demonstrated dilated mucosal vessels, which were confirmed as lymphatic vessels by two immunohistochemical markers for lymphatic endothelium. Extensive evaluation excluded secondary causes of intestinal lymphangiectasia, thereby establishing the diagnosis of PIP. This work shows that PIP can first present in the very elderly and even present in them with a short duration of symptoms. PIP must therefore be included in the differential diagnosis of protein losing enteropathy with compatible clinical presentation in elderly patients. This work also shows that standard colonoscopy and standard EGD may miss the characteristic lesions of PIL, and terminal ileal intubation or enteroscopy may be required because the lesions are often patchy and commonly located in the jejunoileum.

2461 Primary Intestinal Lymphangiectasia Diagnosed in an Octogenarian: Diagnosis by Ileal Intubation and Push Enteroscopy After Failed Diagnosis by Standard Colonoscopy and EGD Ahmed I. Edhi, MD1, Mitual Amin, MD2, Mitchell S. Cappell, MD, PhD, FACG3.. 1Beaumont Hospital, Royal Oak, MI; 2William Beaumont Hospital, Royal Oak, MI; 3Beaumont Health, Royal Oak, MI Primary intestinal lymphangiectasia (PIL) is a rare, presumably congenital lesion that is usually diagnosed in patients < 3 years old, is rarely first diagnosed in adulthood, and when first diagnosed in adulthood has typically manifested symptoms for many years. A patient is reported who initially presented at age 83 with symptoms of watery diarrhea, abdominal distention, 5-Kg-weight gain, weakness for one month, and had the typical clinical findings of PIP on evaluation including chylous ascites, pleural effusions, bilateral pitting leg edema, hypoalbuminemia, borderline lymphopenia, hypovitaminosis B12, hypovitaminosis D, Iron deficiency anemia and hypocalcemia. Protein losing enteropathy was demonstrated by a positive test for alpha-1-antitrypsin. Standard colonoscopy did not reveal any significant

[2461B] High power view of terminal ileum biopsy showing numerous vascular spaces in the lamina propria. A single villus at the upper end shows extremly dilated lymphatic space (lymphangiectasia).

[2461C] High power view of illeal biopsy tissue shows numerous lymphatic spaces highlighted by positive staining with antibodies to D2-40 which stains brown the cytoplasm of lymphatic endothelial cells. Note absence of staining of cells lining the illeal glands.

2462 Neurofibromatosis-associated Malabsorption Shirley Cohen-Mekelburg, MD1, Rhonda Yantiss, MD2, Charles Maltz, PhD, MD1. 1New York-Presbyterian/ Weill Cornell Medical Center, New York, NY; 2Weill Cornell Medical College, New York, NY

[2461A] Push enteroscopy demonstrates small creamy white punctae of dilated lymphatic vessels noted throughout the distal duodenum and jejunum.


We report on a case of a young woman who presented with anemia secondary to malabsorption in the setting of neurofibromatosis with intestinal involvement. A 25-year-old woman presented with symptomatic iron deficiency anemia. There was no history of menorrhagia or pregnancy and she was eating


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a regular diet. For the prior 18 months, she suffered from diarrhea and weight loss. Her family history was significant for both her mother and brother having neurofibromatosis type 1. She, herself, had been previously diagnosed with neurofibromatosis based on café au lait spots. Her exam was significant for several café au lait spots, a 2.5cm neurofibroma on the chest, a firm yet non-tender abdomen, and a body mass index of 17.3. Labs revealed a microcytic anemia of 6.4g/dL with an associated ferritin of 2.7ng/ mL. Further laboratory testing revealed a low serum copper of 29μ g/dL, hypoalbuminemia of 2.0g/ dL, and a low 25-OH vitamin D at 6.1ng/mL. Thiamine, vitamin E, vitamin B12, folate and IgA tissue transglutaminase were normal. A CT scan showed multiple segments of severely thickened jejunal and ileal loops. Some areas contained polypoid luminal masses. A conglomeration of low-density masses

was noted throughout the small bowel mesentery (Figure 1). The terminal ileum and proximal duodenum were not involved. A subsequent diagnostic push enteroscopy revealed markedly dilated lacteals in the jejunum (Figure 2). Jejunal biopsies confirmed diffuse mucosal involvement by neurofibroma with associated dilated lacteals (Figure 3). This led to a diagnosis of small bowel neurofibromatosisassociated malabsorption. Neurofibromatosis type 1 is an autosomal dominant condition associated with gastrointestinal tumors in up to 25% of cases.1 Neurofibromatosis causing lymphatic obstruction of the extremities with resultant lymphedema is well reported. Neurofibromatosis involving the small bowel may present with occult bleeding, intussusception, or constipation.3-5 In the case described here, infiltration of the mesentery as well as the small bowel with neurofibromatosis resulted in dilated lacteals, associated hypoalbuminemia, as well as multiple vitamin deficiencies. The patient’s anemia and copper improved with parenteral iron and copper supplementation, but her hypoalbuminemia and diarrhea persisted. Because of extensive small bowel involvement, surgical resection was deferred and she was referred to a nutritionist for dietary manipulation.

[2462C] Jejunal biopsies showing diffuse neurofibroma with dilated lacteals.

2463 Large Gastrointestinal Stromal Tumor in Long-Standing Crohn's Disease on Adalimumab Ihab Kassab, MD1, Meetal Mehta, MD1, Bilal Saleem, MD1, Razvan Arsenescu, MD, PhD2. 1Morristown Medical Center, Morristown, NJ; 2Atlantic Health System Morristown Medical Center, Morristown, NJ

[2462A] CT demonstrating segments of thickened jejunal and ileal loops, polypoid luminal masses. and a conglomeration of low-density masses throughout the small bowel mesentery.

[2462B] Push enteroscopy revealing markedly dilated lacteals in the jejunum.


Small intestinal tumors are rare and generally benign. However, malignant tumors may also develop. Gastrointestinal stromal tumors (GIST) arise from the interstitial cell of Cajal or precursors in the myenteric plexus of the gastrointestinal tract. The association between GIST and Crohn’s disease (CD) is debated, as the tumor inconsistently present in areas of inflammatory bowel disease (IBD) activity. We describe a case of CD maintained on Adalimumab, in which a presumed flare revealed a large GIST in the jejunum. A 45-year-old man with history of CD presented with 3 days of right lower quadrant abdominal pain associated with nausea, fever, and chills. He was being treated with Adalimumab for 3 years and sulfasalazine since diagnosis at age 22. Upon presentation, he was tachycardic with an abdominal exam revealing distension, tenderness and hyperactive bowel sounds. Laboratory findings were leukocytosis and anemia, and otherwise unremarkable. Abdominal CT scan demonstrated an 11.8 x 11.2 x 8.8 centimeter (cm) mass, which was recruiting multiple mesenteric and pelvic vessels, radiologically suggesting a necrotic

[2463]


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or infected mass. The lesion was drained and biopsied. Culture showed S. anginosus and S. intermedius and pathologyrevealed scant fragments of spindle cell proliferation, consistent with GIST. A successful laparoscopic 20 cm resection of small bowel was performed, followed by Imatinib as adjuvant therapy. At three months, colonoscopy revealed inflammation, friability and ulcerations in a discontinuous pattern diffusely throughout the colon, secondary to CD, and abdominal CT scan showed postoperative changes with no new lesions. The coexistence of GIST and IBD is extremely rare. It is possible that immunosuppressive treatment may enhance the development and progression of such tumors. An association between Adalimumab and an increased risk of malignancy in a dose-dependent manner in rheumatoid arthritis patients has been shown. With this, we propose that there may be an association between immunosuppressive therapy and malignancy in IBD patients as well. Our patient’s age and location of the tumor were similar to previous reports. However, long standing immunosuppressive therapy, Adalulimab, and tumor size (14.1 x 12.6 x 8.4 cm) were two differing features. Further analysis is needed to establish causality between GIST and immunomodulator therapy in IBD as well as a need for increased surveillance for such tumors in these patients.

cm submucosal mass was found. The biopsy result showed benign jejunum with pancreatic glands and ducts extending from the mucosal surface to the muscularis propria consistent with heterotopic pancreatic glands (Figure 3, HE, x10). He has had no further episode following the surgery. Discussion We present a rare case of heterotopic pancreas of the jejunum causing recurrent jejunal intussusception. Heterotopic (or ectopic) pancreas is a rare congenital anomaly defined as pancreatic tissue that lacks anatomical or vascular communication with the normal body of the pancreas. It is usually found in the stomach, duodenum and jejunum. It generally has a diameter of 1-4 cm and is commonly submucosal in nature. Heterotopic pancreas is commonly asymptomatic but can cause pancreatitis, abscess, pseudocyst, malignant transformation, or local complications such as obstruction or intussusception. The diagnosis of this lesion can be challenging. Endoscopic features include umbilication and duct opening, but these findings are non-specific. Endoscopic biopsies are generally superficial and not diagnostic. As the diagnosis is challenging, surgical or endoscopic excision is recommended for both diagnosis and treatment.

2464 Recurrent Jejunal Intussusception From Heterotopic Pancreas Thoetchai Peeraphatdit, MD, Thomas Smyrk, MD, Glenn Alexander, MD. Mayo Clinic College of Medicine, Rochester, MN Introduction Heterotopic or ectopic pancreas is usually asymptomatic. We present a unique case of heterotopic pancreas of the jejunum causing recurrent jejunal intussusception. Case description A 39-year-old male presented locally with a one-year history of recurrent left mid abdominal discomfort. Prior contrast-enhanced computed tomography (Figure 1) was reviewed and showed two areas of jejunal intussusception (arrows). Subsequent diagnostic laparoscopy done at his local hospital was unrevealing. Given ongoing recurrent pain, he came for further evaluation. On examination at our institution, the patient did have pain to palpation in the left mid abdomen without an appreciated mass. Laboratory evaluation revealed a normal complete blood count, liver test and chromogranin A. Capsule endoscopy did visualize a submucosal jejunal lesion. Double balloon enteroscopy showed a 3-centimeter distal jejunal submucosal umbilicated mass (Figure 2). The biopsy of the lesion showed normal jejunal mucosa without dysplasia. Small bowel resection was recommended for definitive diagnosis and to treat the probable recurrent intussusception. Pathologically, a solid 1.2 x 0.8 x 0.6

[2464C]

2465 Stuck in the Gut. An Unusual Duodenal Bezoar Following Pyloric-exclusion Gastrojejunostomy Keshav Kukreja, MD, Matthew Meriwether, MD, MBA, Abhishek Maiti, MD, Adeel Faruki, MD, Ahmed Salahudeen, MD, Erik F. Rahimi, MD. University of Texas Health Science Center at Houston, Houston, TX Introduction: Bezoars are foreign-bodies classified by their composition, with phytobezoars (indigested vegetable matter) being the most common. They are a rare entity usually found incidentally on imaging or routine endoscopy and tend to occur in patients with altered gastric anatomy such as following surgery. To our knowledge, no case reports exist of a small-intestinal phytobezoar following an unreversed pyloric-exlusion gastrojejunstomy. Case: A 19 year-old female with a history of blunt abdominal trauma at 18-months requiring pyloric-exclusion gastrojejunostomy presented with

[2464A]

[2464B]


[2465A] MRI showing mass in the duodenal bulb.


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right-upper-quadrant (RUQ) abdominal pain, nausea, vomiting, and diarrhea associated with a 20-lb weight loss over the past few months. Her vital signs, complete blood count, and basic metabolic profile were unremarkable. Abdominal computed tomography with intravenous contrast revealed a large, ovoid, low-attenuation mass within the RUQ measuring 6.6 cm x 5.3 cm x 6.9 cm. Magnetic resonance imaging confirmed a mass in the duodenal bulb, most consistent with a bezoar (Panel A). Subsequent upper endoscopy exposed the yellow-colored bezoar extending from the 3rd portion of the duodenum into the proximal jejunum (Panel B). Additionally, it was noted on endoscopy that the patient’s pyloric-exclusion was never reversed, suggesting the bezoar likely formed due to years of reflux from the jejunum into the duodenum. A schematic diagram of the location of the bezoar is provided (Panel C). Due to technical difficulty reaching the bezoar and insufficient pyloric dilatation endoscopically, she ultimately required surgical intervention with pyloroplasty to achieve complete removal of the bezoar. At follow-up, she reported resolution of symptoms and improvement in appetite with weight gain and regular bowel function.

Discussion: Pyloric-exclusion gastrojejunostomy is performed as a temporizing measure when duodenal ischemia is suspected, as in our patient following blunt abdominal trauma. However, in unusual cases where patients do not have the pyloric exclusion reversed, reflux of food material into the duodenum can occur and result in a symptomatic bezoar formation.

2466 Mesenteric Volvulus With Superior Mesenteric Vein Obstruction Presenting as Hemorrhagic Ascites and Bowel Ischemia Tagore Sunkara, MD1, Emmanuel Ofori, MD2, Mitchell Gorman, DO3, Gerard A. Baltzar, DO3, Nithan Narendra, MD3, Vinaya Gaduputi, MD3. 1The Brooklyn Hospital Center, Brooklyn, NY; 2Brooklyn Hospital Center, Brooklyn, NY; 3SBH Health System, Bronx, NY Introduction: A spontaneous mesenteric volvulus in case of non-reduction, can cause venous obstruction resulting from the entaglement of superior mesenteric vein (SMV) around the superior mesenteric artery (SMA) thereby ultimately causing fluid accumulation in abdomen and eventual bowel necrosis. More commonly seen in neonates, this process is extremely uncommon in adulthood. We here present a case of a 54-year old woman who presented with mesenteric volvulus resulting in SMV obstruction and bowel necrosis. Case Presentation: A 54-year old woman with medical history of hypertension presented with complaints of mild diffuse abdominal pain and worsening distention for about 3 weeks. Patient denied any nausea, vomiting or blood in the stool. Patient was hemodynamically stable and examination was significant for abdominal distention with ascitic fluid thrill. A diagnostic paracentesis revealed hemorrhagic ascites but no malignant cells. Patient was found to have anemia (Hemoglobin of 10gm/dL) and severe leucocytosis (25 × 103/μ L). Computerized tomography scan of abdomen revealed mesenteric volvulus (Figure 1) with

[2465B] EGD showing the yellow-colored bezoar extending from the 3rd portion of the duodenum into the proximal jejunum.

[2466A] Sagittal CT image showing swirling mesentery consistent with volvulus (red arrow).

[2465C] Schematic diagram indicating the procedure (pyloric-exclusion gastrojejunostomy) and anatomic location of the bezoar.


[2466B] CT showing loop of small bowel extending through mesenteric defect. Bowel loops at the right abdomen demonstrate wall thickening and decreased enhancement consistent with volvulus and ischemia (red arrow).


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[2466C] Perioperative description A) Mesenteric defect B) Hypermic small bowel C) Necrotic small bowel D) Resected necrotic small bowel

small bowel wall edema/ischemia (Figure 2) and SMV obstruction. Patient underwent an emergent laparotomy that showed ischemic bowel which was resected (FIgure 3). Discussion: Unlike SMA obstruction, SMV obstruction rarely causes small bowel ischemia because of collateral venous circulation. SMV obstruction commonly happens due to hypercaogulable states, prior abdominal surgeries, mechanical obstruction from an adjacent mass. To the best of our knowledge, a case of SMV obstruction secondary to mesenteric volvulus presenting as chronic abdominal pain with hemorrhagic ascites eventually leading to small bowel necrosis- in a middle aged adult, was never reported. SMV obstruction usually presents with severe abdominal pain with distention and rectal bleeding. In our case, patient presented with ascites which was found to be hemorrhagic on paracentesis. The likely pathophysiology behind the hemorrhagic ascites could be the venous congestion in the SMV leading to bowel wall edema and hyperemia. The gold standard to diagnose SMV obstruction is CTA. Patient with SMV obstruction with mesenteric volvulus should be managed surgically to relieve the mechanical obstruction of the SMV in a prompt manner to prevent bowel wall ischemia. If surgical intervention is deferred, outcomes can be devastating.

2467 Lumenal Stent Placements Through a Balloon Overtube Terrence Smith, MD, FACG, FASGE. Vanderbilt University Medical Center, Brentwood, TN INTRODUCTION: The placement of a self-expanding metal stent (SEMS) in the setting of a malignant obstructing small bowel (SB) stricture is frequently considered a standard palliative intervention.1 Malignant SB lesions, however, can be difficult to access due to a more distal location, lumenal distortion, and/or dilation of the upstream GI tract. Such factors may therefore prevent the stent introducer

[2467A] BAE-assisted guidewire placement through malignant stricture.


system from accessing or traversing the lesion. The following cases describe the unique deployment of SEMS through a single balloon overtube positioned just proximal to the stricture. CASE 1: A 91 year old male was admitted for oral intolerance with recurrent nausea and vomiting. His evaluation revealed an inoperable metastatic pancreas adenocarcinoma that had encased the entire descending duodenum resulting in a near-complete bowel obstruction. CASE 2: A 68 year old female underwent a Whipple procedure for a pancreas adenocarcinoma. About 9 months later, she presented with recurrent, widely metastatic disease and obstructive symptoms related to high grade structuring of the efferent limb. Both patients were initially evaluated via standard endoscopy followed by single balloon enteroscopy. In each case, the overtube (OT) tip was positioned near the superior edge of the stricture. The stenotic segment was delineated fluoroscopically after which clips were placed at the edges and a guidewire was advanced through the stricture. The enteroscope was withdrawn and a stent introducer system was passed over the wire, through the inflated overtube, and across the stenosis. It was unveiled under fluoroscopic guidance. Each stent placement provided significant palliative relief. DISCUSSION: While stent deployments through OTs that traverse an obstruction have previously been described, the above cases simplify placement by merely advancing a smaller diameter enteroscope through the stricture or passing a soft wire across the site.2-4 The OT balloon is kept inflated to center the lesion while the stent introducer is appropriately situated and unveiled under fluoroscopy. Thus, with distorted or more distal anatomy, OT use allows for deeper bowel access, loop prevention, and the straightening of acute or tight angulations. REFERENCES: 1. Baron T. N Engl J Med 2001; 1681-87. 2. Pinho R, et.al. Endoscopy 2015; 266-69. 3. Samalin E, et.al. Endoscopy 2007; E101. 4. Neumann H, et.al. Endoscopy 2013; E369-70.

[2467B] Unveiling of stent through overtube.


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[2468A] Picture on the left demonstrates CT imaging of SMA thrombosis. Picture on the right demonstrates mesenteric angiogram showing SMA thrombosis.

2468 Total Eclipse of the Gut: A Case of Mesenteric Ischemia From Endocarditis Alfredo Camero, Jr., MD1, Juan Echavarria, MD2. 1University of Texas Health Science Center at San Antonio, San Antonio, TX; 2UT Health San Antonio, San Antonio, TX Mesenteric ischemia is defined as a loss of blood flow to the mesenteric vasculature. Acute presentations can be dramatic, leading to metabolic derangements, bowel necrosis, sepsis, and death. We present a case of mesenteric ischemia associated with endocarditis with normal laboratory values, yet dramatic intra-operative findings. A 50-year-old man was admitted to the hospital with abdominal pain. The pain was diffuse, sharp, and associated with increasing distension, dark coffee ground emesis, and inability to pass flatus. He also reported 2 weeks of fevers, night sweats, and weight loss. His physical exam was notable for tachycardia, low grade temperature of 100.6 degrees Fahrenheit, poor dentition, diffuse abdominal tenderness and distension. Initial laboratory data included normal electrolytes, renal function, liver chemistries, and lactic acid. CT scan of the abdomen showed pneumatosis of the duodenum and jejunum and dilated small bowel loops without any evidence of free air. A nasogastric tube was placed to intermittent low wall suction for decompression. On hospital day 2, gram stain on the blood cultures showed gram positive cocci in chains. An echocardiogram showed a 1.2 x 2 cm vegetation on the mitral valve with resultant severe mitral regurgitation. A CT angiogram and subsequent mesenteric angiogram were performed which showed an obstructive thrombus in the mid to distal superior mesenteric artery (SMA). He was taken for an exploratory laparotomy which showed diffusely necrotic bowel and a clot in the mid SMA. 185 cm of small bowel were removed along with the ascending colon. He had a lengthy recovery and remains dependent on paternal nutrition. Acute mesenteric ischemia is a dramatic and serious entity with a mortality risk reported as high as 60%. Lactic acidosis can arise from tissue hypoperfusion, and thus, it is thought classically that bowel ischemia will present with an elevated lactate. However, several studies have shown that early ischemia does not correlate with elevated lactate levels. Rather, transmural infarction and necrosis is where elevated lactate levels are typically seen. A few case reports have shown profound necrotic bowel but normal lactate levels, which is hypothesized to occur due to a high hepatic capacity for clearance. We present such a case with a dramatic clinical presentation, yet normal laboratory values but still resulted in necrotic bowel. Prompt recognition and management is crucial for improved outcomes.

[2468B] Echocardiogram demonstrating mitral valve vegetation.

[2468C] Operative specimen demonstrating necrotic small bowel.



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2469 An Interesting Case of Acute Mesenteric Ischemia Secondary to Non-bacterial Thrombotic Endocarditis Obada Tayyem, MD, Hamzeh A. Saraireh, MD, Omar Al Asad, MD, Solly Chedid, MD. University of Texas Medical Branch at Galveston, Galveston, TX Acute mesenteric ischemia is a life-threatening condition that occurs when an abrupt decrease in blood flow results in inadequate supply to the intestines, leading to bowel infarction. Etiologies may include arterial embolus, arterial or venous thrombosis, and nonocclusive mesenteric ischemia. Other causes include vasculitis, traumatic injury, dissection of the aorta and intestinal obstruction. Nonbacterial thrombotic endocarditis (NBTE) is a rare condition that refers to a spectrum of noninfectious lesions of the heart valves. It is often an autopsy finding, found in approximately 1%–1.5% of adults during autopsy. We herein present a case of a 42 year-old male patient with a significant history of smoking presented with a new onset diffuse abdominal pain of 2 days prior to admission. Physical exam was unremarkable. CBC and CMP did not reveal any abnormalities. CT angiography of the abdomen visualized a superior mesenteric artery (SMA) thrombus. The patient underwent an emergent exploratory laparotomy with SMA thrombectomy and endarterectomy and resection of 285 cm of small bowel. Workup for coagulopathy, systemic lupus erythematosus (SLE) and antiphospholipid syndrome was nondiagnostic. Transthoracic echocardiogram showed a small mobile structre attached to the aortic valve, so transesophageal echocardiogram was done and showed a freely mobile pedunculated homogenous mass that is attached to the sub valvular aortic area. Patient underwent thoracotomy and the vegetation was excised. Surgical histopathology was consistent with fibrinous thrombus and no evidence of infective organisms. The patient was started on low molecular weight heparin, then transitioned to rivaroxaban. Acute mesenteric ischemia is a lifethreatening disease, with mortality rates that can approach 90% in the setting of bowel infarction. As such, it is important to establish an early diagnosis before the onset of bowel infarction. Thorough history, physical exam and workup should be done to identify the cause of mesenteric ischemia. Nonbacterial thrombotic endocarditis is characterized by the deposition of sterile

[2469C] Homogeneous Mass Attached To The Subvalvular Aortic Area (Diastole).

platelet thrombi on heart valves, commonly aortic and mitral. It is mostly associated with advanced malignancies (80 percent of cases) and systemic lupus erythematosus (SLE). Although it is rare, it should be kept in mind as an important cause of acute mesenteric ischemia.

2470 CapsoCam: An Alternative Method of “Second Look” Endoscopy in a Patient With a Duodenal GIST and Upper GI Bleeding Sara Cerrone, MD1, Ian Michael Storch, DO2. 1Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY; 2Hofstra North Shore-LIJ School of Medicine, Woodbury, NY Video capsule endoscopy (VCE) is the gold standard for small bowel(SB) evaluation in obscure gastrointestinal bleeding. We present a case of a patient in which CapsoCam©, a novel VCE system with a panoramic view, was used for second-look endoscopy (SLE) in an elderly patient with multiple comorbidities. An 87-year-old woman, with a known GIST tumor of the duodenum, presented to the ED with melena and jaundice. On admission, she was found to be hypotensive with a hemoglobin of 4 mg/d and an INR of 4. A computerized tomography revealed a 5cm GIST tumor in the duodenum, compressing the common bile duct. EGD failed to allow for good visualization of the tumor and duodenoscopy could not be performed because of hemodynamic instability. The patient underwent percutaneous

[2469A] CT Scan Showing SMA Occlusion.

[2470A] CT scan showing GIST.

[2469B] Homogeneous Mass Attached To The Subvalvular Aortic Area (Systole). [2470B] Capsule endoscopy image GIST.



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[2470C] Capsule endoscopy image GIST.

transhepatic cholangioscopy with internal and external stent placement with clinical improvement of her coagulopathy and bleeding. After discharge, due to a drop in her hemoglobin without any overt bleeding, EGD was requested by hematology. Due to the patient's age and comorbidiites, however, the test was deferred. VCE was performed with the CapsoCam©. The GIST was visualized with a large ulceration but no active bleeding. Appropriate stent placement was also noted. VCE has become the gold standard for primary SB evaluation. VCE is indicated for the evaluation of obscure GI bleeding, Crohn's disease and evaluation of SB tumors.A new small bowel capsule, capsule, CapsoCam© provides the ability for 360° imaging (panoramic view) with a larger number of images captured per second than standard VCE. This technology allows for better visualization of the duodenum and duodenal papilla making it ideal for diagnosing difficult-to-visualize areas, like the duodenal sweep This case highlights the use of the CapsoCam© capsule for a SLE in a patient with a GIST tumor of the duodenum, a drop in hemeglobin and a potential overt bleed. Due to its ability to provide a 360° view, the capsule enabled us to visualize the second portion of the duodenum, rule out active tumor bleeding and avoid traditional endoscopy in a high-risk patient. Further studies will be needed to determine if the CapsoCam© capsule can consistently provide a reliable alternative to endoscopy for “second-look” evaluation of duodenal lesions.

2471 Small Bowel Intussusception Secondary to Inflammatory Fibroid Polyp of the Ileum Nataliya K. Sostin, MD, Saad Baqai, MD, Amarpreet Bhalla, MD, Jeraldine Orlina, MD, Hani El-Fanek, MD. Danbury Hospital, Danbury, CT Introduction: Inflammatory fibroid polyps (IFP) are rare, benign, tumor-like lesions that can develop anywhere in the gastrointestinal tract. Most frequently, they are localized in the gastric antrum. Ileum is the most common site where these polyps cause small bowel obstruction. Most IFPs are polypoid masses smaller than 5 cm, although sizes up to 20 cm have been reported. Case report: We report a case of a 56-year-old man presented with progressive abdominal pain for 7 days. He denied any nausea and vomiting but did have foul smelling bloody diarrhea. His abdomen was soft, slightly distended, tympanic to percussion, and tender in left lower quadrant. Bowel sounds were hyperactive. CT scan revealed a tubular, elongated, both intraluminal and extraluminal ileal mass causing mild partial obstruction and short segment intussusception. The patient underwent resection; gross examination showed a large solid tan-white elongated mass protruding into the small bowel lumen on one side and pushing the serosal surface on the other side. The large luminal portion of the protruding tumor measured 15.0 x 5.5 x 4.0 cm, and the extraluminal portion measured 5.5 x 4.0 cm. The total length was 20.5 cm. Multiple sections showed a well demarcated, non-encapsulated, polypoid, fibrohistiocytic mass, composed of hypocellular stroma with proliferation of widely spaced bland spindled and stellate-shaped cells emdedded in a collagenous fibromyxoid stroma. The intervening stroma demonstrated prominent vascularity, diffuse eosinophils, and few scattered plasma cells with foci of benign

[2471]


lymphoid aggregates. No mitoses or necrosis was present. There was no other histologic evidence of malignancy. The histopathologic features, as well as the immunoperoxidase stains, were consistent with a benign, non-neoplastic tumor-like mass, consistent with a Giant Inflammatory Fibroid Polyp-Tumor Like (Vanek Tumor). Discussion: The present lesion is the largest inflammatory fibroid polyp reported to date. The ileal location is rare. Even if inflammatory fibroid polyps are benign lesions, surgical treatment is the only option when they present with intestinal intussusception. Preoperative diagnosis of inflammatory fibroid polyps is often difficult, and confirmation can only be obtained by histological and immunohistochemical examination.

2472 Isolated Collagenous Duodenitis: A Rare Cause of Malabsorption Andrew MacMillan, DO, Gena Han, DO. OhioHealth Riverside Methodist Hospital, Columbus, OH Collagenous gastroenteritides are uncommon disorders with distinct histopathology, characterized by subepithelial collagen deposition. We describe collagenous duodenitis in an adult male with six months of weight loss. Collagenous duodenitis in the absence of collagenous colitis is rare, with less than 120 reported cases, and can lead to malnutrition and death if untreated. A 49 year old Caucasian male with hypertension and history of stage I testicular seminoma presented with a 70lb weight loss over 6 months, and intermittent melena and hematochezia for 2 months. His hemoglobin was 12g/dL with Hct of 36.5; AST was 118 U/L, ALT 27 U/L, and alkaline phosphatase 241 U/L. Prealbumin was 11.9 mg/dL. Examination revealed active bowel sounds but nontender, nondistended abdomen. Stool was heme positive. Computed tomography demonstrated asymmetric nodular thickening of the rectal wall 7cm above the anal verge concerning for possible mass. No adenopathy or retroperitoneal mass was identified. Pantoprazole twice daily was started. Esophagogastroduodenoscopy found diffuse, moderately scalloped mucosa at the 2nd and 3rd portions of the duodenum. Tissue transglutaminase IgA was normal, with elevated total serum IgA. Duodenal histopathology revealed a sub-epithelial collagen band 25μ m in thickness with preserved villous architecture consistent with collagenous duodenitis. Colonoscopy showed sigmoid diverticulosis and colonic polyps, which were resected. Surrounding non-adenomatous tissue showed no features of collagenous colitis. The patient’s hemoglobin remained stable; he was discharged on daily pantoprazole with plans for outpatient follow up. Collagenous duodenitis is often described as sharing histopathologic features of collagenous sprue. However, our patient had collagen banding with preserved duodenal villous architecture in the absence of celiac disease. Pathogenesis is thought to be secondary to immune/autoimmune inflammation from unknown luminal antigens, and collagenous duodenitis has been associated with T cell lymphoma. Left untreated, patients often have progressive malnutrition, which can lead to death. Various therapies have been trialed, including corticosteroids, H2 blockers, PPI therapy, hypoallergenic diets, and tumor necrosis factor inhibitors with varying results. Physicians should consider collagenous gastroenteritides in the differential in a patient presenting with malabsorption.

2473 Lymphoma in the Mist: A “Misty Mesentery” Mystery Sam Davis, DO, Shamyal Khan, DO, John Alvarez, MD, MPH, Jonathan Ramirez, MD. Baylor Scott & White Health, Temple, TX Primary intestinal follicular lymphoma (FL) accounts for less than 1% of gastrointestinal malignancies.Nonspecific symptoms such as epigastric pain, anorexia, nausea, and vomiting along with variable imaging can make the diagnosis elusive. A 54 year-old Hispanic female with a history of type II diabetes and mild CAD presented with epigastric pain and vomiting. CT abdomen/pelvis at an outside hospital reported retroperitoneal mesenteric lymphadenopathy. Labs and other studies including EGD and KUB were unremarkable. Biopsy was pursued; however her lymphadenopathy was too small for biopsy. Surveillance CT Abdomen/Pelvis noted “stable findings of misty mesentery within the central midabdomen with multiple associated enlarged mesenteric and periarotic lymph nodes.” Gastric emptying study was normal. CT abdominal angiogram showed no evidence of mesenteric ischemia. Symptoms of brief melena prompted a pill cam revealing strictures in the small bowel with ulcerations

[2473A] CT Abdomen/Pelvis demonstrating mesenteric lymphadenopathy measuring up to 1.1 cm.


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2474 Refractory Ileal Fecaloma Causing Small Bowel Obstruction Huai-Shiuan Huang1, Shawn L. Shah, MD2, David Wan, MD2. 1National Taiwan University College of Medicine, Taipei City, Taipei, Taiwan (Republic of China); 2New York-Presbyterian/Weill Cornell Medical Center, New York, NY Fecalomas are extremely rare and often occur in the in the rectum and sigmoid colon. In patients with multiple comorbidities limiting clinical decisions, it is important to understand the treatment options available with fecalomas and their outcomes. Here we present a 61-year-old ventilator-dependent male with advanced dementia, status post heart and lung transplant, and status post prior small bowel resection for unclear reasons who presented with abdominal distention and bilious emesis following a recent hospitalization for respiratory failure secondary to pneumonia. Vitals were notable for tachycardia to the 110s and exam was significant for palpable stool along the right side of abdomen. An abdominal radiograph revealed dilated loops of small and large bowel with air-fluid levels (Figure 1). Conservative treatment with a nasogastric tube, crystalloids, and rectal laxatives were unsuccessful. An abdominal

[2473B] Pill Cam with small bowel stricture with erythema and ulceration.

[2474A] An abdominal radiograph showing dilated loops of small and large bowel obstruction with air-fluid levels.

[2473C] Single balloon enteroscopy with deep small bowel stricture.

and erythema. Single balloon enteroscopy and biopsy of deep small bowel stricture would return positive for Grade 1-2 FL. PET/CT reported mildly hypermetabolic portacaval, peripancreatic and central mesenteric/retroperitoneal lymph nodes. Moderate hypermetabolic activity was also reported at the caudate lobe of the liver. Laparoscopic lysis of adhesions and small bowel resection was performed. Pathology findings were consistent with biopsy. Her grade 2 FL was classified to be in Stage 3-4 given lymphadenopathy above and below the diaphragm. the completion of her chemotherapy, repeat PET/ CT demonstrated interval resolution of previously identified hypermetabolic activity within the liver as well as the identified lymph nodes. This case illustrates the difficulty in establishing a diagnosis of primary intestinal FL. Differentials such as sclerosing mesenteritis, mesenteric ischemia, and diaphragm disease were considered. Biopsy remains the standard for diagnosis for primary intestinal FL. Diagnosis can be delayed by difficulty of biopsy as well as non-specific findings on traditional imaging. If there is a high enough suspicion for intestinal lymphoma, persistent symptoms warrant further investigation with advanced imaging modalities such as pill cam endoscopy. If these studies are able to localize a lesion and if biopsy cannot be obtained by other means, single or double balloon enteroscopy should be pursued.

[2474B] An abdominal CT scan showing a 9 cm stool ball in a postsurgical aperistaltic segment of bowel with a distinct transition point.



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CT scan showed a dilated fluid-filled small bowel extending to distal ileum where there was a 9 cm stool ball in a postsurgical aperistaltic segment of bowel with distinct transition point (Figure 2). Multiple attempts at laxatives from patient’s gastrostomy tube and rectally were trialed with no significant improvement in patient’s abdominal distension and pain. Unfortunately, the patient was a poor candidate for surgery due to his multiple comorbidities. The family ultimately decided to pursue hospice. Fecalomas, or hard intraluminal tumor-like mass of feces, are most commonly found in the rectum and sigmoid colon. It has been more commonly reported in patients with old age, long-term enteral feeding, and neuropsychiatric disease, likely leading to sluggish bowel function. Fecalomas in the small bowel causing obstruction has only been reported in a 10-year-old boy. Fecalomas in the distal colon are often managed by conservative methods such as bowel rest, rectal suppositories, enemas, digital evacuation and rectal decompression. More aggressive treatments include endoscopic disimpaction and surgical intervention for those who are otherwise good surgical candidates. Our case posed a management dilemma in that the fecaloma was located in an aperistaltic segment of the ileum rather than more distally, making colonoscopic decompression difficult, and as patient was not a surgical candidate, surgery was a nonviable option. Since patient has exhausted all conservative managements, comfort care became the best available option.

2475 Perplexing Malignant Peritoneal Mesothelioma in a Young Woman Without Exposure Josiah McCain, MD, Neej J. Patel, MD, Karl Mareth, MD, Matthew Robertson, MD. Mayo Clinic, Jacksonville, FL Introduction: Malignant mesothelioma is a rare disease that most often occurs in the pleura as a result of environmental exposure. Malignant peritoneal mesothelioma (MPM) is an even less common disease, accounting for approximately 10-15% of all cases of mesothelioma. Interestingly, MPM occurs more often in females than pleural mesotheliomas do for reasons that are not entirely understood. This higher proportion of females is thought to reflect their higher incidence of non-asbestos related disease. We report the case of a young woman with no known environmental exposure history who was diagnosed with MPM. Case Report: A healthy 20-year-old woman presented with dehydration and malnutrition. She reported a 2 month history of nausea, vomiting, diarrhea and abdominal pain. She also endorsed anorexia and an associated 20-30 pound weight loss over the same period. She had presented to her local emergency department 3 times with these complaints and had been found to have small pockets of ascites as well as hepatic sinusoidal dilatation on ultrasound. Additional workup including CT imaging, liver biopsy, paracentesis, colonoscopy and upper endoscopy had failed to identify any pathology. An MRI showed extensive soft tissue implants and omental caking in the abdomen and pelvis with abnormal peritoneal thickening and enhancement. The patient underwent a CT-guided biopsy of the omental soft tissue, which demonstrated a mesothelioma of epithelioid type. She was treated with peritonectomy, omentectomy, small bowel resection, total abdominal hysterectomy and installation and circulation of hyperthermic intraperitoneal chemotherapy. Biopsies of all sampled tissue showed extensive involvement by MPM. Of note, extensive imaging and evaluation did not capture any pleural involvement. Discussion: MPM is an exceedingly rare disease. Although previous studies have demonstrated an association between MPM and asbestos exposure in men, the same association has not been deduced in female populations. Other contributing exposures that have been described include radiation, chronic peritonitis, mica exposure and the simian virus-40. Both this patient’s young age and lack of any such exposures reinforce the prevailing current wisdom that the risk factors for this rare, yet highly deadly disease have yet to be properly defined.

2476 A Novel Approach to Palliative Bowel Decompression in Malignant Bowel Obstruction for Patients With Contraindications to Venting Gastrostomy Tube Alice Lee, MD1, Nancy Kim, MD2, Sebastian Cousins, MD2, Alex Kim, MD2, Heidi Young, MD2, Kathleen Anderson, MD, MS3. 1MedStar Georgetown University Hospital, Falls Church, VA; 2MedStar Georgetown University Hospital, Washington, DC; 3Washington, DC Introduction: Malignant bowel obstruction (MBO) is a common complication in gastrointestinal and metastatic malignancies. Beyond the immediate intervention of nasogastric tube (NGT) for decompression, the literature supports placement of endoscopic metal stents and venting gastrostomy tube (G-tube) to provide symptom relief without requiring long-term hospitalization. However, in clinical practice at MedStar Georgetown University Hospital, providers encountered difficult cases for which these standard approaches could not be offered due to contraindications to G-tube placement. Although

[2476] Summary of Cases Case #

Age Gender

Clinical History

Nausea/Vomiting after PTBD?

Successful discharge home?

Time from PTBD to death (months)

1

30F

Metastatic appendiceal cancer Rib overlying stomach•Peritoneal carcinomatosis

N

Y

24

2

32F

Metastatic appendiceal cancer Transverse colonic interposition over stomach

Y

N

2.5

3

46F

Metastatic gastric cancer Failed endoscopic stent Altered anatomy

N

Y

>3.5

4

62M

Metastatic gastric cancer History of esophagogastrectomy Poor surgical candidate

N

Y

>3.5

5

36M

Metastatic gastric cancer History of subtotal gastrectomy Active peritonitis due to large ascites

N

Y

>1

[2475] A) Coronal MRI revealing broad sheet of omental caking along the left abdomen extending into the pelvis and diffuse peritoneal thickening and enhancement both along the abdominal wall and the bowel surfaces. Overall findings are suspicious for peritoneal malignancy. B) Coronal MRI revealing overall reduction in diffuse peritoneal disease burden with resolution of omental caking after therapy.



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[2476A] Pre- and post-PTBD CT images of Case #1-4 demonstrating radiographic improvement of dilated loops of bowel.

[2476B] Pre- and post-PTBD CT images for Case #5 showing no significant radiographic change in dilated loops of bowel. However, patient had symptomatic improvement.



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percutaneous transhepatic biliary drainage (PTBD) procedure is not traditionally performed for bowel obstruction, it was used as alternative bowel decompression in these difficult cases. The use of PTBD in MBO has not been previously reported. We present this alternative palliative treatment approach in a case-series study to contribute to the literature as a possible intervention to consider in difficult MBO cases. Description of Cases: A total of five cases were reviewed. Patients were between 30 to 62 years old, had metastatic malignancy, were at end-stage of their disease and were diagnosed with MBO. Based on evaluation by gastroenterology, interventional radiology and general surgery teams, patients had various reasons for being deemed poor candidates for venting G-tube or endoscopic stent placements: failed decompression attempt with endoscopic stent, malignant ascites, extensive distension of bowel, difficult anatomy due to prior intra-abdominal surgeries and high peritoneal tumor burden. All patients underwent PTBD as a “last resort” attempt at relieving bowel obstruction. On pre- and post-PTBD CT scans, the radiographic evidence of bowel decompression was visualized in four cases. (Figures 1 and 2) Overall, four of five patients had symptom control and were successfully discharged home with PTBD. One case was unsuccessful due to persistent symptoms, requiring replacement of NGT. (Table 1) Discussion: In five palliative patients with MBO who were poor candidates for endoscopic stent or G-tube placements, with no other options beyond NGT, the placement of PTBD provided successful symptom relief, bowel decompression and discharge home in four cases. It can be a novel use of an existing procedure to provide improved quality of life in patients with end-stage MBO. More identification of cases may provide more data on complications and success rates.

Biopsies showed fibroadipose and granulation tissue. He was discharged at his request and returned 4 days later with recurrent melena and symptomatic anemia requiring blood transfusions. Repeat EGD showed persistent ulceration without active bleeding. Epinephrine was injected at the base, a detachable snare was deployed, and the lesion was resected with hot snare. No immediate postpolypectomy bleeding was noted. The polyp was retrieved with a rat tooth forceps and a 4-prong grasper using a therapeutic upper endoscope. Ileocolonoscopy was unremarkable. He had no recurrent bleeding up to 2 months later. Pathologic examination of the lesion was consistent with a duodenal angiolipoma. Angiolipomas are benign submucosal tumors consisting of mature adipose tissue and a prominent vascular component consisting of numerous small capillaries that are dilated or filled with fibrin thrombi. Duodenal angiolipomas are exceedingly rare tumors with only 5 reported cases to our knowledge. They present in the 7th to 8th decade with no gender predilection and manifest with overt GI bleeding or dyspepsia. The lesions are pedunculated and range in size from 1 to 5 cm. Endosonographic findings include a hyperechoic lesion with internal anechoic densities. Treatment includes snare polypectomy with the frequent requirement of additional hemostatic interventions. Surgery is an option when endoscopic resection fails. Two reported cases had synchronous colonic angiolipomas. Duodenal angiolipomas are being increasingly recognized within the differential diagnosis of benign small bowel tumors and should be considered in patients with small bowel bleeding. Endoscopic resection with a hot snare appears to be safe although additional hemostatic measures are often required. The tendency of these lesions to bleed may be due to a significant vascular component of these tumors. Surgical resection appears to be a feasible therapeutic option when endoscopic resection fails.

2477 Duodenal Angiolipoma Presenting With Overt Upper Gastrointestinal Bleeding: A Case Report and Review of the Literature Fernando H. Calmet, MD, Erin M. Forster, MD, MPH, Afonso C. Ribeiro, MD. University of Miami, Jackson Memorial Hospital, Miami, FL Gastrointestinal (GI) angiolipomas are rare benign tumors that present with overt or occult GI bleeding or intussusception and arise anywhere from the esophagus to the rectum. To our knowledge there have been 5 prior case reports of duodenal angiolipomas. A 53 year-old man presented with 5 days of melena and a drop in hemoglobin from 13.8 g/dL to 8.6 g/dL. Esophagogastroduodenoscopy (EGD) revealed a 5 cm elongated polypoid mass in the 3rd portion of the duodenum with several ulcerations at the tip.

[2477B] A. 5 cm pedunculated polyp with ulcerated tip. B. Site of polypectomy after hot snare with detachable snare in place.

2478 Duodenal Schwannoma: An Incidental Finding on PET Scan Marianna G. Mavilia, DO1, Imad Ahmad, MBBS1, Arti Easwar, MD2, Jonathan Williamson, MD3. 1University of Connecticut Health Center, Farmington, CT; 2Hartford Hospital, Hartford, CT; 3Hartford, Hartford, CT

[2477A] 5 cm pedunculated polyp in the third portion of the duodenum. B. Ulcerations noted on the tip of the polyp.


Introduction: Gastrointestinal schwannomas (GS) are benign nerve sheath tumors arising from Auerbach’s plexus. They are rare, accounting for 0.4-1% of all submucosal tumors. GS are most common in the stomach followed by small bowel, then colon and rectum. They may be associated with neurofibromatosis or present as isolated lesions. We present an incidental finding of duodenal schwannoma (DS). Case report: A 58 year old male with history of HTN presented as an outpatient for evaluation of an FDG-avid incidental duodenal mass discovered on PET scan. He was initially found to have nontender cervical lymphadenopathy on routine dental exam. He was otherwise asymptomatic and physical exam


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[2477C] A. Polyp gross pathology. B. Angiolipoma with small intestinal mucosa in the bottom left (2× mag). C. Mature adipose tissue with increased vasculature (10× mag). D. Mature adipose tissue with increased vasculature (20× mag).

was unremarkable. He had no significant past surgical, family, or social history. A lymph node biopsy revealed poorly differentiated squamous cell carcinoma (SCC) of unclear origin. He then underwent PET scan, which identified an oral and duodenal lesion. Primary site of cancer was later confirmed as

oropharyngeal SCC, for which he underwent modified radical neck dissection and adjuvant chemoradiation. The duodenal lesion was further evaluated with EGD/EUS with FNA. Endoscopically, an 18x12 mm pedunculated, subepithelial lesion with a long, broad-based stalk was seen in the second portion of the duodenum. Sonographically, it appeared mostly hypoechoic with internal hyperechoic, nonshadowing regions. The exact wall layer of origin could not be delineated. FNA revealed a spindle and epithelioid cell neoplasm, which stained positive for S-100 and SOX10, but negative for CD117, DOG-1 and desmin, supporting the diagnosis of DS. Laparoscopic-assisted, minimally-invasive transduodenal resection is currently scheduled. Discussion: GS is a mesenchymal tumor of the GI tract. Endoscopic and radiologic exams can identify submucosal lesions but cannot differentiate between the types of mesencyhmal tumors. The diagnosis is made histologically, with immunohistochemical staining for S-100 indicating GS. Although benign, schwannomas can demonstrate avid FDG uptake on PET imaging, and may be mistaken for malignant lesions.GS are typically asymptomatic but can present with nonspecific symptoms. Surgical excision or endoscopic submucosal dissection is recommended for large tumors to avoid complications, such as bleeding or bowel obstruction. Endoscopic surveillance is an option for smaller tumors with asymptomatic presentation due to the benign nature of GS.

[2478A] Endoscopic view of 18x12mm pedunculated duodenal lesion.

[2478B] Sonographic image of the duodenal lesion taken during EUS.



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[2478C] Fine needle aspiration of subepithelial duodenal lesion showing spindle and epithelioid cell neoplasm, favoring schwannoma (A). Tumor cells positive for schwannoma markers S100 (B) and SOX10 (C).

2479 Out on a Limb, a Case of Idiopathic Ischemic Bowel 10 Years After Roux-en-Y Gastric Bypass Ryan Coil, MD, Abdul Haseeb, MD, MPH, Anna Ibele, MD, Michael Sossenheimer, MD, PhD, FACP, FACG, FASGE, AGAF. University of Utah, Salt Lake City, UT Laparoscopic Roux-en-Y gastric bypass has a tolerable risk profile with dramatic reduction in complications 10 years post-op and enduring highly significant decrease in obesity-related comorbidity. Small bowel ischemia is often an acute post-op issue that commonly results from SBO due to volvulus, intussusception, or adhesions. We present a case of isolated small bowel ischemia as a rare, late complication of gastric bypass. A 73 year old male presented to the Emergency department with one day history of increasing sharp, crampy epigastric abdominal pain that was worsened by any oral intake. He also reported that his BMs had recently changed to black, tarry stool over the prior week. Upon examination, he had moderate epigastric tenderness to palpation but his abdomen was soft with normal bowel sounds. Labs showed mild leukocytosis with normal hgb, LFTs, lactate, lipase and PT/INR. CT angiogram of the abdomen and pelvis was obtained which showed a thickened Roux limb with mesenteric stranding and patent mesenteric vasculature. An EGD was performed which identified ischemic appearing mucosa (figure 1) concerning for intestinal ischemia of the Roux limb distal to the gastrojejunostomy. After urgent Bariatric/Foregut surgery consultation, the patient underwent diagnostic laparoscopy with observed ischemic bowel (figure 2) resulting in conversion to open exploratory laparotomy with resection of approximately 25 cm of hemorrhagic jejunum. Post-resection pathology was consistent with diagnosis of ischemic bowel injury. Over the course of 4 days, diet advancement was well tolerated with minimal nausea and the patient was stable for discharge. Laparoscopy has contributed to great deal of reduction in surgery related morbidity and mortality in high risk patients undergoing gastric bypass. Despite improvements, early morbidity is as high as 18-23% and mortality rates up to 1.5%. The etiology of this patient’s ischemia remained unknown as he had no intraoperative evidence of internal hernia or adhesive band, echocardiogram was negative for thrombus and CTA abdomen combined with intraoperative exam were not consistent with mesenteric occlusive disease. A referral to Hematology to evaluate for hypercoagulable state was unremarkable. Thorough examination of the excluded limb and higher endoscopic vigilance are required in identifying isolated ischemic bowel as a cause for GI bleeding in the high risk gastric bypass population.

[2479B] Diagnostic laparoscopy with observed ischemic bowel resulting in conversion to open exploratory laparotomy.

2480 Asymptomatic Duodenal Penetration by Inferior Vena Cava Filter: 3-Year Follow-up Syed Abdul Basit, MD1, Syed R. Shah, MD2. 1University of Nevada School of Medicine, Las Vegas, NV; 2 University of Nevada School of Medicine Las Vegas, Las Vegas, NV

[2479A] Ischemic appearing mucosa concerning for intestinal ischemia of the Roux limb.


INTRODUCTION: Inferior vena cava (IVC) filters are used to reduce the risk of thromboembolic events in subjects who are either not a candidate for anticoagulant therapy (ACT) or have failed ACT. Complications of IVC filters could be either early (bleeding, infection, acute venous thrombosis, hematoma and arteriovenous fistula formation) or late (filter migration and chronic thrombosis/recurrent thromboembolism). IVC filter penetration of the surrounding structures including bowel (duodenum), is a known although rare complication which can manifest as abdominal pain, gastrointestinal bleeding, cava-duodenal fistula, or small bowel obstruction. We present a rare case of asymptomatic duodenal penetration by IVC filter which was managed conservatively. CASE REPORT A 64-year-old male with history of multiple, recurrent DVTs and pulmonary embolism secondary to heterozygous MTHFR gene mutation presented to our facility 3 years ago for progressively worsening dysphagia. He had Greenfield IVC filter placed a few years back and was on long term ACT. Esophagogastroduodenoscopy(EGD) incidentally revealed a piece of metal protruding from the second portion of the duodenal wall, as shown in figure 1.CT scan of the abdomen and pelvis showed multiple IVC filter struts extending beyond the IVC wall with one of the struts extending anteriorly to penetrate the duodenal wall, as in figure 2. IVC venography confirmed CT scan findings, showing four struts of a patent IVC filter extending beyond the IVC wall. Vascular surgery (VS) and interventional radiology (IR) recommended conservative management in the absence of any symptoms. He remained asymptomatic for the next three years. Repeat EGD performed 3 years later revealed unchanged IVC filter strut in the duodenum, as shown in figure 3.


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DISCUSSION IVC filter migration into the GI tract is extremely rare and patients are usually symptomatic. Duodenum is the most common extra-caval involved organ. Current literature directs surgical treatment of patients with symptomatic duodenal perforation, however, there are no consensus guidelines for management of asymptomatic IVC filter penetrations in GI tract. Such cases should be managed by a multidisciplinary team of IR, VS and gastroenterologist. CONCLUSION Our patient was managed successfully with a non-surgical approach and remained asymptomatic during next 3 years.

2481 Transient Intussusception Patricia Guzman Rojas, MD1, Chirin Orabi, MD1, Juan J J. Oharriz, MD2. 1University of Central Florida College of Medicine, Orlando, FL; 2Orlando VA Medical Center, Orlando, FL

[2480A] EGD performed in 2013 showing IVC filter strut in duodenum.

Intussusception is the invagination of a bowel segment into the contiguous intestinal tract. It can be further classified according to their location as enteroenteric, colocolonic and enterocolonic, being ileocecal the most common. On CT images, we can recognize three different patterns like target, reniform and sausage shaped. This is a 33-year-old man with a PMH of heroin abuse. Patient was brought to the ER complaining of a right lower abdominal pain. This pain started 2 hours prior arrival to ER and it was described as sharp, stabbing, and radiating to the entire abdomen with associated nausea and vomiting. He denied Any fever. Vital signs showed a BP of 139/80 mmHg, pulse of 80 bpm, RR of 20 and temperature of 99.4 F. On physical exam, the abdomen was soft with tenderness to palpation of RLQ but without rebound. A CT abdomen was done diagnosing short segment of jejunal-jejunal intussusception in the left mid abdomen. Fifteen hours later a repeated CT showed a resolved intussusception, after which the patient underwent a diagnostic laparoscopy where a normal appearing jejunum and ileum without was seen, without any evidence of intussusception. There were no bleeding points or tumors noted on the external surface of both the jejunum and ileum and the appendix appeared grossly normal. Procedure was terminated and the patient was discharged, without any further workup. It is interesting to mention that the mechanism of any intussusception seems to be related to a bowel lesion that serves as a lead point. Although rare, cases of transient episodes have been seen in patients with celiac or Crohn’s disease. Unfortunately, our patient was discharge without any further evaluation of the etiology of this episode.

[2481A] CT abdomen at admission showing intussusception. [2480B] CT scan of the abdomen and pelvis showing multiple IVC filter struts extending beyond the IVC wall, with one of the struts penetrating duodenal wall.

[2480C] EGD performed in 2016 showing IVC filter strut at the same location in duodenum.


[2481B] CT abdomen- coronal view at admision: intussusception measuring about 5.5 cm in length in the left abdomen.


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Moreover, other diagnostic methods like intraoperative enteroscopy, push-enteroscopy or MR enterography could have been appropriate in this case to find any intraluminal tumors and/or inflammatory process. We report this case to encourage physicians to perform a deeper assessment of the etiology of an episode of intussusception, regardless of its transient nature, since patients can have reoccurring events in the future. References: Shenoy S. Adult intussusception: A case series and review. World J Gastrointest Endosc. 2017 May; 9(5): 220-227.

[2482B] CT enterography showing a 10 mm enhancing focus in the ileum concerning for a neoplastic process.

[2481C] CT abdomen 15 hours after: where previously seen intussusception has resolved.

2482 Mixed Adenoneuroendocrine Carcinoma: A Rare Tumor of the Gastrointestinal Tract Molly Orosey, DO, MS1, Kristin McBeath, DO, MPH2, Jared Bortman, MD1, Mitchell S. Cappell, MD, PhD, FACG1, Seifeldin Hakim, MD1. 1Beaumont Health, Royal Oak, MI; 2Beaumont Hospital, Royal Oak, MI Mixed adenoneuroendocrine carcinoma (MANEC) is a rare tumor of the gastrointestinal tract. Classification requires at least a 30% component of both an adenocarcinoma and a neuroendocrine carcinoma. There are only nine reported cases in the cecum, which makes this case exceptionally rare. A 55-year-old female presented with abdominal pain for one month. Physical exam was remarkable for mild abdominal distention and diffuse tenderness to palpation. Computed tomography (CT) abdomen/pelvis with contrast demonstrated a small bowel obstruction likely secondary to an inflammatory process in the terminal

ileum. Gastroenterology performed a colonoscopy, which revealed a severe non-traversable stenosis in the terminal ileum. The patient was then started on high dose steroids due to concern for Crohn’s ileitis. However, pathology was inconsistent with Crohn’s. CT enterography revealed a six centimeter segment of ileum with irregular wall thickening and a nodular mucosal enhancement with a ten millimeter focus of enhancement concerning for a neoplastic process. Multiple adjacent mesenteric lymph nodes were also noted. An ileocolic resection was performed. Pathologic examination revealed a mixed adenoneuroendocrine carcinoma with invasion through the muscularis propria into the pericolonic adipose tissue and perineural invasion. Adenocarcinoma component was positive for CK20, CK7, and faintly positive CDX2. The neuroendocrine component was positive for CK7 synatophysin, and CD56 and negative for CK20 and CDX2. Ki67 showed a high proliferative rate (97%). All margins of resection were negative and patient was treated with folinic acid, fluorouracil, and oxaliplatin (FOLFOX). She completed two cycles with plan to continue chemotherapy outpatient. MANEC tumors have a high metastatic potential, which is attributed to the neuroendocrine component. Laboratory and imaging findings are inconsistent. Thus, diagnosis is based on the tumor architecture and must include immunohistochemisty. Tumors must stain positive for two of the following: chromogranin, synaptophysin, and/or CD56. Due to the rarity of the tumor, treatment is inconsistent and requires further future investigations.

2483 Is it Celiac Disease or CVID-Associated “Celiac-Like Disease”? Ryan Coil, MD, Abdul Haseeb, MD, MPH, Adi Gundlapalli, MD, PhD, MS, Kathleen Boynton, MD. University of Utah, Salt Lake City, UT Common Variable Immunodeficiency (CVID) is the most common primary immunodeficiency in adults. Gastrointestinal (GI) symptoms are common in CVID patients, and up to 50% of patients have chronic diarrhea with malabsorption. CVID is commonly associated with intestinal villous atrophy mimicking Celiac Disease (CD). The prevalence of true CD in CVID remains unknown. We present a case of gluten-free diet (GFD) responsive CD in a patient with CVID. A 67 year old Caucasian female with long standing history of CVID on IgG replacement therapy, chronic kidney disease, and severe iron deficiency presented for evaluation of persistent nausea, anorexia, weight loss and non-healing chronic leg ulcer. She underwent EGD after initial anti tissue transglutaminase (anti-TTG) was found to be 17 U/mL, which showed marked villous blunting and mild lymphocytic infiltration with inflammatory pathology. Enteral access was obtained for nutritional supplementation in a setting of ongoing weight loss. An EGD 1 month after high fidelity enteral GFD showed resolution of inflammatory changes and improvement in villous blunting. (Table 1) The ensuing 3 months of strict diet adherence resulted in removal of the feeding tube with resolution of anorexia and nausea, as well as a 35 pound weight gain with return to healthy baseline weight. A dramatic improvement in her chronic leg wound was observed that had previously been resistant to all therapies. Anti-TTG levels at 4 month mark improved to 8 U/mL. Common variable immunodeficiency (CVID) with an estimated prevalence of 1/100,000 to 1/50,000 is the most common symptomatic primary antibody deficient syndrome. Up to 50% of CVID patients have chronic diarrhea with malabsorption. CVID is commonly associated with intestinal villous atrophy mimicking Celiac Disease (CD). Due to unreliable antibody testing and inconsistent response to GFD making a diagnosis of CD in CVID remains a challenge. Based on a few recent studies, the only criterion to confirm CD in CVID population is histological response to GFD. Our patient had significant improvement in symptoms and showed a histological response with GFD. CVID and CD can co-exist, hence a high level of clinical suspicion is warranted to diagnose CD in the CVID population.

[2483] Sequential Duodenal Bulb Biopsies

[2482A] CT enterography showing a 6 cm segment of the ileum with irregular wall thickening and nodular mucosal enhancement with a 10 mm enhancing focus concerning for a neoplastic process.


Duodenal Bulb Biopsies November 2016

Duodenal Bulb Biopsies May 2017

1. Prominent villous blunting with increased intraepithelial lymphocytes and associated epithelial injury 2. Prominent apoptotic bodies.

1. Preserved villous architecture with patchy intraepithelial lymphocytosis 2. No apoptotic bodies seen.


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2484 Non-Steroidal Anti-Inflammatory Drug-Induced Protein-Losing Enteropathy: A Great Masquerade of Crohn’s Disease Daniela G. Vinsard, MD, Mark Stark, MD, Ming-Hsi Wang, MD. Mayo Clinic, Jacksonville, FL Introduction: NSAIDs are one of the most commonly prescribed drugs in the world. NSAID-induced erosions and stenosis in the small bowel can resemble the clinical and endoscopic findings in Crohn’s disease (CD). We present a young woman with history of chronic NSAID use for arthralgia, who subsequently presented with relapsing abdominal pain, GI bleeding and small bowel ulcerations with stenosis mimicking CD. Case presentation: A 29-year-old woman was referred to our tertiary center for a 2-year history of relapsing abdominal pain associated with melena, diarrhea, chronic joint pain, severe iron deficiency anemia, weight loss, and new onset of bilateral lower extremity edema. Previous workup in an outside facility included negative HLA B-27, negative radiologic features of spondyloarthropathy and gastric ulcers previously treated with proton pump inhibitors. Capsule endoscopy revealed erosions, circular ulcers and concentric stenosis in the proximal jejunum and ileum (Fig.1). Abdominal CT scan revealed non-obstructing dilated and stenotic segments within the ileum (Fig.2). She was empirically treated for CD with mesalamine and budesonide with no improvement. A thorough medication history revealed chronic use of lysine clonixinate (NSAID derived from nicotinic acid), metamizole (active breakdown products include NSAID conjugates), propinox, scopolamine butylbromide and tramadol for joint pain

[2484C] DBE showed diaphragm-like concentric stenosis with superficial ulceration in the distal ileum, a unique finding suggestive of NSAID enteropathy.

relief. Physical examination revealed substantial bilateral lower extremity pitting edema (3+) with negative Homans sign and left-sided abdominal tenderness. Noteworthy laboratory findings included: anemia (Hgb 8.0 g/dl), low serum albumin (1.9 g/dl), low IgG (377 mg/dl), negative autoimmune and celiac panel and normal renal function. Double balloon enteroscopy showed 2 diaphragm-like stenotic lesions with circular ulcerations in the distal ileum (Fig.3). With the diagnosis of NSAID-induced enteropathy, NSAIDs were discontinued. Her abdominal pain, melena, and edema gradually improved in 3 weeks. Discussion: Although NSAID-induced upper GI complications have been well described, the small intestinal manifestations (e.g. circular ulcer and diaphragm-like concentric stenosis) are not well-recognized by clinicians. Raising awareness of this disease entity is crucial to establish an early diagnosis. Simply eliminating the causative agent could reduce the impact of hospitalization and costs of care while improving the quality of life of affected patients.

2485 Unique Obstructive Intestinal Manifestations of Metastatic Melanoma: A Case Series Neej J. Patel, MD, Karl Mareth, MD, Josiah McCain, MD, Neema Patel, MD, Jacob Lewis, MD, Andrew Bowman, MD, Mary S. Hedges, MD. Mayo Clinic, Jacksonville, FL

[2484A] Small bowel capsule endoscopy showed circular inflammation, erosions, and fibrostenotic change in the proximal small bowel.

[2484B] Contrast enhanced CT scan of the abdomen and pelvis showing normal distal ileum alternated with mid-ileum dilation (arrow).


Introduction: Though rare in adults, intussusception can occur anywhere in the gastrointestinal (GI) tract causing variable symptoms. 90% of cases may be due to disorders like neoplasm or postoperative status and may cause 1% of small bowel obstructions (SBO). Metastatic melanoma (MM) may involve the GI tract, and its various manifestations accentuate the need for astute awareness when treating patients

[2485A] A) Axial fused PET/CT of the pelvis reveals a hypermetabolic focus in the ileum. B) Axial contrast-enhanced CT of the pelvis reveals ileal bowel wall thickening and associated intussusception caused by melanoma metastatic mass functioning as a lead-point (orange arrow). Oral contrast reveals distended small bowel proximal to intussusception indicating secondary partial SBO (yellow arrows).


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bilateral upper quadrant pain, postprandial emesis and decreased stool output. 2 months prior, a SBO resolved with conservative therapy. She had no prior abdominal surgery. In addition to intra-abdominal metastases, CT showed 2 areas of small bowel intussusception (D-E) with likely MM lead points causing pSBO. She improved without surgery and resumed chemotherapy. Discussion: These cases highlight the importance of maintaining high clinical suspicion of metastatic GI masses as culprits for SBO. When GI symptoms exist in patients with known malignancy such as MM, attempting to identify a soft tissue mass on imaging as a lead-point in intussusception or transition point in SBO for timely and accurate diagnosis is imperative to optimize management.

2486 Systemic Mastocytosis: A Rare Cause of Gastrointestinal Hemorrhage Saamia Faruqui, MS, MD1, Brent Rhodes, MD2, John J. Hutchings, MD2, David L. Smith, MD2, Cacey Peters, MD3. 1Tulane University School of Medicine, New Olreans, LA; 2Louisiana State University Health Sciences Center, New Orleans, LA; 3Tulane University School of Medicine, New Orleans, LA

[2485B] C) Enhancing partially obstructing mass (orange arrow) within the bowel lumen which expands the small bowel at that level. There is an adjacent distended loop of proximal small bowel which is partially filled with gas.

INTRODUCTION: Systemic mastocytosis is a rare disease defined by the proliferation of atypical mast cells in one or more extra-cutaneous organs. It is most commonly found cutaneously, however up to 80% of patient report gastrointestinal complications including a higher incidence of duodenal ulceration. Though rare it is an important diagnosis to consider in patients with gastrointestinal bleeding and skin findings. CASE: A 62 year old man with presented to our facility with complaints of abdominal pain and melena, having been admitted three times in the previous year with similar complaints. During his three previous admissions, his melena was attributed to mesenteric ischemia, although workup up to that point was not suggestive of this diagnosis. At that time, his hemoglobin and hematocrit were found to be 5.9 and 19, respectively. CT angiogram demonstrated multiple areas of small bowel thickening, splenomegaly, mesenteric lymphadenopathy, and osteosclerosis, suggestive of systemic mastocytosis. Gastrointestinal workup

[2486A] Shows three centimeter area of circumfrential ulceration in the distal duodenum significant for active bleeding.

[2485C] D) Axial contrast CT with right lower quadrant intussusception, likely ileocolonic. E) Axial contrast CT with small bowel intussusception of the left mid-abdomen.

with MM for GI symptoms.We report the cases of 3 women with MM diagnosed with partial SBO (pSBO) of varying types due to metastases. Case Presentations: Case 1: A 55-year-old woman with MM (right inguinal primary lesion) to right axillary lymph nodes post excision and radiation underwent positron emission tomography/computed tomography (PET/CT) to address mild abdominal pain and for surveillance. PET/CT detected hypermetabolic activity in the small bowel (A) concerning for a soft tissue mass acting as a lead-point for intussusception and pSBO (B). Surgical excision of the mass confirmed MM. She received chemotherapy, but CT showed new mesenteric and hepatic masses. Case 2: A 75-year-old woman with MM (right heel primary lesion) throughout her abdomen was admitted for SBO causing left lower quadrant pain and constipation. She underwent prior excisions (several intra-abdominal surgeries) and several courses of chemotherapy. CT showed a left lower quadrant intraluminal enteric mass with proximal bowel distention consistent with a metastatic mass causing intermittent or pSBO (C). She improved with nonsurgical therapy. She was too ill for a novel chemotherapy trial and pursued hospice. Case 3: A 58-year-old woman with MM (periumbilical primary lesion) to the shoulder, lung, kidney, spleen, mesentery and brain presented with


[2486B] CT Abdomen showing small bowel wall thickening. The American Journal of GASTROENTEROLOGY

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distention and mild prominence of the intra-and extra hepatic bile duct. MRI abdomen showed double duct sign. He underwent esophagogastroduodenoscopy (EGD) which showed infiltrative thickening of the duodenal bulb, the second and third portion of the duodenum. Multiple biopsies were taken and he underwent endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent and drain placement. His abdominal pain improved significantly and was discharged in a stable condition. Pathology of the biopsied mass was consistent with metastatic squamous cell carcinoma of tonsil. The most common presentation of head of neck metastasizing to small bowel is gastrointestinal bleeding, perforation, gastric outlet obstructive symptoms but rarely they develop obstructive jaundice. This patient had a history of tonsillar SCC with metastasis to jejunum so suspicion was very high for SCC metastasis. Only twelve cases of small bowel metastasis from head and neck have been reported. The majority of them originate from laryngeal SCC and only one case reported tonsillar cancer metastasizing to ileum2. Our case is the first one to illustrate tonsillar cancer with metastasis to the duodenum causing obstructivejaundice3. Diagnosis is made through endoscopic biopsy.

2488 Severe Gastrointestinal Dysmotility in Patients With Ehlers-Danlos Syndrome: Case Series - 1 Center Experience Mohammad Alomari, MD1, Abdullah Shatnawei, CNSC, MD2, Sulieman Abdal Raheem, MD1, May Olayan, MD1, Rami Abdulbaki, MD3, Nizar H. Senussi, MD1. 1Cleveland Clinic Foundation, Cleveland, OH; 2Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH; 3Cleveland Clinic Foundation, University Heights, OH

[2486C] Cutaneous Biopsy CD117+ for mast cells.

included esophagogastroduodenoscopy and colonoscopy demonstrating a 1.5 cm clean based gastric ulcer and multiple ileal ulcerations, respectively. However, no etiology of his recurrent hemorrhage was noted. Video capsule endoscopy was performed which noted an approximately three centimeter area of circumferential ulceration in the distal duodenum significant for active bleeding. Of note, during admit, patient had a skin punch biopsy, which showed a superficial perivascular and interstitial infiltrate of lymphocytes and mast cells. At this time, the patient is following up with general surgery for consideration for partial small bowel resection to prevent further hemorrhage, given the focal nature of this lesion. DISCUSSION Systemic mastocytosis is a rare diagnosis, but one to consider in a patient with non-specific symptoms and recurrent gastrointestinal hemorrhage. It is a rare cause of recurrent GI bleeds, and thought to be due to hypersecretion of gastric acid from the elevated serum level of histamine, leading to the presence of peptic ulcer disease. Ulcer hemorrhage, ulcer perforation, and severe esophagitis has been reported in cases of systemic mastocytosis with GI manifestations. Therapy includes treatment of the underlying condition, acid suppression, and endoscopic or surgical intervention when appropriate.

2487 Unusual Case of Obstructive Jaundice Rajesh Essrani, MD, Eric Nellis, MD, Patrick Hickey, DO, Hiral Shah, MD. Lehigh Valley Health Network, Allentown, PA Small bowel metastasis from head and neck are very rare. Autopsy studies showed that the most common sites of metastases in head and neck cancer carcinoma are lungs (72%), liver (38.6%), kidney, and adrenal (21% each), bone (23%). Two rather rare sites are heart (12%) and small intestine (7%)1. We present an unusual case of obstructive jaundice secondary to metastatic tonsillar cancer to the duodenum that was successfully treated by endoscopic stenting. A 60 year old male with a remote history of tonsillar squamous cell cancer (SCC) treated with chemoradiation presents with a three day history of abdominal pain. Three months prior to this presentation he was found to have metastatic SCC in the jejunum which was treated with curative resection. He admitted weight loss of 14 pounds in last 3 weeks due to anorexia. Abdominal exam was very tender to palpitation in epigastric region, but normal bowel sounds. On initial laboratory assessment, he had multiple abnormalities in his liver function panel including AST - 160 U/L, ALT - 218 U/L, Alkaline phosphatase – 281 U/L, Lipase - 10304 U/L, Total Bilirubin - 3.0 mg/dl. Right upper quadrant ultrasound showed biliary sludge. CT abdomen with contrast showed gallbladder

Gastrointestinal complications are relatively frequent in Ehlers-Danlos syndrome (EDS). Intestinal dysmotility is significantly more frequent in EDS patients than in general population and it has a very difficult investigational approach, requiring a high clinical suspicion for diagnosis. Therapeutic approach may be challenging in the context of limited options and disabling nature of the disease. EDS is considered a multisystem disease, as connective tissue is present throughout the body, the digestive tract can be affected as well. Previous studies have associated EDS with a spectrum of gastrointestinal complications such as chronic constipation, hiatus hernia, Crohn's disease, fecal incontinence, rectal evacuatory dysfunction, functional gastrointestinal disorder, gastroesophageal reflux, recurrent gastritis, delayed gastric emptying and recurrent abdominal pain. In this case series, the authors report six cases of global gut dysmotility in Ehlers-Danlos syndrome. We try to highlight that EDS can lead to significant gut failure that is not only difficult to diagnose but is challenging to treat. All the patient’s required at least one form of nutritional support either by tube feeding or intravenous nutrition. Some of the patient’s required surgical intervention to treat the significant dysmotility. The table below shows our patients characteristics, diagnostic and feeding methods and the surgical intervention if needed. All the reported patients were females diagnosed clinically with EDS hypermobility type (type 3), mean age was 24 years, mean BMI was 23 kg /m2. Five of them diagnosed with POTS (cases 1, 2, 3, 4, 5), only one patient had Mast cell activation syndrome (case 1).Three patients were diagnosed with SIBO (cases 3, 4, 6), five patients required parenteral nutrition (cases 1, 2, 4, 5, 6). Five patients needed tube feeds at some point (cases 1, 2, 4, 5, 6). (See table1). Sever gut dysmotility among patients with Ehlers-Danlos syndrome is not uncommon and possibly underdiagnosed. It must always be taken into account when treating EDS patients with persistent gastro-intestinal symptoms, especially in the presence of autonomic dysfunction features (including POTS) and failure to maintain weight.

2489 I Am Losing Weight, Nothing Works Ashref Mohamed, MD, Nebiyou Wondimagegnehu, MD, Mohamed Zitun, MD. Texas Tech University Health Sciences Center, Lubbock, TX Olmesartan use has been associated with chronic diarrhea and weight loss due to sprue-like enteropathy. The previous is significant medication side effect, yet it still not well recognized among Gastroenterologists and primary care providers. We present an unusual case of a 58-year-old man diagnosed with Olmesartan-induced enteropathy after extensive lab work and empiric treatments failed to unfold the diagnosis. This case illustrates the importance of reviewing patient medications in creating a list of differential diagnosis for patients with chronic diarrhea. It also raises awareness of rare, yet important cause of medication induced diarrhea. A 58-year-old man with a history of hypertension presented with 6 weeks’ history of severe, watery diarrhea accompanied by abdominal bloating and distention. Initial work-up was notable for acute kidney injury and mild hypernatremia with elevated liver enzymes. Complete blood count and lipase were normal. Stool studies including fecal leukocytes, Giardia, Cryptosporidium antigen and Clostridium Difficile toxin PCR testing all returned negative. Tissue transglutaminase and endomysial IgA antibody testing were negative for celiac disease. His diarrhea persisted despite attempting different empirical treatment regimens including antibiotics, Lactose and gluten free diet. On reviewing patient's medications, he was found to have been taking Olmesartan for 4 years. Olmesartan-associated sprue was suspected, and EGD revealed duodenal mucosal changes with marked villous atrophy, and extensive intraepithelial lymphocytosis. Olmesartan was switched to Amlodipine. Noticeable improvement of diarrhea was reported. Complete resolution of symptoms was observed at the subsequent clinic visit 4 weeks later. Olmesartan-induced enteropathy can manifest with clinical and pathological picture similar to Celiac disease. Likewise, Olmesartan induced enteropathy presents with diarrhea, weight loss and malabsorption syndrome. Histopathological findings include villous atrophy with increased intraepithelial lymphocytes infiltration. In contrast to Celiac disease, no clinical or pathological improvement with gluten free diet with negative Tissue transglutaminase. Early recognition and diagnosis is a key. Simple treatment strategies that constitute of switching Olmesartan with other antihypertensive drug can provide clinical and pathological improvement. It would save extensive work up and alleviate prolonged patient suffering.

2490 Paralytic Ileus in a Chronic Strongyloides stercoralis Carrier Patricia Almeida, MD, Jose Melendez-Rosado, MD, Leyla Maric, MD, Eduardo Perez, MD, Pablo Bejarano, MD, Roger Charles, MD. Cleveland Clinic Foundation, Weston, FL Strongyloides stercoralis (SS) is a nematode with a complex life cycle that penetrates the skin of the host and replicated in the small intestine. We present a rare case of paralytic ileus caused by SS associated with HTLV-1 infection. 57 year-old man with type II diabetes mellitus, prior infection with SS, with recent

[2487] EGD showing infiltrative thickening of duodenal bulb.



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[2488] POTS, postural orthostatic tachycardia syndrome; SIBO, small intestinal bacterial overgrowth; MCAS, mast cell activation syndrome; SBFT, small bowel follow through

EDS type

Case 1

Case 2

Case 3

Case 4

Case 5

Case 6

EDS–HT (Type 3)

EDS–HT (Type 3)

EDS–HT (Type 3)

EDS–HT (Type 3)

EDS–HT (Type 3)

EDS–HT (Type 3) Genetic testing

Diagnosis

Clinical

Clinical

Clinical

Clinical

Clinical

POTS

Present

Present

Present

Present

Present

Absent

SIBO

Absent

Absent

Present

Present

Absent

Present

MCAS

Present

Absent

Absent

Absent

Absent

Absent

Age

22 years

19 years

26 years

19 years

29 years

24 years

Sex

Female

Female

Female

Female

Female

Female

BMI

19.67 kg/m2

20.31 kg/m2

24.13 kg/m2

21.55 kg/m2

31.61 kg/m2

22.5 kg/m2 Constipation, bloating

Predominant symptoms Smart pill CT Enterography/ SBFT

Abdominal pain

Vomiting, weight loss

Constipation, bloating

Early satiety, vomiting

Bloating and vomiting

Small bowel delayed transit

Global dysmotility

Not done

Global dysmotility

Global dysmotility

Not done

Unremarkable

Unremarkable

Delayed transit

Unremarkable

Unremarkable

Delayed transit

Delayed

Delayed to liquids

Normal

Sever delay

Mild delay

Delayed

No

No

No

No

No

No

J-tube

Corpak

None

J-tube

J-tube

PEG tube

Gastric emptying Mechanical obstruction Tube feeding Parenteral nutrition

Yes

Yes

No

Yes

Yes

Yes

Surgical intervention

Loop ileostomy

None

Total abdominal colectomy

None

Loop ileostomy

Intestinal transplant

[2490A] Duodenum inflammation. [2490C] Strongyloides stercoralis.

biopsies demonstrated many SS parasites (Image 2,3). The patient was started on Ivermectin 200 mcg/kg/ day per rectum, which resulted in bowel movements and decrease in nasogastric output within 72 hours. HTLV-1 antibodies were positive. Our patient had a history of prior SS infections manifesting as diarrhea, however, on admission, presented with paralytic ileus and significant weight loss. Our case presents some interesting diagnostic and therapeutic challenges. First, obtaining a stool sample was not possible given the paralytic ileus. Analysis of stool samples are commonly performed, but they have low sensitivity due to intermittent parasite excretion. Duodenal biopsies were necessary to make the appropriate diagnosis. Medications used for treatment of SS are usually given orally, however, this was not possible given the patient’s ileus. Our only option was to administer Ivermectin rectally. Our patient had an excellent response within 72 hours. Our case is one of four previously reported cases of SS causing paralytic ileus. This should be on our differential especially in persons traveling to endemic areas. HTLV-1 infections should always be investigated, as this can be a cause a chronic carrier state and higher risk of complications.

2491 Salmonella Aortitis: A Rare Life-Threatening Complication of Non-typhoid Salmonella Bacteremia

[2490B] Strongyloides stercoralis.

travel to the Dominican Republic presenting to the hospital with abdominal pain, vomiting and constipation. The patient was having gastrointestinal symptoms 8 weeks prior to admission that included bloating, malodorous and floating watery diarrhea. Stool samples showed no infectious etiologies and the patient was empirically treated with antibiotics. During the preceding week the diarrhea ceased and he became constipated. During his hospital stay of 3 weeks he did not passed any bowel movements or gas and lost around 28 pounds. Nasogastric tube had an average output of 2-3L per day. Physical exam revealed a cachectic man with dry mucous membranes and generalized abdominal tenderness. Labs were pertinent for eosinophilia. CT abdomen showed loops of small bowel with concentric wall thickening measuring up to 7.5 mm. EGD showed edematous and erythematous folds in the duodenum (Image 1). Duodenal


Seifeldin Hakim, MD1, Mitual Amin, MD1, Ismail Hader, MD2, Mitchell S. Cappell, MD, PhD, FACG1. 1 Oakland University William Beaumont School of Medicine, Royal Oak, MI; 2William Beaumont Hospital, Royal Oak, MI A 65-year-old Japanese male with past medical history of hypertension and chronic hepatitis B presented with diffuse body aches, fever up to 102°F, chills and acute intermittent lower back and abdominal pain that was not related to meals. Physical examination revealed stable vital signs, no jaundice, or pallor, soft non-tender abdomen, and no localized tenderness over the spine. Laboratory analysis revealed WBC=10.1 bil/L, neutrophils=7.4 bil/L, Hgb=16.4 gm/dL and platelets=266 bil/L. Serum parameters of kidney function were normal. AST=74 U/L, ALT =81 U/L and ALKP=101 U/L with normal bilirubin and albumin. ESR=107 mm/hr, CRP=15.6 mg/dl, HIV was negative, and RPR was nonreactive. Immunoglobulin G subclasses, ANA, rheumatoid factor, CCP, myeloperoxidase, proteinase 3 antibodies and


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[2491B] Reconstructive CT abdomen showed pseudo-aneurysm formation.

[2491A] Sagittal view of CT abdomen with IV contrast showed pseudo-aneurysm formation (upper arrow) and peri-aortic soft tissue thickening (lower arrow).

ANCA were within normal limits. CT scan of the abdomen with intravenous contrast on admission showed inflammatory changes affecting the infra-renal portion of the aorta suggestive of aortitis. Blood cultures grew Salmonella Enteritidis. Intravenous ceftriaxone was administered, however, the patient continued to have abdominal and back pain. Follow up abdominal CT after one week showed interval progression of the inflammatory changes around the infrarenal aorta and extending to involve the common iliac arteries (Figure 1&2). He underwent surgical resection of the infected aortic segment with in situ aorto-iliac rifampin impregnated Dacron graft supported with bilateral iliac arteries stents. Microscopic pathology of the resected aorta revealed numerous neutrophylic infiltration of the arterial wall but no bacteria were detected (Figure 3). He completed a 6-week course of ceftriaxone and currently he is on lifelong suppressive therapy with amoxicillin. The patient was asymptomatic at 20-week follow up. The incidence of extra-intestinal focal infections in non-Typhoid Salmonella (NTS) bacteremia is 39.5%. Endovascular infection is a life-threatening extra-intestinal complication of NTS bacteremia. Salmonella aortitis is a rare cause of aortitis. Usually it occurs with NTS and comprises one third of abdominal aortic infections. CT abdomen with contrast is the study of choice in diagnosing aortitis and aneurysm formation. The treatment of Salmonella aortitis is usually a combination of medical and surgical approaches. The mortality rate is 96-100% with medical therapy alone and is 40% when medical and surgical approaches are combined together.

2492

[2491C] Microscopic pathology of resected aorta with hematoxylin, eosin and gram stain showed numerous neutrophylic infiltrates with lack.

Endoscopy in Outer Space: A Case of Contained Duodenal Perforation David Mossad, MD1, Ankush Sharma, MD2, Mustafa Musleh, MD1. 1Wright State University, Dayton, OH; 2 Wright State University Boonshoft School of Medicine, Beavercreek, OH Duodenal perforation due to peptic ulcer disease (PUD) can result in significant morbidity and mortality if not managed appropriately. Non-operative management has been shown to be a safe strategy in a subset of these patients. The role and safety of endoscopy in assessment of perforation when diagnosis


is equivocal has not been widely studied. We present a case where endoscopy was safely used in the evaluation of a patient who was found to have a duodenal perforation. An 88 year old male with a history of PUD presented with 4 weeks of abdominal pain, 10 pound weight loss, and multiple episodes of emesis with pain radiating to the right upper quadrant. The patient was clinically stable and had mild abdominal tenderness on examination. He had a leukocytosis (11.6) that resolved after his first hospital day. CT abdomen/pelvis showed inflammatory changes in the gallbladder fossa as well as a


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focal air/fluid collection within the duodenum suggesting a large duodenal diverticulum (Figure 1). The admitting surgical service did not believe his pain was biliary and sought an alternative diagnosis. He was started on cefotetan and a proton pump inhibitor. Endoscopy was chosen to help establish a diagnosis. On endoscopy, the esophagus and stomach were normal. In the duodenal bulb, a narrow luminal opening was visualized that appeared friable and irregular. The scope was advanced through the opening, and irregular appearing tissue with omental fat and areas of necrosis were seen (Figure 2). The endoscope was clearly outside of the luminal wall and likely within a contained perforated segment. A follow up upper GI series with barium showed a collection of contrast communicating with the first portion of the duodenum, likely representing a contained perforation (Figure 3). The initial plan was for surgical correction. However, conservative management was chosen given the high risk of the operation and the patient’s clinical stability. After his symptoms improved, the patient was discharged tolerating a soft diet. While not a first-line choice, endoscopy may have a role in evaluating unclear cases that are found to involve perforation. In cases where the diagnosis may be in question, endoscopy may be safely performed. This path is consistent with the knowledge that up to half of all duodenal ulcers seal on their own within a short period of time. Our decision resulted in a good outcome, as this patient avoided an open surgery to characterize and treat his disease.

[2492A] Coronal image demonstrates duodenal thickening with small focus of intraluminal air (arrows) concerning for a duodenal diverticulum by radiology interpretation.

2493 Jejunojejunostomy Intussusception After Roux-en-Y Gastric Bypass: Do We Need to Treat? Yousef Abdel-Aziz, MD, Zaid A. Ammari, MD, Zubair Khan, MD, Umar Darr, MD, Eslam Youssef, MD, MSc, Ali Nawras, MD, FACP, FACG, FASGE. University of Toledo Medical Center, Toledo, OH Jejunojejunostomy (J-J) intussusception is a rare complication that occurs in 0.4% of patient after Roux-en-Y gastric bypass (RYGB). Although reduction or resection with revision of the area of intussusception appears to be effective, in less acute patients, the best treatment options are controversial. Here, we present a rare case of jejunojejunostomy intussusception after Roux-en-Y gastric bypass that resolved after single balloon enteroscopy. A 30-year-old female patient presented to our facility with left upper quadrant abdominal pain of few days duration associated with nausea and vomiting. Past history was significant for partial gastrectomy, Roux-en-Y gastric bypass surgery of 10 years duration, and multiple other abdominal surgeries for enterocutanous fistula. On admission, her vitals were stable, and abdominal exam showed soft, non-distended abdomen with tenderness at the left upper quadrant, with no peritoneal signs. Complete blood count, lipase, and lactate were normal. Serum

[2492C] Upper GI series demonstrating luminal narrowing with fill of contrast within a likely contained perforated duodenal ulcer (arrow). Note there is no extravasation of contrast excluding a frank perforation.

[2492B] Endoscopic appearance of tight stricture in the duodenal bulb (A), and then within the contained perforation with omental fat and necrosis directly visualized (B, C, and D).



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[2493] Image 1: IV Contrast enhanced Axial (A) and coronal (B) computed tomography (CT) of the abdomen demonstrating intussusception at the Roux-en-Y anastomosis (red arrow).

electrolytes were significant for hypokalemia secondary to vomiting. Computed tomography (CT) scan of the abdomen showed J-J intussusception at the Roux-en-Y anastomosis (Image 1). She was scheduled for a single balloon enteroscopy for further evaluation. Endoscopic examination showed no evidence of intussusception or any obstruction of anastomosis sites and limbs. The patient tolerated the procedure well without complications. After the procedure, the patient underwent a follow up CT of abdomen and pelvis that showed no residual intussusception. Although her intussusception might be resolved with air insufflation during the single balloon enteroscopy, spontaneous resolution might be another possibility. On hospital day 3, the patient was tolerating a regular diet and her symptoms completely resolved. Jejunojejunostomy intussusception after Roux-en-Y gastric bypass is uncommon, and might resolve with a single balloon enteroscopy or spontaneously. Watchful waiting could be an appropriate option in less acute cases.

2494 An Unusal Presentation of ACE-Inhbitor Induced Angioedema

2495 Isolated Visceral Angioedema: An Uncommon Complication of ACEI Therapy J. Thomas Dorsey, MD, FACG1, Loc Tran, OMS-I2. 1West Virginia University School of Osteopathic Medicine, Wheeling, WV; 2West Virginia University School of Osteopathic Medicine, Lewisburg, WV Angiotensin Converting Enzyme Inhibitors (ACEIs) are commonly prescribed medicines with well-known side effects. We report a lesser known side effect with a stereotypical presentation, “Isolated Visceral Angioedema” (IVAE). This can occur within hours to years after initiation of ACEIs with a strong female predominance clinically presenting with variable levels of abdominal pain, emesis, and diarrhea. Abdominal CT shows diffuse small bowel thickening and ascites. Recognition of this presentation will prevent unnecessary maneuvers including endoscopic procedures and surgical intervention. A 45-year-old white female with hypertension and hypothyroidism was taking Lisinopril (for 18 months), Levothyroxine and oral contraceptives. She experienced her first episode of abdominal pain with nausea and vomiting six months prior to presentation which spontaneously resolved. She described six additional episodes over the next six months leading to her presentation with severe abdominal pain which brought her into the hospital. At presentation

Yousef Abdel-Aziz, MD, Thaer Abdelfattah, MD, Zaid A. Ammari, MD, Abhinav Tiwari, MD, Mohammad Al-Sarie, MD, Ali Nawras, MD, FACP, FACG, FASGE. University of Toledo Medical Center, Toledo, OH Angioedema of the small bowel (ASB) is an extremely rare side effect of the angiotensin-converting enzyme inhibitors (ACEI). We present a case of ACEI-induced ASB. This case highlights the unique manner in which ACEI-induced angioedema may present. A 44 year old caucasian female with history of hypertension presented to our facility with 3 months history of recurrent episodes of progressively severe generalized cramping abdominal pain, nausea, vomiting and intermittent diarrhea without fever. Home medications included lisinopril that was started 5 years ago. Exam was only significant for a diffusely tender abdomen with no peritoneal signs. Blood tests were notable for a normal serum chemistry, liver function test, C1 esterase level, and complete blood count (CBC). Infectious work up and urine pregnancy test were negative. Abdominal computed tomography (CT) with IV contrast showed small bowel wall edema and mucosal enhancement(Image 1), as well as a small amount of ascites. Push enteroscopy and colonoscopy with random biopsies were normal. Taken together, findings were consistent with newly diagnosed isolated angioedema of the bowel. Within 72 hours of lisinopril discontinuation, the patient had complete resolution of symptoms. No other treatments (ie, corticosteroids, anti-histamines) were used prior to recovery. The patient had no recurrence of symptoms after 3 months follow up. In conclusion, angioedema can only involve the small bowel wall, and should be considered in a patient who presents with severe episodic abdominal pain and diarrhea with concurrent ACEI use.

[2495A] Abdominal oral and IV contrast CT showing peri-hepatic ascites and thickening of the stomach walls.

[2494] Image 1: CT abdomen revealing small bowel wall thickening predominantly on the left side (jejunum).


[2495B] Abdominal oral and IV contrast CT showing peri-hepatic ascites with thickened stomach walls.


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[2495C] Abdominal oral and IV contrast CT showing visible thickening of the intestinal wall.

she was in moderate to severe abdominal pain, vital signs were stable and abdominal exam demonstrated diffuse abdominal tenderness without rebound. CBC showed only a WBC of 17.7, chemistries were normal. CT abdomen and pelvis revealed thickening of her distal jejunum and proximal ileum spanning 30 cm in length and ascites. Negative stool culture, ova and parasites, and C. Difficile. C1 esterase inhibitor, C3 and C4 complement levels were normal. Treatment consisted of discontinuing her Lisinopril. Repeat abdominal and pelvic CT two weeks later, showed complete resolution of small bowel thickening and ascites. To date, 36 months later, the patient has had no recurrence of symptoms. Diagnosis of IVAE is based on the triad of typical symptoms (abdominal pain, nausea, vomiting and diarrhea); typical CT findings of thickened small bowel and ascites; and history of ACEI use. This occurs in the absence of peripheral manifestations of angioedema (lip or tongue swelling, urticaria, and respiratory symptoms). The differential of small bowel thickening and ascites includes: infections, ischemia, inflammation (Crohn’s) and neoplastic causes. IVAE commonly resolves after recognition via history and imaging studies with immediate cessation of ACEIs followed by NPO and IVF hydration, and possible fresh frozen plasma used as second line agent in complicated refractory cases.

[2496B] CT imaging demonstrating RLQ mass in September 2016 upon repeat.

2496 Endometriosis: A Masquerade Nilima Shet, Vikas Gupta, MD, PhD, Felice Schnoll-Sussman, MD, Michael Lieberman, MD. New YorkPresbyterian/Weill Cornell Medical Center, New York, NY KR is a 31 year-old woman with past medical history significant for an atrial septal defect who first presented in August 2016 with constant lower abdominal cramping with nausea, diarrhea, and vaginal bleeding during her usual menstrual cycle. The patient’s menstrual cycles had been painful prior and she had been on an oral contraceptive (OCP) for 13 years though had stopped 3 months prior to presentation. Upon presentation, the patient’s physical exam was notable for guarding and diffuse tenderness along both lower abdominal quadrants. The patient’s pregnancy testing was negative and urinalysis unremarkable. Initial labs were notable only for mild leukocytosis and endovaginal ultrasound was unremarkable. On CT of the abdomen/pelvis, a right lower quadrant soft tissue mass was identified – perhaps an inflamed appendix. The plan was for non-operative management with pain control and antibiotics as the patient completed 7 days of Levaquin and Flagyl. Upon discharge and after completion of antibiotics, the patient felt better. However, in October, the patient presented once more with right lower quadrant abdominal pain – again during menses. Upon re-imaging, CT was unchanged and MRI demonstrated the same soft tissue mass at the ileocecal valve. Given no improvement in symptoms, the patient was planned for open ileocectomy and concurrent diagnostic laparoscopy. Upon laparoscopy, midline endometrial implants were noted scarring the cul-de-sac as well as the anterior bladder. A specimen obtained from the terminal ileum demonstrated full-thickness endometriosis and was, in fact, not a phlegmon. Endometriosis, affecting 10-15% of women of reproductive age, most frequently affects ovaries, the cul-desac, and the uterosacral ligaments. Under rarer circumstances, it has been noted to involve the GI tract. Notably, GI involvement by endometriosis has been noted to occur in 3-7% of menstruating women and ileal localization is even rarer – noted in 1-7% of all cases. Given the rarity of such a presentation, it is easy to commit diagnostic errors and consider more common pathologies such as abscesses. One such case discussed a similar diagnostic dilemma to ours in which the only means by which diagnosis of endometriosis was made was via histopathology. This information highlights the uniqueness of our case and adds perspective to a differential diagnosis we often consider when evaluating abdominal pain in the menstruating woman.

[2496C] MR imaging demonstrating RLQ mass upon second presentation in October 2016.

2497 Strongyloides Infection in Massachusetts: When to Expect the Unexpected Matthew Collins, MBBCh, BAO, Aditya Kalakonda, MD, Tuyyab Hassan, MBChB. Baystate Medical Center, Springfield, MA An 85-year-old woman, raised in AL and residing in MA with a medical history significant for recently diagnosed plasma cell myeloma treated with lenalidomide and dexamethasone, diverticulosis, colon cancer status post hemicolectomy, CKD, CAD on single anti-platelet therapy and chronic macrocytic anemia reported abdominal pain and melena and was found to have guaic positive stool. She was prescribed a PPI and sucralfate, and dexamethasone was temporarily discontinued due to concerns for steroid-induced stress ulcers. Symptoms improved and repeat stool guaiac test was negative. Steroids were restarted at a lower dose and the patient developed recurrent melena. CBC demonstrated pancytopenia with a stable Hb but new eosinophilia. Lenalidomide was discontinued and the patient noted resolution of symptoms. A few months later the patient was found to have recurrent abdominal pain and melena, and was subsequently referred to GI. She denied any nausea, vomiting, heartburn, cough, rash or weight loss. She was hemodynamically stable and abdominal examination was benign. Labs were repeated and notable for a Hb of 7.9, Plt of 91k, MCV of 98.8, RDW of 56 and an absolute eosinophil count of 1600 (25.3%). The patient continued to have melena requiring blood transfusion. She underwent an EGD, which was notable for erythema in the stomach body and normal duodenal mucosa. Biopsies demonstrated chronic active duodenitis associated with Strongyloides infection. Serum Strongyloides IgG Ab returned positive, confirming the diagnosis. Invermectin was prescribed and there were no further reports of melena. A stool sample was sent for O&P analysis and returned negative. Repeat CBC showed resolution of the eosinophilia. Strongyloides is common in institutionalized populations with low SES living in tropical and rural areas. In the US, it is typically seen in the southern Appalachian region. The infection is typically asymptomatic and chronically controlled in immunocompetent hosts, but can become invasive in immunocompromised individuals and cause hyper- or superinfections. While this patient was residing independently in the North-Eastern US, her history of malignancy, immunosuppression and upbringing in AL put her at risk for infection with Strongyloides. While this patient did not develop a superinfection, the case highlights the importance of considering the diagnosis in immunocompromised patients with unclear etiology for melena, especially when eosinophilia is present.

[2496A] CT imaging demonstrating RLQ mass in August 2016.



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2498 Meckel’s Diverticulitis Mimicking Crohn’s Disease Gurpartap S. Sidhu, MBBS, MS1, Jordan Neviackas, MD2, Bashar M. Attar, MD, PhD2, Cammille Go3, Vikram Kotwal, MD4, Hemant Mutneja, MD1, Palashkumar Jaiswal, MBBS4, Gijo Vettiankal, MD2. 1Cook County Health and Hospitals System, Chicago, IL; 2Cook County Health and Hospital Systems, Chicago, IL; 3 Chicago, IL; 4John H. Stroger, Jr. Hospital of Cook County, Chicago, IL Introduction: We report an unusual case of right lower quadrant pain in an adolescent that posed a diagnostic dilemma. Case : 17 year old male with past history of appendectomy presented with 2 days of recurrent right lower quadrant abdominal pain. The history was remarkable for recent hospitalization with similar abdominal pain. Cross-sectional imaging of abdomen reported wall thickening and luminal narrowing with mucosal enhancement of distal ileum, with surrounding free pelvic fluid, concerning for abscess. The findings were in favor for Crohn’s disease. He received a course of ceftriaxone and metronidazole for abscess and a trial of mesalamine for possible associated inflammatory bowel disease . An ileocolonoscopy revealed a normal colon and distal 10 cm terminal ileum. The symptoms recurred leading to readmission. His vitals on current admission were within normal limits. The physical exam was remarkable for bilateral lower abdominal tenderness with voluntary guarding. Routine laboratory investigations including CBC, BMP and liver function tests were unremarkable. The terminal ileum histopathology from previous colonoscopy was reviewed and found to be normal. Meckel’s scan was negative for radiotracer uptake, however MR enterography was remarkable for an inflamed blind ending segmental small intestinal loop within the right hemipelvis, likely from Meckel’s diverticulitis. He received another course of antibiotics with symptomatic improvement and was provided follow up with general surgery for consideration of diverticulectomy. Discussion Meckel’s diverticulum is the most common congenital abnormality of small intestine resulting from incomplete closure of vitelline duct. It is present in 2% of the population, with a male predominance. It is typically asymptomatic and detected incidentally during laparotomy. Most common presenting symptoms are lower GI bleeding due to ectopic gastric mucosa, intestinal obstruction due to intussusception or volvulus and herniation in inguinal sac. It can present with diverticulitis and is often confused with acute appendicitis or IBD. Regional ileitis as initially reported in imaging studies in our case, can be seen in Meckel’s diverticulitis, and does not necessarily suggest Crohn’s disease. Meckel’s scan can be negative if there is insufficient or lack of gastric tissue in the diverticulum. The management is usually with antibiotics and surgical resection of the diverticulum.

[2499] CT abdomen showing thickened bowel wall with inner and outer rim enhancement with central hypo-attenuation consistent with the “target sign”.

prednisone. Lupus enteritis is a known cause of abdominal pain in patients with SLE; however, it is one of the rarest manifestations of the disease. There are only 19 known cases of lupus enteritis as the initial presentation of SLE. Biochemical testing can show low complement and positive ANA, but the gold standard for diagnosis is based on CT findings including: bowel wall thickening, target sign (thickened bowel wall with peripheral rim enhancement or inner and outer rim enhancement with central hypoattenuation), dilation of intestinal segments, or combs sign (increased number of visible vessels with a comblike pattern). Prompt diagnosis of lupus enteritis is critical as delay can lead to various complications, and first line treatment is with high dose corticosteroids. This case highlights a particularly difficult diagnosis in a patient who was not known to have SLE and did not have any other signs or symptoms of the disease. This emphasizes the need to always keep this entity in the differential diagnosis of abdominal pain with consistent CT findings, especially in young to middle age females whether or not they have known SLE.

2500 Lupus Enteritis: A Non-surgical Cause of Acute Abdomen Tamoor Shahid, MD1, Harish Guddati, MD2, Kamran Zahid, MD1, Hilary Hertan, MD1. 1Montefiore Medical Center, Bronx, NY; 2Montefiore Medical Center, Yonkers, NY Introduction: SLE is a multisystem autoimmune disorder. Lupus enteritis is potentially rare complication of SLE presenting as abdominal pain. Case report: A 32 year old woman with the history of SLE came for evaluation of 1 week history of subjective fever, cough, and pleuritic chest pain after failing outpatient treatment for community acquired pneumonia with levofloxacin. She had stable vitals on admission. Laboratory investigations showed leukopenia, anemia, raised C-reactive protein, and positive anti-dsDNA antibodies with higher titers from baseline and low complement levels. Her CXR and echocardiogram showed moderate bilateral pleural effusion and mild pericardial effusion. The patient was started on IV steroid to treat SLE flare. On day four of hospitalization, she complained of nausea, vomiting, and severe abdominal pain. Abdominal CT scan showed dilated and thickened small bowel loops, mild abdominal ascites without any evidence of arterial and venous thrombosis. She was given bowel rest and empirically started on IV antibiotics, and steroids were continued. Stool studies including C diff, bacterial cultures and ova and parasites were negative. She had clinical improvement in 2-3 days and was able to tolerate diet. Antibiotics were discontinued, and she was discharged home on tapering doses of steroid. Discussion: Lupus enteritis is an uncommon condition in SLE patients with the prevalence of about 0.9 %. About 8%-40% of SLE patients have acute abdominal pain during the stage of an active disease. Inflammatory vasculitis secondary to immune complex deposition and thrombosis of the intestinal vessels are the proposed pathogenic mechanisms. It can cause very severe abdominal symptoms and signs and sometimes is diagnosed as the acute surgical abdomen. Early diagnosis is critical to allow prompt treatment to avoid unnecessary surgical intervention. Characteristic CT abdomen findings include dilated bowel, focal or diffuse bowel wall thickening, abnormal bowel wall enhancement which is also called "target sign," mesenteric edema, stenosis or engorgement of mesenteric vessels which is also called "the comb sign" and ascites. Treatment is symptomatic management and high dose intravenous methylprednisolone. Those who do not have an adequate response to steroids should be considered for immunosuppressive agents like intravenous cyclophosphamide. When a rapid response to immunosuppressive therapy is not achieved, surgical intervention should be considered.

[2498] A blind ending segmental loop within the right hemi-pelvis.

2499 On Target: A Rare Case of Lupus Enteritis as the Initial Presentation of Systemic Lupus Erythematosus David Schwarzbaum, MD1, Jason Rubinov, MD2, Ioannis Oikonomou, MD3. 1Mount Sinai Beth Israel Hospital, New York, NY; 2Mount Sinai Beth Israel Medical Center, New York, NY; 3Icahn School of Medicine at Mount Sinai, New York, NY We present a case of a young woman with repeated admissions for abdominal pain who was eventually diagnosed with lupus enteritis as the initial presentation of her systemic lupus erythematosus (SLE). A 29-year-old female had previously presented twice for severe abdominal pain and nausea. At that time a CT scan showed diffuse segments of mild wall thickening in the duodenum, jejunum, and a long segment in the descending and sigmoid colon. She was treated for presumed gastroenteritis with mild improvement and was discharged. She returned 3 weeks later with recurrent abdominal pain, nausea, vomiting and diarrhea. Repeat CT scan showed duodenal wall thickening, ileal circumferential wall thickening with intramural hypo-attenuation, and mild wall thickening in the transverse and distal colon, all increased from 3 weeks prior. Stool studies were negative and the patient was started on IV steroids for suspected IBD vs. vasculitis. She improved rapidly so steroids were tapered and she was discharged. She returned that night with recurrent pain and was restarted on IV steroids. Further workup revealed a positive ANA and low complement levels. Upon review of the CT scan the “target sign” was demonstrated and the diagnosis of lupus enteritis was made. The patient rapidly improved with IV steroids and was discharged on oral


[2500] Thickened loops of small bowel on CT abdomen and pelvis. VOLUME 112 | SUPPLEMENT 1

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2501 A Case of Sodium Polystyrene Sulfonate (Kayexalate)-Induced Bowel Ischemia: A Reminder of Adverse Effects of a Common Medication Sagar Patel, MD, Christina A. Arnold, MD, Darrell M. Gray, II, MD, MPH. The Ohio State University Wexner Medical Center, Columbus, OH Introduction: Acute hyperkalemia is a common yet potentially fatal condition . Sodium polystyrene sulfonate (SPS), also known as Kayexalate, is often used as a first line treatment. We present a case of SPS-induced bowel ischemia as a reminder of a common yet under-reported adverse effect of this medication. Case A 45 year-old male presented in transfer to our tertiary care referral center for evaluation of a newly diagnosed anterior mediastinal mass concerning for thymoma. Amidst his evaluation and treatment, he developed cyclosporine-induced acute kidney injury and consequent acute hyperkalemia (potassium- 5.8 mmol/L) 14 days into his hospitalization. He was given 30 grams of oral sodium polystyrene sulfonate (SPS) with subsequent normalization of his potassium level. At that time, he was not experiencing abdominal pain, overt GI bleeding, or change in baseline stool frequency or consistency. However, colonoscopy performed 4 days after SPS administration, as indicated for evaluation of an abnormal PET scan that demonstrated incidental focal intensities within the anus and cecum, revealed large ulcers at terminal ileum (image A), hepatic flexure (image B), and rectum. Biopsies were taken and

[2501C] Histologic sections of the small bowel mucosa show a rare basophilic resin in the lumen (bracket) and patchy mild acute inflammation (center, lower aspect). Hematoxin and Eosin, 200x.

histology showed acute enteritis and basophilic crystals with "fish-scales" (image C) consistent with of SPS-induced ischemia. Discussion Sodium polystyrene sulfonate (SPS) has been approved by the FDA since the 1950s for the treatment of hyperkalemia. It essentially releases sodium ions in the stomach as an exchange for hydrogen ions. As the resin reaches the colon, hydrogen ions are then exchanged for potassium ions and the modified resin, which now contains potassium ions, is excreted in feces. Yet, it is the cathartic sorbitol that is formulated with SPS that has been widely attributed to causing intestinal necrosis. This adverse effect is well documented in the post-operative, critically ill, and general populations. The incidence is estimated to be 0.003-1.8%. Clinicians were previously guided to screen for risk factors prior to prescribing SPS such as previous bowel surgeries and end-stage renal disease. However, recent evidence suggests that patients may be susceptible to intestinal injury even in the absence of formerly hypothesized risk factors. Thus, it is crucial to be mindful of the risk of bowel ischemia when prescribing this medication.

2502 Terminal Ileitis in Teenagers: Not Always Crohn’s Disease Paola Esparragoza, MD1, Mohammed Saadi, MD1, Linda Mamone, MD1, Suad Taraif, MD2, Michael S. Smith, MD, MBA3. 1Temple University Hospital, Philadelphia, PA; 2Lewis Katz School of Medicine at Temple University, Philadelphia, PA; 3Mount Sinai St. Luke's and Mount Sinai West, New York, NY

[2501A] Terminal Ileum ulceration visualized during colonoscopy.

Introduction: Terminal ileitis in teenagers confers high clinical suspicion for Crohn’s disease. However, many conditions can affect the terminal ileum, including infection, lymphoid nodular hyperplasia, malignancy, NSAID use, vasculitis and infiltrative disorders. Case: An 18 year old Hispanic male without significant medical history presented with a day of acute onset, sharp, constant periumbilical pain with radiation to the right lower quadrant (RLQ) and migration to the left side. He had single episodes of non-bilious, non-bloody emesis and hematochezia. There were no ill contacts, recent illness, unusual food intake, medication or supplement use or animal exposure. Family history was negative for Crohn’s, colitis or colorectal cancer. While he had no recent travel, his father was in the Dominican Republic 6 months earlier. On admission, vital signs were stable. His abdomen was soft with periumbilical tenderness and focal tenderness at McBurney’s point. Rovsing’s sign was positive, with voluntary guarding. Rectal exam had

[2501B] Hepatic flexure ulceration visualized during colonoscopy.

[2502A] Terminal ileum with congestion, erythema and nodularity.



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[2503A] CT of the abdomen and pelvis with oral and intravenous contrast revealing focal fluid collection in the anterior pelvis with a thickened bowel wall.

[2502B] Non-specific ileitis with non-caseating granuloma (40x).

[2502C] Worm in ascending colon.

no perianal lesions or stool. There was a mild leukocytosis. He was admitted with presumed acute appendicitis. Stool studies were negative. Abdominal CT revealed terminal ileal mural thickening with mild appendiceal mucosal thickening but no periappendiceal stranding. Given these findings, appendicitis was deemed unlikely and gastroenterology was consulted for “likely Crohn’s”. Colonoscopy showed terminal ileal congestion, erythema and granularity. Biopsies had a single granuloma and non-specific ileitis. A white worm was removed from the ascending colon. While Anisakiasis was suspected (father works in a fish restaurant), it later was identified as Trichuris trichuria. He was started on mebendazole for apparent infectious ileitis with transient improvement. Given persistent fever and RLQ pain, he had an interval CT with appendiceal hyperenhacement. It lead to exploratory laparoscopy which found a perforated appendix with purulent pockets. After appendectomy, and he was discharged home on broad spectrum antibiotics. Discussion: When presented with findings of terminal ileitis, a broad differential diagnosis must be considered. In this case, an intestinal parasitic infection mimicked symptoms and endoscopic findings typically seen in Crohn’s disease. A delay in diagnosis can lead to inappropriate treatment, with additional unnecessary testing and other potential complications.

2503 Diarrhea in a Post-Colectomy Patient: Should We Still Consider Clostridium difficile? Mihajlo Gjeorgjievski, MD1, Ahmed Edhi, MD1, Seifeldin Hakim, MD2, Estela Mogrovejo, MD2. 1William Beaumont Hospital, Royal Oak, MI; 2Oakland University William Beaumont School of Medicine, Royal Oak, MI

[2503B] CT of the abdomen and pelvis with oral and intravenous contrast revealing focal fluid collection in the anterior pelvis with a thickened bowel wall.

the pathophysiology of this common pathogen infecting an uncommon site. A 50-year-old female presented with fever, chills, nausea, abdominal pain, and increased maroon colored stool through her ileostomy. Past medical history included end transverse diverting colostomy complicated by feculent perforation requiring right hemicolectomy with end-ileostomy. Patient reported recent use of trimethoprim/sulfamethoxazole for genital folliculitis. Physical exam revealed hyperactive bowel sounds, tenderness to palpation around ileostomy site, and increased dark-colored ileostomy output. Pertinent laboratory results included white blood count 9.4 billion per liter (3.3-10.7 billion/ liter), creatinine 0.82 mg/dl (0.4-1.4 mg/dl), and lactic acid 1.9. Computerized tomography of the abdomen revealed right-sided ascites and a focal fluid collection in the anterior pelvis with a thick wall of bowel. Clostridium difficile toxin from the ileostomy output resulted positive and the patient was treated with oral vancomycin every 6 hours with no improvement of the diarrhea severity. Fidaxomicin and rifaximin were then initiated with resolution of symptoms. Clostridium difficile, an anaerobic endospore-forming bacterium, is typically a colonic pathogen and is an important cause of nosocomial infection. Small bowel enteritis, however, is relatively uncommon C. difficile enteritis has been increasingly reported in literature and is not as rare as previously thought. The pathogenesis of C. difficile small bowel enteritis is not clearly established, however, the majority of reported cases occurred after treatment with antibiotics, thus disruption of small bowel flora is needed to establish infection. After colectomy, it is hypothesized that the mucosa of the small bowel undergoes morphologic changes resembling characteristics of colon, especially after gastrointestinal surgery, which makes it a good site for colonization with organisms favoring colonic mucosa. Unlike C. difficile colitis, the majority of the of small bowel enteritis cases present with systemic manifestations and its clinical course is much more severe with higher case-fatality rate.

Clostridium difficile is the most common cause of antibiotic- associated diarrhea resulting in significant morbidity and mortality and is typically limited to the colon. We report a case of refractory diarrhea from C. difficile enteritis in a patient with a colectomy and end-ileostomy to illustrate



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2504 Isolated Small Intestine Angioedema: An Under-Recognized Complication of AngiotensinConverting Enzyme Inhibitor Therapy Moinuddin Syed, MD, Juan Rey-Mendoza, MD, C. Roberto Simons-Linares, MD, MSc. John H. Stroger, Jr. Hospital of Cook County, Chicago, IL Case Presentation: 58-year-old woman with history of hypertension, and recurrent episodic abdominal pain with extensive workup only remarkable for small intestine wall thickening on CT scan; presented to the emergency room with severe abdominal pain associated with non-bloody non-bilious vomitus and watery non-bloody diarrhea. Included in her medications: Enalapril. Examination revealed mild generalized abdominal tenderness. Laboratory indicated an unrevealing infectious workup, and a normal C4 and C1 esterase inhibitor. In previous admissions, bidirectional endoscopy revealed unspecific small bowel mucosal edema and inflammation. Several biopsies of the small intestine exhibited vascular congestion and non-specific mucosal inflammation. During this last admission, esophagogastroduodenoscopy and deep enteroscopy were performed. Endoscopic findings were small bowel edema and inflammation. Angiotensin converting enzyme inhibitors (ACEI) induced visceral angioedema was suspected and enalapril was held. Within 24 hours the patient reported significant improvement in her symptoms, with a repeated CT scan showing resolution of previous bowel thickening. Discussion: ACEI induced visceral angioedema commonly presents with a triad of severe acute abdominal pain (100%), vomiting (87%) and diarrhea (50%). Laboratory tests are frequently unrevealing and CT scan of the abdomen demonstrate segmental thickening of the bowel wall, most commonly involving the jejunum, ileum, and duodenum. Symptoms typically resolve within 24 to 48 hours of stopping the medication. This condition may occur any time during the course of therapy. It is most frequent in women (85% of cases) with a mean age of 50 years. There is frequently a delay in diagnosis before the culprit medication is eventually stopped; and patients usually underwent invasive work up. It is important to rule out hereditary angioedema by testing for C1 esterase inhibitor and C4 level. Diagnosis is established by

[2504C] Edematous Small intestine villi with inflammatory changes.

current use of an ACEI, abdominal pain, CT showing bowel-wall thickening, normal C1-esterase inhibitor level and resolution of symptoms and normal imaging after cessation of ACE inhibitor. Conclusion: Visceral angioedema should be considered in patients using ACE inhibitors with unexplained abdominal pain, early recognition and discontinuation of ACE inhibitors can avoid considerable morbidity, unnecessary medical and surgical interventions. Cessation of ACE inhibitors leads to symptom resolution.

2505 Chronic Radiation Gastroenteropathy Diagnosed by Small Bowel Capsule Endoscopy: A Case Report Andrew R. Scheinberg, MD1, Mai Sedki, MD2, Derek J. Estes, MD2, Fernando H. Calmet, MD3, Amar R. Deshpande, MD, FACG4. 1Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL; 2Jackson Memorial Hospital / University of Miami Miller School of Medicine, Miami, FL; 3 University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL; 4University of Miami Miller School of Medicine, Miami, FL Radiation therapy plays an important role in a vast array of both benign and malignant disease processes. However, gastrointestinal toxicity limits the total radiation dose that can be prescribed. Chronic radiation gastroenteropathy may arise as early as 6 months to as late as several decades after the initial exposure. Microvascular sclerosis, mucosal atrophy, and intestinal wall fibrosis lead to altered intestinal

[2504A] Severe Jejunum walls thickening on CT scan.

[2504B] Resolved jejunum wall thickening after discontinuing ACEI.


[2505A] .


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radiation enteropathy. Despite the decreasing incidence of radiation-induced enteropathy, we continue to encounter patients who present with significant complications after a prolonged latency period. A presumptive diagnosis is often made clinically, although small bowel capsule endoscopy remains a valuable and minimally invasive method to confirm this clinical entity.

2506 An Unusual Presentation of an AIDS-defining Illness in the Duodenum Diagnosed by Endoscopy: A Case Report in South Florida Andrew R. Scheinberg, MD1, Akash Goel, MD2, Daniel A. Sussman, MD, MSPH3. 1Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL; 2University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL; 3University of Miami Miller School of Medicine, Miami, FL

[2505B] .

New diagnoses of HIV have decreased in the United States. However, this is not true for South Florida which currently leads the nation in new HIV infections, over three times the national average. The implications of these increasing rates for physicians in South Florida means an awareness of opportunistic infections that may be the initial presentation of a diagnosis of HIV. While cryptococcal infection is a leading opportunistic infection seen in patients with AIDS, gastrointestinal involvement is rarely described. A 36 year-old Hispanic man presented to the ED with a 5 day history of non-bloody watery diarrhea. 1 month prior, the patient was admitted to an outside hospital with the same symptoms including fevers, chills, and weight loss. He was diagnosed with HIV/AIDS, CD4 count 4cells/mm3, with Cryptococcal meningitis and Campylobacter enteritis. Patient was induced with fluconazole and flucytosine, and was discharged home on fluconazole with resolution of his diarrhea. The patient’s diarrhea returned 1 week later, occurring up to 5 times a day, shortly after eating, and associated with nighttime awakening. On exam, the patient was afebrile with stable vital signs, having a soft non-tender abdomen. Laboratory work-up revealed pancytopenia. Stool studies were all negative. The patient underwent an EGD and colonoscopy to diagnose a cause for symptoms. EGD revealed multiple esophageal ulcerations consistent with CMV infection, a large hiatal hernia, and multiple diminutive white lesions in the second part of the duodenum that were biopsied with positive Mucicarmine staining, confirming the presence of Cryptococcus. Colonoscopy revealed multiple friable erythematous lesions throughout the left colon that were biopsied and consistent with CMV infection. The patient was continued on fluconazole for treatment of his cryptococcal infection and discharged home with improvement in his symptoms. He followed up in HIV clinic and started ART. Gastroduodenal Cryptococcus is a rare disease and an uncommon presentation for an AIDS defining illness. This diagnosis may be difficult due to a variety of presenting findings, ranging from asymptomatic to abdominal pain with diarrhea to GI bleeding, or an acute abdomen related to an ulcer. This case highlights the vigilance necessary to recognize rare opportunistic infections in HIV patients, as well as the importance of timely endoscopic investigation for the immunocompromised patient with gastrointestinal symptoms.

2507 Unusual Case of Abdominal Pain: Hidden GIST Within the Desmoid Parin Shah, DO1, Ayushi Chauhan, MBBS2, Nayla Ahmed, MBBS2. 1University of Connecticut Health Center, Farmington, CT; 2University of Connecticut Health Center, Hartford, CT Both GI stromal tumor (GIST) and desmoid tumors (DT) are associated with ostensibly unrelated familial tumor syndromes. However, numerous reports have recently surfaced describing concomitant, non-random occurrence of these neoplasms. Here we present an incidental diagnosis of GIST within locally aggressive mesenteric fibromatosis (MF). A 53-year-old female with a history of autoimmune

[2505C] .

transit, gut dysmotility, malabsorption, and potentially intestinal obstruction, fistulization, and perforation. We present a case of chronic radiation gastroenteropathy diagnosed by small bowel capsule endoscopy. A 56 year old man presented to the gastroenterology clinic for evaluation of chronic refractory iron-deficiency anemia (IDA). He had a history of Hodgkin lymphoma 30 years prior treated at that time with chemoradiation therapy with which he achieved remission; he then suffered from complications of radiation including mild pulmonary fibrosis, cardiomyopathy, coronary artery disease, and myelopathy resulting in paraplegia. As part of the workup for IDA, prior esophagogastroduodenoscopy (EGD) and colonoscopy had been remarkable for diffuse duodenal lymphangiectasias and a benign traversable transverse colon stricture attributed to radiation therapy. At our institution repeat EGD showed a bleeding gastric Dieulafoy lesion treated with bipolar electrocoagulation leading to hemostasis, and repeat colonoscopy was unremarkable except for the colonic stricture. Postprandial bloating, distention, and flatulence responded to a short course of ciprofloxacin, supporting a presumptive diagnosis of small intestinal bacterial overgrowth; recurrent symptoms were treated with a second course of ciprofloxacin and subsequently amoxicillin/clavulanic acid. Given persistent IDA he underwent small bowel capsule endoscopy, which showed mucosal atrophy interspersed with mucosal congestion and erythema as well as diffuse lymphangiectasias throughout the small bowel; these findings were consistent with chronic


[2507A] B-cretinin positive cells.


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[2507B] neoplastic spindle cells show an infiltrative pattern through the muscularis propria of the small intestine.

hepatitis currently on azathioprine, s/p cholecystectomy presented to the hospital for generalized abdominal pain. She denied any changes in her bowel habits, fever, chills, or B-symptoms. Laboratory evaluation ruled out an exacerbation of autoimmune hepatitis with below baseline levels of liver enzymes and IgG. A CT of the abdomen and pelvis with contrast was obtained which showed three discrete masses on the left side of the small bowel mesentery, measuring up to 3.8cm, concerning for mesenteric nodal disease. Despite the absence of B-symptoms, there was high suspicion for lymphoma in the setting of immunosuppressive therapy. She underwent diagnostic laparoscopy with biopsies of these masses. Pathology reported tumor immunohistochemical profile and morphology consistent with mesenteric fibromatosis (MF), Beta-catenin positive; and negative for CD34, S100, CD117, DOG-1 and KIT. Tumor board was involved in follow-up care for this patient, and she was readmitted for a complete resection of the tumors given a fast growth rate (18 months prior CT scan did not show these masses) and tumor location. The complete pathology report showed evidence of low-grade GIST found in the small bowel wall, positive for KIT and DOG-1. She was referred to oncology for further management. Both GIST and DT are rare mesenchymal tumors with distinct immunohistochemical characteristics. Mutations of KIT and PDGFRA play a key role in oncogenesis of GIST, while mutations in CTNNB1 gene have shown causation in DTs. Although there are no data to support a genetic predilection syndrome, a common germline mutation might underlie predisposition for these tumors. It can be postulated that circulating stem cell factor (KIT ligand) or platelet-derived growth factor in patients with GIST could stimulate the growth of DT. Recent studies in mast cell leukemias have described with nuclear accumulation of β -catenin increased by a gain-of-function mutation of KIT. Further research is needed to bring these hypotheses from the realm of speculations to the world of evidence-based medicine.

[2508A] CT contrast abdomen showing acute aortomesenteric angle at 9 degrees.

2508 Rare Case of Superior Mesenteric Artery Syndrome: A Story of Missed Diagnosis Aakanksha Sharma, MD1, Abdul Wahab, MBBS2, Amr Salama, MD3, Michael Disalle, MD1. 1Unity Health System, Rochester, NY; 2Unity Hospital/ Rochester Regional Health, Rochester, NY; 3Unity Hospital, Rochester, NY Abdominal pain continues to pose the diagnostic challenges for the physicians. Low threshold of suspicion for uncommon etiologies is important to make a timely diagnosis and treatment .We present a rare case of SMA syndrome in an elderly male presenting with abdominal pain. 65 years old male with no PMH, presented with abdominal pain, nausea and vomiting for 7 days. He denied weight loss. On physical exam, he was thin with BMI of 18.9. Lab work-up revealed BUN 71 mg/dl, Cr 3.7mg/dl and Na 133 mmol/L. He was treated with intravenous fluids for presumed diagnosis of gastroenteritis. After 4 days of hospitalization, he continued to have nausea and vomiting. Ultrasound of abdomen showed fluid filled dilated stomach, followed by CT contrast abdomen revealing dilated stomach and duodenum up to 3rd part with abrupt narrowing as it crossed the midline. Aortomesenteric angle (AMA) of approximately 9° was noted, suggesting the diagnosis of Superior mesenric artery syndrome. Nasogastric tube was placed for decompression. Upper GI endoscopy ruled out other mechanical causes of obstruction.On day 7 NGT was removed and he was discharged home to continue mechanical soft diet to gain weight. Unfortunately, 3 days later he was readmitted with similar complaints. This time he had gastrojejunostomy tube placement to try tube feeding for at least 3 months to gain weight before considering surgical treatment options. SMAS is a rare cause of abdominal pain. True incidence of SMAS is unknown. SMA originates from aorta at level of L1-2 and extends anteroinferiorly into mesentery at an angle with aorta known as aortomesenteric angle (AMA) which normally varies from 28°-65. SMAS is characterized by acute AMA , compressing 3rd part of duodenum between aorta and SMA. Several factors are listed which have an effect on AMA. The most common is significant weight loss, most commonly seen in severe debilitating illnesses, such as malignancy, AIDS, trauma and burns. Congenital short ligament of Treitz has also been reported as one of the causes. Symptoms usually include early satiety, nausea, vomiting and epigastric pain. Contrast CT scan is useful in the diagnosis . Upper GI endoscopy may be necessary to exclude mechanical causes of duodenal obstruction. Initially treatment is conservative with fluid and electrolyte


[2508B] Upper GI endoscopy revealed extrinsic duodenal compression without intra luminal pathology.


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resuscitation, gastric decompression and nutritional support to gain weight. If conservative therapy fails surgical treatment is indicated to bypass the obstruction.

2509 Afferent Loop Syndrome Malav P. Parikh, MD1, Niyati M. Gupta, MBBS1, Harsh A. Rawal, MD2, Sreelakshmi Panginikkod, MD3, Madhusudhan R. Sanaka, MD1. 1Cleveland Clinic Foundation, Cleveland, OH; 2University of Illinois at Urbana-Champaign, Champaign, IL; 3Presence Saint Francis Hospital, Evanston, IL Introduction: Distal small bowel obstruction following ileal pouch anal anastomosis (IPAA) can occur secondary to acute angulation or prolapse of the afferent limb at the pouch inlet, namely, afferent loop syndrome (ALS). It is characterized by clinical presentation of partial small bowel obstruction, which can be diagnosed by careful pouchoscopy and/or abdominal imaging. Endoscopic or surgical intervention is often needed and surgical therapy appears to be more definitive. Case Presentation: A 33-year-old female with original diagnosis of ulcerative colitis (UC) underwent a 3 stage total proctocolectomy (TPC) and IPAA in 2014 for medically refractory UC. She had chronic complaints of abdominal bloating, intermittent nausea, vomiting and diarrhea starting one year after closure of stoma. She was treated with nasogastric tube placement and antibiotics intermittently without significant relief of symptoms. In the current encounter, patient presented to the hospital with nausea, vomiting, abdominal pain and cramping. A pouchoscopy was performed, which showed a normal pouch body and cuff. However there was a sharp luminal angulation 20 cm above pouch inlet, where attempted passage of flexible sigmoidscope failed, for which an afferent loop syndrome (ALS) was considered. Defecography showed a 180-degree kink in the afferent limb of the pouch approximately 18 cm above the anal verge correlating with the findings of pouchoscopy. Exploratory laparotomy was performed with extensive lysis of adhesions and plication of afferent loop of the small intestine to the anterior abdominal wall to prevent rotation into the pelvis. Patient experienced a significant improvement in her symptoms after the surgical correction of ALS. Discussion: Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical procedure of choice for patients with UC who require surgery. Small bowel obstruction is one of the common complications after IPAA. When a patient presents with recurrent intermittent obstructive symptoms after IPAA, then we recommend considering ALS and conducting both endoscopy and abdominal imaging for the diagnosis. Bypass of the obstructed segment from the distal ileum to the pouch has been attempted. Due to risk of recurrent afferent limb angulation, pouchopexy may also be considered.

2510

overt abnormality. Given the clinical scenario, CT angiography was expediently pursued and it revealed dissection within the celiac artery (Figure 1), which extended into the very proximal hepatic artery and the proximal 3 cm of the splenic artery. The true lumen was severely narrowed throughout this segment. Distally, the common hepatic artery and splenic artery were both widely patent. The superior and inferior mesenteric arteries were normal in appearance. Conservative measures with expectant management and vigorous control of systemic blood pressure were advocated. Systemic hypertension was controlled with ramipril, amlodipine and metoprolol. Dabigatran and low-dose aspirin were also prescribed. The patient’s persisted over several weeks, albeit to a lesser extent. Repeat CT angiogram 8 weeks later showed no improvement in the radiographic appearance. Given this and his persistent and ongoing symptoms, decision was made to intervene surgically, and the patient underwent revascularization at a tertiary care center. Acute, isolated celiac artery dissection can cause severe postprandial upper abdominal pain. In our case, surgical intervention was required given lack of clinical and radiographic improvement despite maximal medical therapy.

2511 Lisinopril-Induced Small Bowel Angioedema Joseph C. Yarze, MD1, Daniel Sablich, MD2. 1Gastroenterology Associates of Northern New York, Glens Falls, NY; 2Adirondack Radiology Associates, Glens Falls, NY A 49 yo female attorney presented with an 18-hour history of acute mid abdominal pain, vomiting and voluminous watery diarrhea. Her past medical history was significant for anxiety, depression and recently diagnosed systemic hypertension. Her symptoms began acutely and prior to this, there were no chronic gastrointestinal complaints. Due to rapid escalation of her symptomatology, she presented to the emergency care department. Her medications included alprazolam, fluoxetine and lisinopril. Bloodwork was significant for a peripheral WBC 23.0 (N=4.0-10.5) with a normal differential. CT scan of the abdomen showed loops of jejunum with mural thickening and submucosal edema (see Figure 1). The patient was admitted to the hospital with a working diagnosis of infectious gastroenteritis and was afforded IV hydration, analgesia and entiemetic therapy. GI consultation was requested the following morning. By this time, the patient’s symptoms had nearly resolved and she felt well. Given the CT radiographic findings and clinical presentation, further inquiry was made in relation to her lisinopril therapy. The patient then mentioned that her hypertension was diagnosed earlier that week and lisinopril was prescribed at that time. The patient took only one dose of the medication, 6 hours prior to the onset of her acute GI symptoms. On this basis, it was presumed that the patient had ACE-inhibitor-induced small bowel angioedema. Her symptoms resolved completely and she remained asymptomatic. It was recommended she avoid angiotensin converting enzyme (ACE) inhibitors and angiotension receptor blockers (ARB) in the future. Isolated ACE-inhibitor-induced gastrointestinal angioedema is an unusual but potentially serious problem. Rapid diagnosis is imperative to not only improve patient outcome, but also to avoid unnecessary medical intervention and surgery.

Isolated Celiac Artery Dissection as a Cause of Acute Post-Prandial Abdominal Pain Joseph C. Yarze, MD1, Daniel Sablich, MD2. 1Gastroenterology Associates of Northern New York, Glens Falls, NY; 2Adirondack Radiology Associates, Glens Falls, NY A 49 yo male with a history of systemic hypertension and prior sigmoid resection (for perorated diverticulitis) presented with a 1-week history of acute, severe postprandial supraumbilical pain. The pain progressed and was occurring after each meal and with attempts to jog prolonged distances. His only medication was ramipril and he did not smoke tobacco. There were no other symptoms. Physical examination was unremarkable aside for a blood pressure of 170/110 mm Hg. CT scan of the abdomen with IV contrast revealed an expanded configuration of the celiac axis with “blurred margins.” Urgent vascular surgical consultation was requested and ultrasound interrogation of the celiac artery revealed no

[2511] CT scan of the abdomen demonstrating loops of jejunum with mural thickening and submucosal edema.

2512 A Rare Case of Strongyloides stercoralis Hyperinfection Syndrome in an Immunocompetent Host Sundeep Kumar, MD1, Natalia E. Castillo Almeida, MD1, Arun Rajasekaran, MD1, Lakhinder Bhatia, MD2, Maria Wallis-Crespo, MD2. 1University of Central Florida College of Medicine, Orlando, FL; 2Osceola Regional Medical Center, Kissimmee, FL

[2510] CT angiographic axial image demonstrating focal dissection of the celiac artery.


Strongyloides stercoralis is an intestinal nematode endemic in humid and tropical regions. In the US, most cases occur in immigrants and military veterans who have lived in endemic regions.


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[2512] .

Immunocompetent patients usually develop an asymptomatic, chronic or mildly symptomatic infection. In immunocompromised, Strongyloides stercoralis may lead to an overwhelming infestation known as a Strongyloides hyperinfection syndrome (SHS). An 88-year-old Hispanic man presented with a three-day history of non-productive cough, nausea, vomiting, abdominal pain, and melena. Medical history was significant for atrial fibrillation (on warfarin); and transitional cell carcinoma of the kidney, status-post right nephrectomy, in remission. On initial evaluation, vital signs and abdominal examination were normal. His Initial laboratory workup was significant for an INR of 4.7 and a hemoglobin (Hb) of 12 gm/dL. Soon after admission, he had an isolated episode of hematemesis with a decline of Hb (6.5gm/dL). Prompt endoscopy revealed antral ulceration with no visible vessel. Biopsy sample obtained from third part of duodenum revealed Strongyloides stercoralis infection in the glandular epithelium. Labs were also significant for eosinophilia and elevated IgE levels. However, stool analysis (ova and parasite) were negative. Hospital course was further complicated by respiratory failure and cardiac arrest. Subsequent bronchoscopy with a bronchoscopic alveolar lavage revealed fragments suggestive of a parasite, though a definitive pathogen could not be identified. Ivermectin was initiated, which resulted in a significant improvement of clinical symptoms. Strongyloidiasis is often underdiagnosed due to nonspecific symptoms. An alteration of the immune status can increase the number of parasites and lead to SHS, dissemination, and death, if unrecognized. As illustrated in our case, SHS patients with dissemination may present with severe gastrointestinal complaints such as bleeding or ulcers, and/or significant respiratory complaints, that lead to the diagnosis of strongyloidiasis via endoscopy or bronchoscopy. SHS is usually associated with immunosuppression. However, SHS should be suspected in immunocompetent patients who hail from endemic areas, and who have persistent gastrointestinal and/or pulmonary manifestations. Rapid diagnosis and treatment can prevent high case-fatality rates.

2513 An Unusual Cause of Small Bowel Intussusception: A Submucosal Lymphangiectasia Hani N. El-Halawany, MD1, Yousaf Zafar, MD2, Tarek Tamimi, MD3. 1University of Missouri Kansas City School of Medicine, Shawnee, KS; 2University of Missouri Kansas City, Kansas City, MO; 3University of Missouri Kansas City School of Medicine, Kansas City, MO Lymphangiectasia is characterized by focal or diffuse dilation of the mucosal, submucosal and/or subserosal lymphatics. The most common sites of lymphangiectasia are head, neck and axilla. Involvement of intra-abdominal organs is quite rare, constituting 1.6% of all cases. The ectatic lymphatics in the small bowel may lead to loss of proteins and lymphocytes into the gut or peritoneal cavity causing protein losing enteropathy and iron deficiency anemia with blood loss. It is extremely rare for lymphangiectasia to present with bowel intussusception or obstruction. A 39-year-old female with history of anxiety was admitted with severe abdominal pain that started two days prior to her admission. A computed tomography (CT) scan was done and showed small bowel intussusception in the left hemiabdomen. The patient had no clinical signs of bowel obstruction and was managed conservatively. After clinical improvement, she underwent a small bowel capsule endoscopy (SBCE) as an outpatient to evaluate for any potential lead point for the intussusception. The SBCE showed a subepithelial lesion in the small bowel with a round, smooth, and shiny mucosal surface. The size of the lesion was estimated to be small to moderate, causing slight narrowing of the lumen; and the location was estimated to be in the jejunum. The patient underwent an elective exploratory laparotomy; however no mass was seen in the small bowel on gross inspection and no mass could be palpated


[2513] Small Bowel Lymphangiectasia on Capsule Endoscopy.

by the surgeons. Therefore, an intraoperative enteroscopy was performed through an enterotomy in the mid-jejunum. The subepithelial lesion was identified endoscopically in the proximal jejunum. The patient underwent resection of this small segment of small bowel containing the mass. On gross pathological exam, a yellow-tanned polypoidal protrusion measuring 1.3 X 1.0 cm was identified. On microscopic exam, a diagnosis of focal submucosal lymphangiectasia was made. The patient had an uneventful post-operative course and had no recurrence of the small bowel intussusception for over 6-month follow-up period. We present an extremely rare case of small bowel intussusception in an adult patient due to a focal lymphangiectasia. Intussusception in adults should be investigated


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thoroughly to evaluate for a lead point which could be a small bowel tumor (benign or malignant) or a metastatic lesion. The use of the small bowel capsule endoscopy proved helpful in diagnosing the etiology of intussusception in our case.

2514 Yersinia enterocolitica: An Unusual Cause of Partial Small Bowel Obstruction Mayur Parepally, MD, Michael Sprang, MD. Loyola University Medical Center, Maywood, IL Introduction: Yersinia enterocolitica, a gram-negative coccobacillus, typically causes a self-limited diarrheal illness, but can also lead to terminal ileitis, pseudo-appendicitis, sepsis or reactive arthritis. We describe a rare case of partial small bowel obstruction due to Yersinia enteritis. Case Description: A 70-year-old male with a history of hypertension and prior cholecystectomy was admitted to an outside institution with abdominal pain and distension, vomiting, and early satiety. He was able to pass flatus and have bowel movements. He had no preceding gastrointestinal complaints and denied recent foodborne illnesses or sick contacts. He did travel to the Philippines four months prior to admission. A CT abdomen demonstrated significant small bowel distension concerning for a distal small bowel obstruction. The patient was urgently taken for an exploratory laparotomy, which demonstrated a dilated area of small bowel and a focal thickened segment with significant edema and erythema. There was no obstructing lesion or stricture noted and the distal terminal ileum appeared grossly normal. No further surgical intervention was performed. Standard stool cultures and ova and parasite exam were negative. The patient’s symptoms improved and he was discharged. The patient was readmitted with symptoms of fever, tachycardia, abdominal pain and distension and was started on broad-spectrum antibiotics. A repeat CT abdomen remonstrated small bowel dilation concerning for bowel obstruction. His inflammatory markers were significantly elevated. Quantiferon-TB test was indeterminate and a multi-pathogen stool PCR assay (BioFire Multiplex PCR) was positive for Y. enterocolitica. The patient was treated with a five-day course of IV ceftriaxone and had significant improvement in his abdominal distension and inflammatory markers. Discussion: Partial small bowel obstruction can be an unusual manifestation of Y. enterocolitica. Although this presentation is rare, it should be considered in some cases of intestinal obstruction or ileitis, which can be misdiagnosed for other etiologies. When there is a clinical suspicion for Yersinia, one should request specific cultures as standard cultures do not screen for the organism. Stool multiplex PCR assays can also be helpful in diagnosis. Early recognition of the infection and initiation of treatment may prevent further complications and the need for surgery.

2515

[2516] Duodenal Foreign Body CT.

denal bulb that was causing a complete obstruction. Removal was accomplished with the combination of a rat-toothed forceps, and a Roth net over an overtube. One non-bleeding linear duodenal ulcer with pigmented material was found in the duodenal bulb. His condition improved and he was discharged back to his nursing home. Most ingested foreign bodies pass readily, but some may be impacted behind a physiologic or pathologic luminal narrowing. Failure to locate an object on radiographic examination does not preclude its presence. In patients with persistent esophageal symptoms, an endoscopic evaluation should be performed. Conservative management is appropriate for the majority of patients since most objects will pass uneventfully. Patients with negative radiographs who are asymptomatic can be followed expectantly. This case is unique as our differential diagnosis was a duodenal mass or perforation when in fact the patient had ingested his sandwich without removing the plastic bag.

Long-Standing Diarrhea Associated With Olmesartan-Induced Enteropathy Deep Patel, DO1, Jay Anderson, DO1, Viral Patel, MD2. 1OhioHealth Riverside Methodist Hospital, Columbus, OH; 2Ohio Gastroenterology Group, Inc., Columbus, OH Drug induced enteropathy is also reported, usually in association with azathioprine, mycophenolate mofetil, methotrexate and colchicine. We present a rare case of olmesartan induced diarrhea. An 81-year-old Indian man with hypertension, type 2 diabetes mellitus and coronary artery disease presented with persistent watery diarrhea and progressive weight loss. The diarrhea started intermittently one year ago with acute worsening in the past month. He reported an associated 16 pound weight loss. Previous investigations at outside facility (approximately one year ago) included a normal colonoscopy with normal random biopsies, and extensive negative evaluation for infectious causes including parasites (Entamoeba, Giardia) and bacterial organisms, (Shigella, Salmonella, Campylobacter, Versinia, Escherichia coli, and Cryptococcus, Clostridium difficle). On admission, he was hemodynamically stable with no abdominal tenderness. Complete blood count was unremarkable. Comprehensive metabolic panel revealed creatinine of 6.35 and potassium of 2.9. Our endoscopic work up was revealing of gastric mucosal atrophy and diffuse mucosal flattening of the duodenum. Duodenal biopsy showed villous blunting, crypt hyperplasia, subepithelial collagen deposition, and focal neutrophils within surface epithelium suggestive of collagenous sprue. Colonic biopsy demonstrated thickened subepithelial collagen layer with collagen deposition in the superficial lamina propria. The patient denied recent travel and serological work up was not indicative of celiac disease. However, further medication reconciliation revealed that he was taking olmesartan 40mg daily for hypertension for at least one year. Thus, olmesartan was discontinued and budesonide 9mg daily was initiated. On follow-up, he reported complete resolution of diarrhea within the first week of the medication change. Olmesartan is a commonly used angiotensin II receptor blocker for hypertensive management. Olmesartan associated enteropathy most often affects individuals in their seventh and eight decades. Symptoms include chronic non-bloody diarrhea, weight loss, fatigue, nausea, vomiting, abdominal pain, and bloating. They tend to occur months to years after starting olmesartan. The delayed clinical presentation of olmesartan enteropathy may delay diagnosis. Symptoms typically resolve within one week of discontinuation of olmesartan.

2517 A Rare and Fatal Case of Dobhoff Tube Placement-Associated Small Bowel Perforation Presenting With Acute Leukopenia Abbas Mandviwala, MD1, Emad Mansoor, MD2, Greg Nizialek, MD1, Ismail Dreshaj, MD1. 1University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH; 2University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH Enteral feeding with Dobhoff tubes is a common mode of nutrition in acute or chronically ill patients. Common adverse events associated with Dobhoff placement include epistaxis and sore throat. More

2516 Foreign Body in the Duodenum Masquerading as an Obstructing Mass Marion Gonzalez, MD, Carl Atallah, DO, Jose Henao Correa, MD, Ami Modi, MS. Advocate Illinois Masonic Medical Center, Chicago, IL Accidental foreign body ingestion occurs primarily in children, patients with psychiatric illness, and in edentulous or mentally impaired adults. The clinical presentation maybe a challenge in these patients with a broad differential diagnosis. Not having a clear history about the foreign body ingested makes this a diagnostic and therapeutic challenge for the endoscopist. Our case is a 75 year old male with a PMHx of hypertension, dementia, asthma, and anxiety who presented from the nursing home to the ER with coffee ground emesis. Nasogastric tube returned 350ml of coffee ground colored material. History limited due to altered mental status and underlying dementia. On physical examination, bowel sounds were hypoactive. Abdomen soft but moderately distended. Labs revealed a mild anemia. CT of abdomen and pelvis revealed duodenitis with a possible obstructing mass in the duodenal bulb, contained duodenal perforation, and marked distention of stomach and proximal duodenum. Orders included NPO, NGT to LIS and Zosyn with surgery on standby. Repeat CT scan 72 hrs later revealed two adjacent enteric contrast and gas filled outpouchings along the proximal duodenum which were felt to represent duodenal diverticula rather than a contained perforation. Given his downtrending Hgb and possible duodenal mass, EGD was performed. To our surprise, a large plastic sandwich bag was found in the duo-


[2517A] Enteric tip overlying the gastric pylorus. Arrow showing “Rigler’s Sign”, suggesting air on both sides of bowel concerning for extraluminal air. VOLUME 112 | SUPPLEMENT 1

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[2517B] Large arrow showing intraperitoneal air in the anterior extraluminal space. Small arrow shows enteric tube possibly in extraluminal space.

serious complications such as esophageal perforation and pneumothorax have been reported. We report a case of small bowel perforation after Dobhoff placement with acute leukopenia as an initial laboratory manifestation. A 75-year-old female presented to the hospital with a 3-year history of worsening hoarseness and shortness of breath. Bedside laryngoscopy demonstrated a large laryngeal mass. Biopsy results were positive for squamous cell carcinoma. Bronchoscopy and esophagoscopy (to pre-pyloric region) were unremarkable. Due to severe protein malnutrition, a Dobhoff was placed for pre-operative optimization for laryngectomy. Post-placement KUB showed tube overlying the body of stomach. 12 hours post Dobhoff insertion, vital signs were notable for hypotension to 72/48 mmHg. Physical exam was notable for diminished bowel sounds. Laboratory results showed an acute leukopenia of 1100 mcL, and lactate of 3.6 mmol/L. KUB showed advancement of the Dobhoff tube, with visualization of bowel wall lumen suggesting pneumoperitoneum. The patient remained hypotensive despite fluid resuscitation and was transferred to the ICU for pressor support. A CT scan of the abdomen revealed intraperitoneal and retroperitoneal air, with the enteric tube noted to be extraluminal with suspected perforation of the second part of the duodenum. Surgery was consulted, however due to the patient progressing to multi-system organ failure, and high surgical mortality risk, the patient was made DNR/Comfort Care and expired 6 hours later. Dobhoff placement is a common procedure performed across the country. Although a relatively safe procedure, it can have complications such as bowel perforation. One of the initial presenting clues may be acute leukopenia. Acute leukopenia has also been reported in laparoscopic bowel perforations during urological surgery. The mechanism of acute leukopenia in bowel perforation could be due to peritonitis leading to sepsis. Sepsis has been shown to cause acute bone marrow suppression leading to leukopenia. Another explanation is the marginalization of leukocytes in conditions of decreased blood flow such as hypotension. Leukocytes are shifted outward by RBCs in laminar flow, and in slow flow the leukocytes will adhere to the endothelial surface in larger number.

2518 Not Just Globetrotters: Zoonotic Transmission of Ascaris Suum in Vermont Neil Volk, MD, Lauren Tormey, MD. Dartmouth-Hitchcock Medical Center, Lebanon, NH A 63-year-old female with a past medical history of a remote cholecystectomy, chronic epigastric pain on opioids, episodic loose stools and a small bowel obstruction (SBO) with lysis of adhesions two months prior presented to the emergency room with 8 weeks of profuse watery diarrhea, abdominal pain and refractory nausea and vomiting, similar to her recent admission for SBO. Her diarrhea developed almost immediately after her recent hospital discharge. As an outpatient she underwent an unremarkable colonoscopy (without TI intubation) and upper endoscopy. Random colonic and duodenal biopsies were normal. On admission her exam was unremarkable aside from diffuse mild abdominal tenderness. Initial workup included a CBC, CMP, lipase, fecal leukocytes and stool culture; the only abnormality was positive fecal leukocytes. Initial impression was of a partial SBO and a CT of her abdomen was ordered. The CT demonstrated a diffuse small bowel ileus and dilation of the duodenum up to the level of the SMA. The GI service was consulted and recommended a small bowel follow through (SBFT) to evaluate for SMA syndrome. Her SBFT identified a cutoff at the location of the SMA with associated proximal dilation of the duodenum. In the ileum, multiple worms were seen, typical of ascaris. When her social history was revisited, she reported obtaining pig manure from a local farmer and using it extensively in her garden. She was likely exposed to ascaris suum, a strain of ascaris common in pigs. Treatment with albendazole resulted in significant improvements in abdominal pain and diarrhea; she also passed multiple 3-4 inch long worms in her stool. Repeat stool studies showed resolution of fecal leukocytes and negative O&P. Ascaris, rare in the United States, is traditionally considered a soil-transmitted helminth; however, emerging evidence suggests a role for zoonotic transmission. The Centers for Disease Control have reported Ascaris infections on small farms in Maine that appear to have been transmitted via pigs. Ascaris can cause intestinal obstruction, biliary obstruction, and pancreatic duct obstruction. It is likely this patient’s presentation of ileus demonstrated both on CT and SBFT was secondary to ascaris.


[2518] Small Bowel Follow Through.

2519 Suspected Gut Fermentation Syndrome (Auto-Brewery Syndrome) Avantika Mishra, MD1, Darren N. Seril, MD, PhD2. 1Robert Wood Johnson Medical School, Rutgers University, Jersey City, NJ; 2Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ The patient is a 45 year-old male with diabetes mellitus (DM) presenting for evaluation of elevated blood alcohol content (BAC) in the absence of exogenous alcohol intake. A year prior to presentation, the patient was involved in a traffic stop and found to have an elevated BAC. However, he reported alcohol abstinence given uncontrolled DM and weight gain; thus, the driving under the influence charge was legally contended. Home Breathalyzer testing revealed repeated BAC of 0.2% (legal intoxication is 0.8% or more). The patient also had witnessed stumbling and confusion, with abdominal distention, lower extremity edema, and 60 lb weight gain. He was admitted to the hospital for further workup for elevated BAC. All of the patient’s personal possessions were checked for alcohol, drugs, and medications, and a 1:1 sitter continuously monitored him. Physical exam revealed an obese male with Cushingoid features, distended abdomen, 1+ pedal edema, and slurred speech. His admission serum ethyl alcohol (ETOH) level was 64.6 mg/dL. He was administered a high carbohydrate (CHO) meal while inpatient with subsequent ETOH levels (measured every 4 hours) of < 10, 42, then < 10 mg/dL. Stool studies were negative for bacterial or yeast infection, including Saccharomyces. Urine toxicology was negative. Hemoglobin A1c was 7.9, with negative Β -hydroxybutyrate. Ethyl glucuronide and ethyl sulfate levels were each >10,000 ng/mL (reference range: < 500 and < 100, respectively). Following discharge, empiric treatment with fluconazole did not impact symptoms or home BAC; however, patient had improved symptoms and reduced BAC with adherence to a low CHO diet and daily probiotic. Gut Fermentation syndrome (GFS), or Auto-Brewery Syndrome, is a rare syndrome of intoxication without ingestion of alcohol. One hypothesis is that GFS results from yeast overgrowth in the gut resulting in fermentation of luminal CHO with formation of ETOH. DM may be a risk factor for yeast overgrowth and GFS. Other cases have suggested specific organisms (ie. Candida species or Saccharomyces) as culprits, although yeast overgrowth in the gut was not noted in our patient. Our diagnostic approach was modeled on a prior case study with high CHO challenge and frequent BAC levels. With CHO loading, this patient had undetectable ETOH followed by a spontaneous increase in serum alcohol and alcohol metabolite levels consistent with endogenous alcohol formation. While the etiology of GFS has not been entirely elucidated, it should be considered when encountering a patient with features of alcohol intoxication in the absence of alcohol consumption.

2520 Inflammatory Fibroid Polyp in the Duodenum Sadat Iqbal, MD1, Abu Hurairah, MD1, Shahzad Iqbal, MD2. 1State University of New York Downstate Medical Center, Brooklyn, NY; 2Brookdale University Hospital, New York, NY Patient found to have inflammatory duodenal polyp on EGD. 6cm peduculated submucosal polyp was removed. Patient remains asymptomatic and is awaiting follow-up. Pathology showed inflammatory fibroid polyp (IFP). 52 year old male whose only complaint was continuous dyspepsia found to have a large submucosal peduculated duodenal bulb polyp s/p biopsy and FNA with EUS. Concern initially was for carcinoid vs GIST; Polyp found to be IFP. Given non-malignant pathology, polyp was removed endoscopically. Patient was told to follow up in clinic. Pathology showed inflammatory fibroid polyp of duodenum with extensive eosinophilic infiltration. Immunohistochemistry showed vimentin and CD34 positivity which is consistent with IFP. IFP is very rare especially in the duodenum; per literature review at least 8 cases reported thus far in the duodenum (fewer than 1% occur in the duodenum).1 Usually occurs in males between the age of 50 and 70 (As in our patient’s case).1 Our patient’s only presenting complaint was dyspepsia which has been reported as a symptom in previous cases, but patients can also present with epigastric pain, melena and/or elevated liver function tests.1 As mentioned before, the lesion itself is benign but needs to be removed quickly given rapid growth.1 EUS has shown promise in being able to diagnose IFP and differentiate between GIST and lipomas given it usually reaches the


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[2520A] .

[2520C] .

[2520B] .

second and third layer of the gastric wall while GIST is transmural and lipomas have well defined margins, but no reported cases to date of diagnosis with just EUS alone without pathology.1 Polypectomy is the ideal treatment but if polyp is sessile and arises from submucosa there is higher risk for perforation or incomplete resection in which case pancreatoduodenectomy may need to be considered. In our patient’s case, though the polyp was submucosal it was also peduculated allowing for endoscopic removal without any complications post procedure. Given the paucity of cases more research is needed as to the risk for recurrence and need for surveillance. 1. Wysocki AP, Taylor G, Windsor JA. Inflammatory Fibroid Polyps of the Duodenum: A Review of the Literature. Digestive Surgery. 2007;24(3):162-168.

2521 Lipohyperplasia of the Terminal Ileum Causing Stricturing Disease and Obstruction in a Patient With Crohn’s Disease Jose Antonio N. Almario, MD, MHS1, Harris Yfantis, MD2, Raymond Cross, MD, MS2, Nathalie Urrunaga, MD, MS2. 1University of Maryland Baltimore, Baltimore, MD; 2University of Maryland School of Medicine, Baltimore, MD A 47-year-old male with a 28 year history of perforating Crohn’s disease (CD) with 2 prior small bowel resections, presents with right lower quadrant (RLQ) pain, post-prandial nausea and vomiting, and constipation. He presented to an outside hospital 15 years after the 2nd resection with the above symptoms; an abdominal CT showed a dilated jejunum and ileum. He was treated with bowel


[2521A] Massive submucosal lipohyperplasia.

rest, nasogastric tube placement, and a prednisone taper. On presentation to our clinic, he reported improved but persistent RLQ pain. A colonoscopy and barium enema were unremarkable. He was started on mercaptopurine and budesonide, but the symptoms persisted. A MR enterography (MRE) showed a dilated terminal ileum (TI) to 4 cm, with a stricture 3 cm in length and 0.6 cm in diameter immediately proximal to the ileocecal (IC) valve. He underwent open ileocecectomy and 32 cm of small and large bowel, including the IC valve, was resected. Pathology showed no evidence of CD; massive submucosal lipohyperplasia (LH) and dilated lymphatic vessels in the TI was noted. LH is characterized by hypertrophy and infiltration of mature adipose tissue in the intestinal submucosa without the presence of a capsule; LH is a pathologically distinct entity from the encapsulated and pedunculated lipoma. LH manifests in middle age, with a predilection for the TI. Abdominal pain, intermittent constipation, diarrhea, and flatulence develop when the excess adipose tissue protrudes into the intestinal lumen causing recurring intussusception and bowel obstruction. Rarely LH can become ulcerated, presenting with overt bleeding. The etiology of intestinal LH is not entirely understood, but has been hypothesized to be a manifestation of dysregulated local inflammation in the TI. We present the first case of LH in a patient with CD. The presentation of LH in this case was unusual as the LH manifested as a stricture rather than a mass causing obstruction. LH, as well as other benign and malignant lesions of the small bowel should be considered as part of the differential diagnosis of TI stricturing disease in a patient with a known or suspected diagnosis of CD. The management is surgical resection when symptomatic.


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[2521B] Muscularis propria with surrounding marked ectasia (dilatation) of the lymphatics. associated with lipohyperplasia. [2522A] CT (axial view). Marked wall thickening and inflammatory stranding involving terminal ileum.

[2521C] MR enterography showing dilated terminal ileum and stricture proximal to ileocecal valve.

2522 Lupus Enteritis in a Young Female: A Rare Disease Requiring a Rapid Diagnosis Natasha Adlakha, MD1, Cassidy Alexandre, MD2, Amit Bhanvadia, MD3, Arun Swaminath, MD4. 1Lenox Hill Hospital, Northwell Health, New York, NY; 2Lenox Hill Hospital, New York, NY; 3Lenox Hill Hospital, Northwell Health, Brooklyn, NY; 4Northwell Lenox Hill Hospital, New York, NY Intro: Though systemic lupus erythematosus (SLE) frequently involves the gastrointestinal tract, lupus enteritis (LE) is a rare manifestation of the autoimmune disease and can have catastrophic effects if missed. We present a case of LE to raise physician awareness of an uncommon disease. Case: A 21-year-old female with newly diagnosed SLE and class V lupus nephritis presented to the ER with a 4 day history of nausea, non-bilious, non-bloody vomiting, abdominal pain and decreased appetite. Symptoms began within 1 week of initiating treatment with mycophenolate mofetil and prednisone 50mg. Physical exam was notable for mild abdominal distention with diffuse tenderness on palpation, and a faint malar rash. Labs were notable for normocytic anemia, paraprotein gap of 5mg/dL, nephrotic range proteinuria, and elevated levels of CRP 1.92mg/dL, ESR 29mm/Hr, doublestranded DNA antibody 39 IU/mL, and anticardiolipin IgM 12.8 MPL. CT abdomen with contrast demonstrated ileitis with marked wall thickening and stranding involving multiple ileal loops from the mid jejunum to terminal ileum, engorgement of mesenteric vessels, and a 0.9 x 1.2 x 1.6 inferior vena cava thrombus between the liver and right atrium. She was to follow up as an outpatient for


[2522B] CT (coronal view). Marked thickening and surrounding inflammatory stranding in the small bowel with engorgement of mesenteric vessels.

colonoscopy. For lupus nephritis and enteritis, she was treated with 3 days of pulse dosed steroids with immediate improvement of symptoms. She was discharged on day 5, with complete symptom resolution on a steroid taper. Discussion: The British Isles Lupus Assessment Group define LE as a vasculitis or inflammation of the small bowel with supportive image or biopsy findings. As seen in our patient, LE most often presents with abdominal pain and vomiting. Abdominal CT is the gold standard for diagnosis and images show bowel wall thickening and dilatation, engorgement of mesenteric vessels, and increased attenuation of mesenteric fat. The disease is reversible and steroid responsive. First line treatment in a severe flare involves IV corticosteroids. Cyclophosphamide and mycophenolate can be added in cases of steroid resistance, enteritis recurrence, or as in our case, if additional organs are involved. If unrecognized, LE may result in perforation and bowel necrosis. Knowledge of this rare complication of SLE is paramount to the diagnosis,


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treatment, and prevention of potentially fatal complications. As depicted in our case, rapid detection and treatment results decreased hospital length of stay, morbidity, and mortality.

2523 Lipase Elevation and Lymphocytosis in Celiac Disease: Is It Lymphocytic Pancreatitis? Vineet Gudsoorkar, MBBS, Alberto Barroso, MD. Houston Methodist Hospital, Houston, TX Significant, persistent elevations of lipase as a manifestation of celiac disease (CD) is rare. Additionally, lymphocytic esophagitis has not been described in association with it. We report a unique case of a CD patient with persistent, significant elevation of serum lipase and lymphocytic infiltration of the entire gastrointestinal (GI) tract including the esophagus. 59 years old female with 10-years history of CD, initially presented in 2007 with nausea, vomiting and diarrhea after non-adherence with glutenfree diet (GFD). Her blood tests showed elevated lipase at 7760 U/L [Upper normal limit (UNL): 300 U/L]. Additional abnormalities included a mild (1.5 x UNL) elevation of amylase; and hypokalemia with metabolic acidosis which corrected after diarrhea stopped. Her lipase remained significantly elevated (above 3 x UNL). Notably, abdominal pain was absent. A tri-phasic abdominal CT scan followed by MRI did not reveal any pancreatic pathology but did show retroperitoneal lymphadenopathy. Esophagogastroduodenoscopy and colonoscopic biopsies showed increased intraepithelial lymphocytes (IELs) involving the esophagus, stomach, small intestine (SI) and the colon. An upper endoscopic ultrasound was also suggestive of benign lymphadenopathy. Lymphoma was excluded by immunohistochemistry of the SI biopsy and peripheral blood flow cytometry. Helicobacter pylori stains were negative. She was discharged on GFD. Her subsequent admissions related to non-adherence to GFD showed persistent lipase elevation > 3x UNL without any clinical or radiologic features of acute or chronic pancreatitis. Fecal fat test excluded chronic pancreatic insufficiency. Immunoglobulin G-4 levels were normal. Budesonide for lymphocytic colitis was started, and with better adherence to GFD, she continues to do well but her lipase remains elevated at 8-12 x UNL. Mild, non-specific (1.5-1.7 x UNL) lipase elevations have been reported in CD patients but striking elevations are rare. Additionally, while IELs in the GI and colonic mucosa have been described, lymphocytic esophagitis has not been shown to be associated with CD. Whether the elevated lipase and lymphocytic infiltration of the entire GI tract in celiac disease represent a link in pathogenesis or disease activity needs to be further elucidated. Lymphocytic pancreatitis as the cause of elevated lipase was considered but the risks of pancreatic biopsy was thought to outweigh the benefits.

2524 Primary Gastrointestinal Follicular Lymphoma: When Lymphoid Infiltrate is not Benign John Bassett, MD, Cheryl L. Gandee, DO, Norman Briones, MD, Benjamin Rodriguez, MD. Naval Hospital Jacksonville, Jacksonville, FL Background Primary gastrointestinal follicular lymphoma is a rare variant of follicular lymphoma. The most common location of involvement is the second portion of the duodenum and detection is often incidental during upper endoscopy. The clinical course is usually indolent. Dissemination is rare and transformation into high-grade lymphoma almost never occurs even without treatment. Histologically, diagnosis can be difficult, appearing as a benign lymphoid infiltrate prior to immunohistochemical staining. We present the case of a patient with a rare primary gastrointestinal follicular lymphoma. Case A 54-year-old Caucasian female previously healthy was referred for evaluation of intermittent epigastric

[2524] Follicular lymphoma duodenal bulb.


pain associated with reflux. There were no fevers, chills or weight loss. Upper endoscopy performed at an outside facility was significant for a nodular duodenal mucosa in the bulb and second portion with biopsy showing atypical lymphoid infiltrate. A repeat upper endoscopy at our facility had identical endoscopic findings with extensive duodenal biopsy showing lymphoid infiltrate. A second pathologic opinion noted lymphoid nodules with small and large cells that were CD20 positive B-cells which coexpressed Bcl-2, Bcl-6 and CD10 consistent with follicular lymphoma. Staging position emission tomography scan showed no hypermetabolic areas and bone marrow biopsy showed no lymphoma but did note an incidental chronic lymphocytic leukemia. Discussion Follicular lymphoma comprises only 1-3% of primary gastrointestinal lymphomas. When follicular lymphoma does involve the gastrointestinal tract, the duodenum is most often affected (89% of cases). Endoscopically, follicular lymphoma usually manifests as multiple white nodules < 10 mm in size. The diagnosis of follicular lymphoma requires identification of a neoplastic infiltrate forming nodular follicles. The majority of primary gastrointestinal follicular lymphomas express Bcl-2 and CD-20. Treatment options include: watch and wait, radiation, rituximab monotherapy or chemotherapy with or without radiation. Conclusions Primary gastrointestinal follicular lymphoma is a rare, indolent neoplasm that may appear as a benign lymphoid infiltrate. Immunohistochemical staining is critical in making the diagnosis particularly in the setting of atypical lymphoid infiltrates that are nodular. In patients with localized disease, clinical outcomes are excellent even without therapy.

2525 Primary Omental Infarct: A Radiological Curiosity or a Real Disease? Nader Emami, MD1, Harish Guddati, MD2, Kamran Zahid, MD1, Hilary Hertan, MD1. 1Montefiore Medical Center, Bronx, NY; 2Montefiore Medical Center, Yonkers, NY Primary Omental Infarction (POI) is a rare cause of acute abdominal pain. Patients may present with severe abdominal pain mimicking acute abdomen or could be completely asymptomatic. This large variation in presentation makes diagnosis confusing and challenging. Here we present two cases of omental infarction with very different presentations. A 25 year old woman who presented with right upper quadrant (RUQ) abdominal pain with radiation to her flank, exacerbated with any movement or cough. Her exam revealed severe tenderness over the RUQ. Lab work was remarkable for elevated transaminases (ALT: 122 U/L, AST: 93 U/L), ESR: 120 mm/h, CRP: 18mg/dL, CPK: 144U/L, WBC count of 15.5 k/uL. Her CT scan of the abdomen revealed right upper quadrant omental fat stranding with trace intrahepatic fluid representing omental infarct (OI). Her viral hepatitis panel and autoimmune panel were negative except for a low titer (1:40) antismooth muscle antibody. Liver inflammation from surrounding omental infarct was thought to be the etiology of elevated AST/ALT. Symptoms gradually improved with morphine. Patient was discharged home with down trending CRP (8.8 mg/ dL) and liver tests (ALT: 62U/L, AST: 24 U/L). A 51 year old man with history of multiple sclerosis, presented with urinary retention, fever, diagnosed with urinary tract infection. He denied any abdominal pain. Lab work was remarkable for elevated transaminases (ALT: 76 U/L, AST: 67 U/L) and WBC count of 4.3 k/uL. His CT scan of abdomen with oral contrast revealed incidental finding of RUQ omental infarct. He was discharged home after treatment of infection. POI is a unusual disease with a wide variation in clinical presentation from asymptomatic imaging finding to severe abdominal pain requiring extensive work up and hospital admission. In acute cases it can be misconstrued with acute appendicitis, pancreatitis, and peptic ulcer disease. A diagnosis of primary OI is made when no discernable etiology is found. Secondary causes for OI include hypercoagulability, vasculitis, and polycythemia. POI is commonly found in the right side of the abdomen. Sudden movement, violent exercise, and hyperperistalsis have been reported as causes of POI. CT scan is the diagnostic test of choice. In the absence of clinical deterioration, watchful waiting and pain control seems to be appropriate but laproscopy and omental necrosectomy might be necessary if the diagnosis is not clear by imaging or if there is no improvement in 48hours.

[2525A] Omental infarct below the liver in case1.


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[2526B] Histopathology of the polypoid specimen showed numerous ectatic vessels and ulcerations.

[2525B] RUQ omental infarct in case 2.

2526 Portal Hypertensive Polypoid Enteropathy Without Overt Endoscopic Features of Portal Hypertension: A Case Report Pujan Kandel, MD, Bhaumik Brahmbhatt, MBBS, Andrea Rodriguez, MD, Mark Stark, MD. Mayo Clinic, Jacksonville, FL Introduction: Portal hypertensive polypoid enteropathy is an under recognized complication of portal hypertension. It is a rare manifestation of portal hypertensive enteropathy (PHE), polypoid lesions are seen in about 0.3% cases in the small intestine. . Endoscopic findings of portal hypertension may or may not be present. Case description: A 60 year-old female with a history of liver cirrhosis from NAFLD and chronic GI bleeding was referred for evaluation of transfusion-dependent anemia requiring IV iron and packed red blood cells. Encephalopathy was her only known complication from cirrhosis. Previous work-up revealed a polypoid lesion in the duodenum which was removed (histology: chronic active duodenitis with ulceration, polypoid inflamed granulation tissue). EGD did not show varices, GAVE, or portal hypertensive gastropathy. She also had a history of large internal hemorrhoids and diverticulosis which were previously treated. Despite management of suspected lesions, anemia persisted with hem occult positive stools. VCE was performed using PillCam system which showed a 6-8mm villous polyp with surface erosion without bleeding in the proximal duodenum. Clusters of erythema and red villi were noted in small intestine which did not appear to be discrete angiodysplasias. At mid-small intestine (57% transit) 1cm sessile polypoid lesion with active bleeding was noted that appeared to be an inflammatory

[2526C] Histopathology of the polypoid specimen showed numerous ectatic vessels and ulcerations.

polyp or granulation tissue. Upper DBE showed small bowel findings consistent with portal enteropathy without discrete AVM (Figure 1). Small inflammatory polyps were removed from duodenum. Histopathology showed benign inflammatory polyp c/w portal enteropathy. Lower DBE revealed a 1 cm sessile polyp in mid- ileum (40 cm upstream of colon) which matched the lesion seen on VCE. Polyp was removed with hot snare. Histopathology of the polypoid specimen showed numerous ectatic vessels and ulcerations (Figure 2, 3). The findings were suggestive of polypoid portal hypertensive enteropathy. Discussion: Introduction of VCE and deep enteroscopy has enabled us to perform diagnostic and therapeutic evaluation of small bowel in PHE. Portal hypertensive polypoid enteropathy should be kept high in the differential in patient s with liver cirrhosis presenting with occult GI blood loss. Management of PHE is yet to be standardized, individualized approach should be sought.

2527 Gallstone Ileus Presenting as Intussusception: Case Report Vimal Bodiwala, MD1, Vidhi Kapoor, MD1, Kevin Skole, MD2. 1Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ; 2University Medical Center of Princeton at Plainsboro, Princeton, NJ

[2526A] Upper DBE showed small bowel findings consistent with portal enteropathy without discrete AVM.


Gallstone ileus accounts for 0.5 % of all mechanical small bowel obstruction cases.1 A gallstone is suspected to enter the bowel through a cholecysto-enteric fistula.1 Elderly women are more likely to experience gallstone ileus.1 Here we report a rare case of gallstone ileus leading to intussuception of the small bowel. A otherwise-healthy 81 year old woman was admitted with 5 days of crampy abdominal pain, nausea and non bilious non bloody vomiting. She reported having had non-bloody diarrhea during the first three days of her illness; she had no further bowel movements but reported passing flatus. She noted her symptoms coincided with taking Trimethoprim- Sulfomethaxole for a urinary tract infection. She also reported eating “uncooked” fish at a restaurant on the day her symptoms began. She had no history of prior abdominal surgeries. At presentation, her vital signs were stable. She was in no distress and was anicteric. Her abdomen was soft, nondistended with normoactive bowel sounds; mild lower


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[2527A] CT scan of the abdomen performed on day 3 showing intussusception of the small bowel. [2527C] Coronal view of CT scan of the abdomen performed on day 3 showing intussusception of the small bowel.

Am J Gastroenterol 2017; 112:S1378–S1449; doi:10.1038/ajg.2017.326

ACCEPTED: CLINICAL VIGNETTES/CASE REPORTS—STOMACH 2528 An Unusual Cause of Upper Gastrointestinal Bleeding in a Young Patient Kristen Suchniak-Mussari, MD, Katie Farah, MD. Allegheny Health Network, Pittsburgh, PA

[2527B] This is the gallstone that was removed. It measured 6 cm x 5 cm.

abdominal tenderness was noted. Admission labs were notable for a WBC of 17; they were otherwise unremarkable. She was admitted for a presumptive diagnosis of gastroenteritis and treated with bowel rest and intravenous fluids. When her pain persisted despite 3 days of supportive care, we obtained an abdominal CT scan, which showed a small bowel obstruction near the junction of ileum and jejunum with a concentric intraluminal ring, suggestive of intussception. An exploratory laparotomy was performed. A transition point was confirmed in the distal jejunum, where a 6 x 5 cm green stone-like mass was found adhering to the small bowel. A small bowel resection of 11 cm x 7 cm was performed followed by a small bowel anastomsis. Her symptoms resolved after surgery; she had an unremarkable post surgical course. Pathologic review confirmed an impacted gallstone. As per our literature review, ours is the third case of gallstone ileus leading to intussuception. In the two prior cases, one patient passed away shortly after family declined surgery2 and another patient survived after timely surgery.3 1. Halabi, et al. Ann Surg. 2014 Feb;259(2):329-35 2. Voore, et al. BMJ Case Rep. 2015; 10.1136 3. Prasad, et al. Int J Surg Case Rep. 2017; 30: 37–39.


Burkitt’s lymphoma is a very rare cancer, comprising only 1% of lymphomas, though its incidence is rising. Although extranodal involvement in Burkitt’s lymphoma is rare, the gastrointestinal tract is the most common site where it occurs, leading to a myriad of gastrointestinal symptoms that are important for clinicians to recognize. A 20-year-old man who had recently sustained a sacral fracture presented with epigastric pain and melena. His course began one month prior when he developed back pain, and he was started on NSAIDs and steroids. As his back pain persisted, he underwent MRI of the spine revealing a sacral fracture and a density in the right piriformis concerning for a hematoma versus a mass. Notable initial labs revealed hemoglobin 6.8, white blood cells 14, platelets 502, albumin 1.6, total protein 3.2, and INR 1.1. He underwent EGD for evaluation of the epigastric pain and melena that revealed numerous one- to two-centimeter polypoid masses with heaped-up edges and central ulcerations throughout the stomach. Pathology from biopsies of these gastric lesions as well as from a CT-guided biopsy of the piriformis mass confirmed Burkitt’s lymphoma. A CT scan confirmed stage IV disease and revealed an entero-enteric intussusception. HIV testing was negative. He was subsequently started on chemotherapy. Patients with gastrointestinal involvement of Burkitt's lymphoma can present with a myriad of symptoms including abdominal pain, obstruction, intussusception, gastrointestinal bleeding, and a palpable mass. When present, the stomach is involved most frequently, comprising 60% of gastrointestinal extranodal sites, followed by the small and large intestines, encompassing 30% and 10% respectively. Few cases have been described of patients with Burkitt’s lymphoma presenting with gastrointestinal tract involvement as evidenced by concurrent melena and intussusception as occurred in this case. Additionally, most cases described have occurred in HIV positive patients. It is important to consider this diagnosis in young patients presenting with abdominal pain and melena, especially in the setting of a fragility fracture, as these findings are unusual in young patients. In conclusion, it is vital that clinicians recognize the diverse signs with which Burkitt’s lymphoma can present, as the incidence is increasing, and it is important to make the diagnosis and initiate treatment promptly so as to ensure the best possible prognosis.


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