Diffuse Thickening Research Articles

734 APHASIC AORTITIS - A CASE REPORT

Abstract A 66yo man, without previous cardiological history, 3-month history of asthenia and left leg claudication, presence of tibial painless nodular lesions, was admitted at our emergency department in the clinical context of an acute aortic syndrome with chest and interscapular pain, fluctuating systemic BP (215/90 ←→ 90/60 mmHg) ​​and 60 mmHg pressure gradient between the arms. EKG documented diffuse negative T waves. Echocardiography revealed normal biventricular morphology and function and normal valve system. TC angiography documented a dilated aortic root (46mm), diffuse thickening of the aortic walls from the valvular plane (8mm), with involvement of the coronary and epiaortic arteries (50% stenosis of left subclavian artery), extended up to the aortic bifurcation to affect the common iliac arteries. Blood chemistry showed high C-reactive protein levels (29 mg/L; n.v. <5 mg/L) and low troponin levels. In the suspicion of an aortic wall hematoma, the patient was rushed to the OR with evidence of a lardaceous-looking aorta and free from wall hematomas. Surgery was stopped. Histological sample of left inguinal artery showed diffuse wall sclerosis and rare intramural lymphocyte infiltration. PET-CT showed an increased metabolism of the aortic walls. On the second postoperative day, the patient developed fluctuating aphasia aggravated by orthostatic position and arterial hypotension. In the suspicion of TIA, CT angiography was performed and showed no acute brain lesions, but a critical stenosis of the right carotid bifurcation, a right vertebral artery occlusion and a left internal carotid subocclusion. DAPT (clopidogrel + aspirin) was initiated. Blood chemistry showed normal WBC count, elevated C-reactive protein (133 mg/L; n.v. < 5 mg/L) and erythrocyte sedimentation rate (90 mm/h; n.v. < 35 mm/h). Blood and urine cultures, bacterial serology (syphilis, tubercolosis), viral serology (HBV, HCV, HIV) and autoantibodies tested (ANA, ENA, ANCA, MPO, PR3) resulted negative. In the context of a great vessel arteritis, IV methylprednisolone was introduced with clinical and biochemical response (C-reactive Protein 10 mg/L). MRI on day 10 demonstrated the presence of two cerebral subacute ischemic lesions with hemorrhagic infarction. Aspirin was discontinued. In suspicion of Takayasu arteritis, methotrexate was initiated with clinical benefit. Takayasu arteritis has an incidence of 2.6/1 million, female:male 8:1 and the age of onset is usually between 15 and 30 years. The cause is unknown. It can manifest as an acute aortic syndrome. It is important to be aware of this disease and to consider it in clinically ambiguous cases like this one.

Berardinelli-Seip Congenital Lipodystrophy Discovered Following a STEMI Event.

Berardinelli-Seip congenital lipodystrophy (BSCL) is a rare congenital lipodystrophy, with an incidence of 1-9 per million population, which is usually diagnosed at birth and is associated with pathogenic variants of the BSCL2 and AGPAT2 genes.Due to the absence of functional adipocytes, lipid storage occurs in other tissues, including skeletal muscle and liver.Diagnosis is based on the presence of three major or two major and two minor characteristics.

Craniofacial Fibrous Dysplasiaa Rare Case Report in a Tertiary Eye Hospital

Purpose: Fibrous dysplasia (FD) is a rare fibro-osseous lesion of the osseous structures of the body. Craniofacial FD confined to contiguous bones of the craniofacial skeleton. Purpose of the study is to report such a rare case which was diagnosed and managed in the outpatient department in our tertiary eye hospital.
 Method: A 12-year-old girl complaint of painless swelling over right side of eyebrow for 4 months.Facial examination revealed well-defined bony swelling rounded in shape with hard consistency, nontender; diameter 10x10 mm; overlying skin free; no regional lymphadenopathy. Visual acuity was 6/6. Anterior and posterior segment revealed normal. Ocular motility was full. No other swelling was present in body and café-au-lait spots were absent. Routine investigations such as hemogram, serum calcium and serum alkaline phosphatase (ALP) were performed. Among them ALP was raised to 300 U/L. CT scan showed a radio dense mass with ground-glass appearance involving right frontal bone whose expansion causing facial asymmetry .An incisional biopsy with histopathological analysis was done. It showed irregular bony trabeculae in chinese script pattern scattered within fibrous stroma. The bone appeared woven rather than lamellar. MRI suggest diffuse thickening of right frontal bone.
 Result: Clinical history, radiographic assessment and histological features suggested that it was a case of craniofacial FD involving right side of frontal bone.
 Conclusion: Detection of early suspicious sign for diagnosis and early initiation for management is crucial to prevent the long-term complication with avert the process of optic nerve compression.
 J. Natl. Inst. Ophthalmol. 2022;5(1):46-50

Lymphoma of the urinary bladder with concomitant septic peritonitis in a dog

AbstractA 6‐year‐old, female, neutered German shepherd dog presented with an acute history of stranguria and pollakiuria. The dog was depressed but the remainder of the examination was unremarkable. Urine cytology revealed severe bacteriuria and pyuria, suggesting urinary tract infection, and a low number of large atypical lymphoid cells. Abdominal ultrasound revealed the presence of diffuse thickening of the urinary bladder wall in the area of the trigone, enlargement of the left medial iliac lymph node and a large volume of peritoneal effusion. Cytology of the lymph node confirmed large cell lymphoma, and cytology of the abdominal effusion revealed septic neutrophilic inflammation. Urinary bladder lymphoma and septic peritonitis were diagnosed, and euthanasia was elected. Full gross and histopathological postmortem examination concluded the presence of a primary urinary bladder B‐cell lymphoma. No definitive cause of the septic peritonitis could be established, but bacterial translocation from the urinary bladder was suspected.

Fatal Case of Hypertrophic Cardiomyopathy in a Donor Heart: A Case Report

Hypertrophic cardiomyopathy is a genetically determined heart muscle disease, and patients are at an increased risk for sudden cardiac death. We report the case of a 39-year-old White man who was found dead at home unexpectedly. He had a cardiac transplant for congenital heart disease at the age of 12 and his condition was maintained with immunosuppression ever since with good cardiac function and right bundle branch block. At autopsy, the heart was enlarged with a weight of 591 g and had fibrous adhesions of the pericardium with endothelialized sutures in the atria and great vessels in keeping with heart transplant. There was focal septal hypertrophy noted on short axis cut. There was diffuse thickening of the coronary arteries, but no significant stenosis was noted. On microscopic examination of the heart, sections of right and left ventricle showed myocyte hypertrophy with extensive widespread myocyte disarray and replacement fibrosis. The histologic appearance was that of hypertrophic cardiomyopathy, which was responsible for his sudden unexpected death. This postmortem diagnosis of hypertrophic cardiomyopathy in a transplanted heart has major implications for the donor family because of the inherited nature of the condition. Follow-up with the donor family is essential in this unique case. This case highlights the importance of autopsy in transplant death cases. Hypertrophic cardiomyopathy in the donor heart most likely did not manifest phenotypically at the time of transplant in this case because the majority present in adolescence and early adulthood, rarely in childhood. This is first report of such a case.

Benign Multicystic Peritoneal Mesothelioma as a Rare Cause of Death

Abstract Introduction/Objective Benign multicystic peritoneal mesothelioma (BMPM) is a tumor arising from the serosa of the peritoneal cavity, often in the pelvis, and is comprised of multiple cysts lined by bland mesothelial cells. It is a rare entity with less than 200 cases reported. The clinical course is often indolent with nonspecific symptoms. It has a strong predilection for females (90%) and is commonly associated with endometriosis or prior surgeries. A high local recurrence rate (50%) following excision has been reported, but malignant transformation is rare. Methods/Case Report The decedent was a 53-year-old male with a history of multiple hernia repairs who presented following three days of diffuse abdominal pain and obstipation. Imaging showed large volume, complex ascites with multiple rim-enhancing fluid collections, diffuse peritoneal thickening, and a soft tissue density in the lower abdomen/pelvis. Exploratory laparotomy was congruent and revealed 2L of purulent ascites, numerous peritoneal cystic lesions, and a bulky tumor in the pelvis. Blood and ascites cultures later grew Bacteroides species, and Escerichia coli was also isolated from the blood. Postoperatively, the decedent continued to decline, and death occurred the following day. Autopsy demonstrated that the firm pelvic mass entrapped the bladder, rectum, and segments of the small intestine. Sectioning revealed numerous cystic spaces of varying size. Microscopically, they were lined by a single layer of benign cells with mild to focally moderate atypia. These cells stained positive for Calretinin, Pan-cytokeratin, and D2-40 and negative for CD31, which is characteristic of mesothelial cells. These findings are consistent with BMPM. Results (if a Case Study enter NA) NA. Conclusion The decedent’s death is the result of sepsis following acute peritonitis due to BMPM. Death resulting from this entity is exceedingly rare, and to our knowledge this case is only the second reported death due to BMPM.

Abstract 14421: Avoid Pericardiectomy in Transient Constrictive Pericarditis

Case Presentation: A male in his 40s presented for chest pain, dyspnea and bilateral leg edema. He has a history of hypertrophic cardiomyopathy treated with septal myectomy complicated by constrictive pericarditis (CP) that was treated with right-sided pericardiectomy, NSAIDs, colchicine, and steroids. Echo showed LVEF of 55% with thickening of the pericardium, abnormal septal bounce, tethering of the right atrium, respiratory variation in flow across the mitral and tricuspid valves and IVC plethora. Cardiac MRI showed diffuse mild thickening of residual left-sided pericardium, mild diffuse circumferential pericardial enhancement, mild diastolic septal bounce, diastolic restraint, exaggerated inspiratory flattening and conical deformity of the ventricles without evidence of myocardial inflammation or scarring. Right heart catheterization showed near equalization of RV and LV pressures, RV and LV respiratory concordance, aortic pulsus paradoxus with an inspiratory decrease of 15 mmHg, and Kussmaul’s sign with an inspiratory increase in RA pressure of 68 mmHg. Left heart catheterization showed normal coronaries. The patient was diagnosed with CP and underwent repeat pericardiectomy and was treated with NSAIDs and diuretics. On follow-up, patient had symptomatic improvement but still had evidence of residual constriction on echocardiogram. Discussion: Pericardiectomy is the definitive treatment for CP, however it carries high morbidity and mortality rates. Recurrence of constrictive pericarditis requiring repeat pericardiectomy is very rare and risk factors for recurrence are not well-defined. His initial pericardiectomy was complicated with evidence of active visceral epicarditis with epicardial constriction. This case suggests that active inflammation at the time of pericardiectomy is a potential risk factor for recurrent CP requiring repeat pericardiectomy, and surgery should be deferred until the active inflammation has subsided.

Dysphagia and Tongue Deviation: An Unexpected Cause.

Dysphagia and Tongue Deviation: An Unexpected Cause.

Differentiating malignant pleural mesothelioma and metastatic pleural disease based on a machine learning model with primary CT signs: A multicentre study

Rationale and ObjectivesIt is still a challenge to make confirming diagnosis of malignant pleural mesothelioma (MPM), especially differentiating from metastatic pleural disease (MPD). The aim of this study was to develop a model to distinguish MPM with MPD based on primary CT signs. Materials and methodsWe retrospectively recruited 150 MPM patients and 147 MPD patients from two centers and assigned them to training (115 MPM patients and 113 MPD patients) and testing (35 MPM patients and 34 MPD patients) cohorts. The images were analyzed for pleural thickening, hydrothorax, lymphadenopathy, thoracic volume and calcified pleural plaque (CPP). The selected clinical characteristics and primary CT signs comprised the model by multivariate logistic regression in the training cohort. Then the model was tested on the external testing cohort. ROC curve and F1 score were used to validate the capability of the model in both two cohorts. ResultsThere were significant differences between two groups: (1) carcinoembryonic antigen (CEA); (2) nodular and mass pleural thickening; (3) the enhancement of pleura; (4) focal, diffuse and circumferential pleural thickening; (5) the thickest pleura; (6) thickening of diaphragmatic pleura; (7) multiple nodules and effusion of interlobar pleura; (8) hilar LN and ring enhancement of LN; (9) punctate and stipe CPP. The AUC and F1 score of the model were 0.970 and 0.857 in the training cohort, 0.955 and 0.818 in the testing cohort. ConclusionThe model holds promise for use as a diagnostic tool to distinguish MPM from MPD.

PSAT028 Congenital Adrenal Hyperplasia with Adrenal Myelolipoma: Gender Identity and Choice of Therapy

Abstract Background Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder characterized by impaired glucocorticoid and mineralocorticoid synthesis with excessive adrenal androgen production. In affected females, most forms of CAH lead to virilization. Persons with CAH have a higher prevalence of adrenal myelolipomas compared with the general population. Clinical case A 38-year-old Spanish speaking individual who identified as male presented with headache and chest pain. Imaging revealed diffuse nodular thickening and enlargement of the right adrenal gland consistent with hyperplasia as well as 11 cm multilobulated left adrenal lesion containing macroscopic fat and soft tissue consistent with myelolipoma. A small uterus posterior to the bladder and presumed ovaries were also visualized with no visualization of prostate, spermatic cord or testicles. He reported a brother with a childhood hormone condition leading to an attempt to raise as female, resulting in subjective distress and unhappiness. Our patient never had breast development, menstrual cycles, or recurrent abdominal pain. There was no history of adrenal crisis, lightheadedness, or syncope and no hyperpigmentation on exam. He recalled salt craving as a child. Genital exam was refused by the patient. Labs demonstrated plasma cortisol 4.5 mcg/dl (6-18.4), ACTH 123 pg/ml (7-63), serum aldosterone 30 ng/dl (<=21), plasma renin activity 3.0 ng/ml/h (<=0.6-4.3), sodium 139 mEq/l (135-145) and potassium 4.2 mEq/l (3.5-5). The 17-hydroxyprogesterone concentration was 16,713 ng/dl (<=138), androstenedione was 36.52 ng/ml (0.33-1.34), and total testosterone was 621 ng/dl (male reference range 249-836). Based on the above findings and clinical history, his biologic sex was strongly felt to be female. A decision had to made regarding the need for glucocorticoid therapy and for possible adrenalectomy for the large myelolipoma. Because he had no symptoms of adrenal insufficiency and quite content with his gender identity, neither hormone therapy nor surgical intervention were performed. As of 8 months after presentation, he reported on going health and well-being. We recommended follow-up adrenal imaging and discussed glucocorticoid coverage for possible future stress conditions and educated him for this potential need. Discussion This case is unusual in that he was asymptomatic for adrenal insufficiency yet maintained male gender identity into adulthood. His adrenal myelolipoma likely developed from untreated CAH. We felt that treating with steroids and/or resecting his adrenal gland might well suppress ACTH and adrenal androgen production which would be detrimental to his gender identity and quality of life. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Pycnodysostosis: Case report

Pycnodysostosis is a rare genetic osteopathy that combines: dysmorphic syndrome, osteocondensation and growth retardation. This is an newborn of 09 months old in whom a pycnodysostosis was suspected, he was referred by a geneticist to look for radiological signs of this disease. He was born in a first degree consanguineous marriage and had been suffering from repeated spontaneous fractures since birth. The examination revealed a facial dysmorphism with macrocephaly, a persistent anterior fontanel, protruding frontal bumps and micrognathia with a curved aspect of the left lower limb. Skeletal radiographs showed densification of the skull base bones, persistence of the anterior fontanel, hypoplasia of the lower jaw bone and several fractures of different ages with bone calluses, diffuse cortical thickening and metaphyseal enlargement with a short aspect of the upper limb bones were found. In view of the clinical signs and radiological manifestations, the diagnosis retained is pycnodysostosis. Orthopedic management was proposed for the family. Pycnodysostosis is a rare disease, sometimes difficult to diagnose and of delayed onset, which poses a differential diagnostic problem with osteopetrosis and osteogenesis imperfecta.

Accuracy of point‑of‑care ultrasonography in the diagnosis of necrotizing fasciitis: A case report

Necrotizing fasciitis is a serious infectious condition that may compromise the patient's life. In the present case study, a 42-year-old male patient was reported. The condition manifested as the presence of subjective fever, general malaise, myalgia, non-productive cough, dysphagia and neck pain ~1 week prior to hospital admission. Vascular dissection was considered as the initial diagnostic suspicion, and thus, angiotomography of neck vessels was performed, ruling out aortic and neck vessel dissection. Radiology indicated negativity for aortic syndrome and cervical vascular disease, but the presence of cervical-mediastinal edema, lamellar fluid between muscular and fatty planes and posterior pulmonary atelectasis, absence of pleural fluid or consolidations, and tonsillar hypertrophy without abscesses. Due to the rapid evolution of the condition, the presence of dyspnea with the need for supplemental oxygen, and the disproportion between the intensity of the pain described by the patient and the external findings observed, the presence of necrotizing fasciitis was considered. Point-of-care ultrasonography was performed, indicating a cobblestone pattern of the subcutaneous cellular tissue, with diffuse thickening of the anterior cervical fascia and increased echogenicity with soft tissue edema posterior to the fascia. Magnetic resonance imaging confirmed the inflammatory findings in the fascia and other cervical soft tissues, without exhibiting any signs of necrosis, but with the presence of abscesses in the visceral and carotid space.

S3127 Peritoneal Tuberculosis in an Immunocompetent Patient With Findings of Chronic Liver Disease and Peritoneal Carcinomatosis

Introduction: Peritoneal tuberculosis (PT) accounts for 1-2% of all tuberculosis cases. Diagnosis of PT can be challenging due to non-specific symptoms, insidious onset, and variable imaging findings. We present a case of PT presenting with ascites and imaging studies suggestive of chronic liver disease (CLD), and peritoneal carcinomatosis. Case Description/Methods: A 48-year-old man presented to our clinic with complaints of increased abdominal girth, weight loss, and night sweats for the past 3 months. Physical exam revealed soft and distended abdomen with shifting dullness. Laboratory tests showed a mild anemia of Hb at 13.0 g/dL (13.1-17.2) and ESR at 34 mm/h (0-15). Abdominal ultrasound (US) revealed the presence of free abdominal fluid, and diffuse heterogenous granular liver parenchyma supporting the diagnosis of CLD. His liver tests were within normal ranges. Ascitic fluid analysis revealed serum ascites albumin gradient (SAAG) of 0.2 g/dL, WBCs of 1.70 × 103 cells/dL (91.8% lymphocytes). Ascitic fluid cytology was negative for malignant cells. Ascitic fluid acid-fast bacilli (AFB) test and mycobacterial culture were negative. Adenosine deaminase (ADA) level in ascitic fluid was 108.5 U/L (0-40). Interferon-gamma release assay (IGRA) test was positive. Contrast-enhanced computed tomography (CT) scan revealed normal liver parenchyma, diffuse thickening and nodularity of the peritoneum, and thickening of omentum with omental cake appearance. CT scan was suggestive of peritoneal carcinomatosis. EGD and colonoscopy were unremarkable. With consistent clinical history, SAAG < 1.1, ascitic fluid with lymphocytic predominance, high ADA levels, and positive IGRA, a diagnosis of PT was made. Anti-tuberculosis treatment was initiated, and the patient’s clinical symptoms have improved. CT scan at the end of treatment showed the resolution of ascites and peritoneal findings (Figure 1). Discussion: Ascites is the most common presenting symptom of PT. High suspicion of PT is important in the setting of ascites of unknown origin. Despite the US findings were suggestive of CLD in this patient, CT scan revealed normal liver findings. Differing PT from peritoneal carcinomatosis might be challenging due to overlapping findings on imaging. Ascitic fluid analysis of SAAG < 1.1, high ADA levels, positive IGRA test should lead towards the diagnosis of PT. AFB and mycobacterial culture of the ascitic fluid may often have low diagnostic yield in PT. Early diagnosis and treatment are important to prevent complications.Figure 1.: A1, A2, Before treatment; axial contrast-enhanced computed tomography scan showing moderate ascites, and diffuse thickening and nodularity of peritoneum. Imaging is suggestive of peritoneal carcinomatosis. B1, B2, After treatment; resolution of ascites and peritoneal findings.

AN ALTERNATE APPROACH: TRANSESOPHAGEAL BRONCHOSCOPIC ULTRASOUND-GUIDED FINE NEEDLE ASPIRATION (EUS-B-FNA) TO ASSESS PLEURAL MESOTHELIOMA

AN ALTERNATE APPROACH: TRANSESOPHAGEAL BRONCHOSCOPIC ULTRASOUND-GUIDED FINE NEEDLE ASPIRATION (EUS-B-FNA) TO ASSESS PLEURAL MESOTHELIOMA

S2203 A Rare Case of Amyloid-Induced Colonic Pseudo-Obstruction

Introduction: Colonic pseudo-obstruction is a rare complication of AL Amyloidosis that is described as a diffuse colonic dilation without underlying mechanical cause. In AL Amyloidosis, extracellular protein deposits disrupt tissue structure and function. Manifestations of colonic involvement of AL Amyloidosis include chronic diarrhea, weight loss, abdominal pain, and pseudo-obstruction. Here we present a patient with worsening abdominal pain and distention, found to have colonic pseudo-obstruction likely from AL Amyloidosis. Her symptoms improved with colonic decompression and with the utility of prokinetic agents. Case Description/Methods: A 79-year-old female presented with 3 days of progressively worsening abdominal pain and distention, with associated constipation. Her past medical history was significant for anemia, AL-Amyloidosis diagnosed 4 months prior to arrival, and PEG placement 3 weeks prior to arrival due to worsening dysphagia secondary to macroglossia. Vital signs were normal. She did not appear in acute distress and was hemodynamically stable. Pertinent examination findings included abdominal distention, decreased bowel sounds, and diffuse abdominal tenderness. Pertinent labs included WBC 5.6 k/uL, albumin 2.1 g/dL, AST 39 U/L, ALT 43 U/L, ALP 196 U/L, and total bilirubin 0.3 mg/dL. Clostridium difficile, giardia lamblia, salmonella, and stool occult blood were negative. CT abdomen and pelvis revealed gaseous distention of the transverse colon and diffuse colonic wall thickening, as displayed in figure 1. Colonoscopy revealed diffuse dilation of the transverse colon, with components of inflammation including friability and loss of vascularity. Decompression was successfully performed through the colonoscope. The patient tolerated the procedure well and had marked improvement of abdominal distention and pain. Her percutaneous tube feeds were reinitiated and tolerated well. (Figure) Discussion: Colonic pseudo-obstruction is a rare complication of AL Amyloidosis that is caused by deposits of protein in extracellular tissue. AL Amyloidosis is a multisystem disease that rarely presents with colonic manifestations. However, colonic manifestations may be the sole presentation of AL Amyloidosis. Colonic pseudo-obstruction remains a clinical challenge and can lead to bacterial overgrowth and malnutrition. Here we demonstrate successful air decompression of a colonic pseudo-obstruction due to AL Amyloidosis. We hope to increase awareness of AL Amyloidosis as an etiology colonic pseudo-obstruction.Figure 1.: CT Abdomen Pelvis reveals diffuse gaseous distention of the transverse colon with bowel wall thickening.

S3656 Primary Diagnosis of Metastatic Breast Cancer via Esophagogastroduodenoscopy With Gastric Biopsies

Introduction: Gastric metastases are a rare manifestation of breast cancer and previous case reports suggest they typically occur in patients with a long standing history of breast cancer. We present a case of a patient whose primary diagnosis of breast cancer was made via gastric biopsies taken during esophagogastroduodenoscopy (EGD) after the patient presented to the hospital with symptoms of persistent nausea and vomiting. Case Description/Methods: The patient is a 58-year-old female with a reported history of alcohol use disorder who presented to the emergency department with intractable nausea and vomiting. On arrival, the patient’s vitals were stable and labs were only significant for a mildly elevated creatinine of 1.40, which normalized with IV fluids. Computed tomography (CT) of the abdomen and pelvis showed diffuse gastric wall thickening. Following the results of the CT, an EGD was performed which revealed diffuse gastritis with friable mucosa and concern for malignancy or ischemia. Gastric biopsies were suggestive of adenocarcinoma with likely primary being breast cancer. Immunohistochemical staining was positive for CDK7, GATA3, mammaglobin, and 80-90% estrogen receptor. Following consideration of both the pathologic appearance and immunohistochemical staining, the diagnosis was made of metastatic lobular carcinoma. Due to the patient's poor support system and functional status, the patient elected to pursue hospice, and therefore further workup was not performed (Figure 1). Discussion: Breast cancer is the second most common malignancy in women in the United States, with metastasis of breast cancer classically spreading to lungs, liver, bone, soft tissue, and adrenal glands. Metastasis to the gastrointestinal (GI) tract is rare, with lobular breast cancer having higher predilection over ductal carcinoma. The average time for breast cancer to metastasize to GI tract has been previously reported as many years after primary diagnosis. Here we present a case of breast cancer where the primary diagnosis was made after EGD assisted gastric biopsies. After extensive literature review, there is sparse information on early gastric metastasis of breast cancer. While our patient's previous history of breast cancer screening is unknown, she had no prior knowledge of her breast cancer diagnosis. This case signifies the importance of endoscopic evaluation and gastric biopsies in patients with nonspecific symptoms, especially with abnormal imaging findings suggestive of gastritis.Figure 1.: Endoscopic appearance of the gastric mucosa.

Menetrier’s disease: A rare diagnosis established by ultrasonography and computed tomography

Menetrier’s disease is a rare condition of the stomach characterized by giant mucosal folds in the gastric fundus and body, diminished acid secretory capacity, and a protein-losing state with hypoalbuminemia. It is also called protein-losing hypertrophic gastropathy. It was first described by the French pathologist Pierre Menetrier in 1888. Menetrier’s disease has also a recognized premalignant potential although the precise risk of progression to gastric cancer is not known. Several studies reported regression of disease after treatment with the monoclonal antibody against the EGFR receptor. But the only satisfactory treatment has historically been and remains the surgical intervention with total or partial gastrectomy.A case report of A 10-year male presented to the emergency room with a history of progressively increasing abdominal pain on and off for 1 month with epigastric region fullness, nausea, and vomiting. Generalized edema was noted on examination. An abdominal ultrasound examination was performed, and the patient was found to have diffuse mucosal thickening of the gastric wall with prominent rugal folds and echogenic mucosal lining with generalized subcutaneous edema and mild ascites. The patient underwent surgery and the diagnosis was confirmed by the histopathological report.

S2190 A Case of Colorectal Signet Ring Cell Carcinoma Presenting as Ulcerative Recto-Sigmoiditis and Stricture

Introduction: Signet ring cell carcinoma accounts for about one percent of all colorectal cancers. It is an aggressive subtype of adenocarcinomas with the tendency for intramural spread and peritoneal carcinomatosis. Here, we reported a middle-aged male with circumferential colonic stenosis and inconclusive histology, found to have stage 4 colorectal signet ring cell carcinoma (SRCC). Case Description/Methods: A 41-year-old male without significant past medical history was referred to a gastroenterology clinic with bright red blood per rectum. Colonoscopy showed ulcerative recto-sigmoiditis with rectal bleeding, and there was stricture in the rectum, in the recto-sigmoid colon, and from anus to descending colon (Figure A). Biopsy was obtained from the stricture. The pathology revealed granulation tissue and abundant fibrinopurulent exudate showing small clusters, and individual atypical cells stained positive for CDX-2 immunostain. Unfortunately, the patient subsequently lost follow-up. Three months later, the patient was hospitalized for small bowel obstruction. CT showed markedly enlarged heterogeneous and edematous rectum, an abnormal mass within the posterior pelvis/rectum, retroperitoneal and pelvic lymphadenopathy with thickening and nodularity of the peritoneum. Biopsy was obtained from an inguinal lymph node with histological examination showing metastatic adenocarcinoma composed of poorly cohesive signet-ring cells (Figure B). Immunostains revealed that the neoplastic cells were strongly and diffusely positive for CDX2 and CK20 while negative for CK7, confirming a colorectal primary. Accordingly, the diagnosis of colorectal signet ring cell carcinoma was made. Discussion: The colonoscopic findings of colorectal SRCC could be nonspecific as diffuse circumferential thickening, stricture, or ulcerations. Typical pathological features may not appear on the initial biopsy sample. Immunohistochemical testing could help increase diagnostic yield and early identification of cancer cells. Our case hallmarked the importance of close follow-up for abnormal diffuse stricture and ulcerations in the colorectal area. These lesions may need to be rebiopsied, co-screened with abdominal imaging, and undergo an immunohistochemical investigation to characterize pathology further.Figure 1.: A: Colonoscopy: An intrinsic inflammatory circumferential fibrosis friable severe stenosis measuring 20cm (in length) * 9 mm (inner diameter) was found in the rectum, in the recto-sigmoid colon, and from anus to descending colon. B: Hematoxylin & eosin stain of tissue from lymph node showed metastatic adenocarcinoma composed of poorly cohesive signet-ring cells.

S2797 Closing the Gap: First Report of Endoscopic Suture Closure of Malignant Gastric Hemorrhage

Introduction: Gastrointestinal bleeding secondary to luminal malignancy is typically difficult to manage with conventional endoscopic therapies. Endoscopic suturing devices have become increasing popular for the management of various resection defects, inadvertent perforations, and bariatric endosurgery. Limited recent data suggests that this technology is effective for refractory bleeding from benign peptic ulcer disease. Herein we describe a case of the successful endoscopic closure of a bleeding malignant gastric ulcer using endoscopic suturing. Case Description/Methods: A 60-year-old male with a past history of primary thrombocytopenia, and recent diagnosis of signet ring gastric adenocarcinoma/linitis plastica (T2, N2, M0) on FLOT chemotherapy (5-fluorouracil, leucovorin, oxaliplatin, and docetaxel) presented with hematemesis and acute on chronic anemia. Physician examination was notable for tachycardia and hypotension. Laboratory evaluation was notable for a hemoglobin of 7.8 g/dL from 15.0 g/dL four days prior. The patient was intubated and urgent upper endoscopy in the intensive care unit was performed which showed active oozing and bleeding from a cratered gastric ulcer (previously biopsy proven adenocarcinoma) on the proximal lesser curvature measuring approximately 20 mm in size (A). Diffuse thickening of gastric folds consistent with linitis plastica was also seen. Initial attempts with bipolar cautery and epinephrine injection were unable to achieve hemostasis. An endoscopic suturing system was employed to place a suture in a figure of eight fashion and cinched at end with closure of the ulcer bed (B). The ulcer bed was not visible after suturing and hemostasis was achieved (C). Repeat upper endoscopy after two weeks for nasojejunal feeding tube placement did not show presence of ulcer and any recurrent bleeding. Patient is being clinically optimized to resume chemotherapy. Discussion: To our knowledge, we describe herein the first case of successful use of endoscopic suturing for closure of a bleeding malignant gastric ulcer. We hypothesize that the thickened gastric folds secondary to the histologic nature of linitis plastica allowed for adequate tissue purchase at the margins of the bleeding gastric ulcer which would typically be precluded in malignant tissue due to its friable nature.Figure 1.: A: Endoscopic image of gastric adenocarcinoma and associated cratered ulcer with oozing hemorrhage. B: Endoscopic image of suture device during closure. C: Endoscopic image of successful approximating edges of ulcer after endoscopic suturing without evidence of bleeding.

Effect of Intravitreal Ranibizumab Injection on Different Optical Coherence Tomographic Patterns of Diabetic Macular Edema

Giriş ve Amaç: Spektral-domain optik koherens tomografi (SD-OKT) ile belirlenen farklı paternlerdeki diyabetik maküla ödemi (DMÖ) olgularında intravitreal ranibizumab (İVR) enjeksiyonunun erken dönem etkinliğini karşılaştırmak.&#x0D; Gereç ve Yöntemler: Tek doz İVR uygulanmış nonproliferatif diyabetik retinopatiye sekonder DMÖ olguları retrospektif olarak analiz edildi. Klinik anlamlı santral DMÖ’sü olan ve santral fovea kalınlığı (SFK)≥250 µm olan gözler çalışmaya dahil edildi. Olgular SD-OKT morfolojisine göre; süngerimsi diffüz retina kalınlaşması (DRK), kistoid maküla ödemi (KMÖ) ve seröz retina dekolmanı (SRD) gruplarına ayrıldı. Gruplar enjeksiyon öncesi ve enjeksiyon sonrası birinci ay kontrollerinde, en iyi düzeltilmiş görme keskinliği (EİDGK), SFK ve total maküla volümü (TMV) değişimi açısından karşılaştırıldı. SFK değişimi üzerindeki başlangıç SFK değerlerinin etkisini dışlamak için ANCOVA analizi ve gruplar arasında randomizasyon yapılarak alt analizler yapıldı. &#x0D; Bulgular: Çalışmaya 101 olgu (44 DRK, 40 KMÖ ve 17 SRD) dahil edildi. Gruplar yaş ve cinsiyet dağılımı açısından benzerdi (p&gt;0,05). Başlangıç EİDGK ve TMV değerleri arasında anlamlı fark yok iken (p&gt;0,05), başlangıç SFK değerleri büyükten küçüğe doğru sırası ile SRD, KMÖ ve DRK şeklinde sıralandı (p