Episodes Of Hematochezia Research Articles

Intraoperative Frozen Section Biopsy for the Auxiliary Diagnosis of Transmural Intestinal Intermediate T-Cell Canine Lymphoma

Intestinal lymphoma is characterized by a malignant lymphoid neoplasm with multifactorial causes, variable clinical symptoms, and, in some cases, rapid progression. This article describes a case of intestinal lymphoma in a dog that had a history of diarrhea lasting two months, accompanied by episodes of hematochezia, which was treated using the CHOP 19 protocol. A seven-year-old male Golden Retriever presented to a veterinary clinic with clinical signs of diarrhea, prostration, and the presence of bloody feces, as reported by the owner. Initial examinations, including hematology, serum biochemistry, and imaging, revealed an abnormal structure in the intestinal region. Considering the circumstances, a surgical procedure was conducted with the aid of a trans-surgical frozen section biopsy. This biopsy aimed to verify the presence of the neoplasm, assess the suspected diagnosis, evaluate the viability of the surgical margins, and determine the possibility of expanding the surgical area. An enterectomy with enteroanastomosis and trans-surgical biopsy was performed, leading to an initial diagnosis of intestinal lymphoma. The tissue fragment was sent for immunohistochemistry, which ultimately confirmed the diagnosis of intestinal T-cell lymphoma. The patient underwent the CHOP protocol for 19 weeks, but during the maintenance phase, abdominal ultrasound examination findings indicated tumor recurrence. Despite being informed of the potential benefits of further chemotherapy, the owner opted not to continue treatment for the animal. Frozen section biopsy can help with diagnosis during surgery, avoiding more invasive procedures and the removal of lymph nodes, since in some cases, the systemic treatment of the disease is recommended.

Case report: juvenile paracoccidioidomycosis with intestinal involvement

Introduction: Contact of Paracoccidioides sp. with the human organism presents in a variety of clinical forms of the disease. Intestinal clinical manifestation is found in 10 to 30% of cases, commonly in juvenile form. This case report seeks to describe a patient with juvenile paracoccidioidomycosis with atypical intestinal involvement. Case report: A 14 years old woman with an updated vaccination schedule and no reports of chronic diseases, allergies or continued use of medications, presented a diarrheal condition that was characterized by pasty stools, where episodes became gradually more intense, associated with episodes of hematochezia, retroauricular lymphadenopathy on the right, as well as shivering and fever. A colonoscopy revealed multiple polypoid formations, ulcerations and friability throughout the colon. After biopsy results, the diagnosis of Paracoccidioidomycosis with intestinal involvement was established. Due to the wasting syndrome, anemia and persistent diarrhea, the patient was hospitalized for blood transfusion and intravenous treatment with conventional Amphotericin B. Discussion: Unlike what was presented by the patient in this case, involvement of the gastrointestinal tract is uncommon in paracoccidioidomycosis. This disease presents a range of clinical manifestations, which makes diagnosis difficult. Since this type of infection is not always considered, it may result in underdiagnosed cases, especially in women and young adults. The prognosis depends on the initial severity of the disease, the presence of comorbidities and the treatment used. Conclusion: Especially for the intestinal form, earlier treatment will better the results. The disease has a good chance of effective treatment using antifungal therapy.

Colonoscopic polypectomy of juvenile polyps in children: Experience from a tertiary centre of Bangladesh

AimsTo assess the specifics of juvenile polyps and the value of polypectomy with complete colonoscopy in pediatric patients. MethodsI retrospectively reviewed the medical records of 81 children diagnosed with juvenile polyps from 2017 to 2021. ResultsThe patients' ages ranged from 1.5 to 18 years. Hematochezia was present in 100% of cases, in which 97.5% of the bleeding was painless. The most frequent was red or dark red hematochezia in 71.6% of cases, followed by red stool with blood dripping in 9 (11.1%) cases. The time interval between the first episode of hematochezia and the colonoscopy ranged from 1 to 47 months. Only 24.7% of polyps were diagnosed by digital rectal examination. Most of the Juvenile polyps were solitary (82.8%) and located in the rectosigmoid part of the colon. The size of the polyps varied from 0.3 to 4 ​cm. Early post-polypectomy bleeding occurred in two cases, while late post-polypectomy bleeding occurred in only one case. ConclusionsAlthough solitary juvenile polyps in the rectosigmoid colon are more common, some patients had multiple and some had proximal polyps. Therefore, a colonoscopy of the entire colon with therapeutic polypectomy is important for improved outcomes when evaluating painless, intermittent hematochezia in children.

A rare cause of hematochezia: colonic extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALToma): A case report and literature review.

Colonic extranodal mucosa-associated lymphoid tissue lymphoma as a cause of hematochezia is rare. Here, we report a case of colonic extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALToma) with presentation of freshy bloody stool and successfully treated by endoscopic mucosal resection. This case was a 69-year-old woman with history of hypertension, reflux esophagitis, and peptic ulcer. She had several episodes of hematochezia and thus sought medical attention at the outpatient clinic. Colonoscopy revealed a 12-mm semipedunculated lesion in the ascending colon. Histopathological examination and immunochemistry were compatible with colonic extranodal mucosa-associated lymphoid tissue lymphoma. Endoscopic mucosal resection was done for tumor removal and hemoclipping was done to achieve hemostasis. The patient remained well without recurrence during 3 years of outpatient follow-up. Colonic MALToma is a rare disease, and could present as hematochezia. En bloc endoscopic resection could achieve long-term remission. The prognosis of colonic MALToma is excellent with its indolent characteristics.

S2138 TACE-Induced Ischemic Colitis

Introduction: Transarterial chemoembolization (TACE) is a locoregional treatment used in patients with hepatocellular carcinoma (HCC). This therapy entails injecting a chemotherapeutic agent into a branch of the hepatic artery supplying blood to the tumor while cutting off blood supply through particle embolization. This procedure may be utilized in a patient who is not a candidate for surgical resection or as a bridge to liver transplantation. Here we present a case of a ischemic colitis in the setting of a recent TACE. Case Description/Methods: A 65-year-old female with history of HCC underwent an outpatient TACE procedure for a 3.6 cm liver lesion. Soon after the procedure the patient complained of severe abdominal pain and was admitted. On day 2 of hospitalization, she developed significant bright red blood per rectum. Computed tomography (CT) demonstrated mild wall thickening and pericolonic fat stranding in the ascending colon concerning for acute colitis. Lactic acid was elevated at 5.8 mmol/L (normal < 2). Colonoscopy demonstrated multiple ulcers and erythema stretching from the cecum to descending colon suggestive of ischemic colitis. Biopsies demonstrated superficial mucosal erosion and necrosis, crypt atrophy, and lamina propria hemorrhage with hyalinization, consistent with acute ischemic colitis. CT angiography demonstrated a patent abdominal aorta and all major branches. The patient was treated conservatively without further episodes of hematochezia and was discharged home (Figure). Discussion: Postembolization syndrome is the most common adverse effect of TACE, which occurs in 60 to 80 percent of patients. This has been reported to be related to either tumor necrosis or due to ischemic damage to normal liver parenchyma. One case of gastrointestinal ulceration has been reported after TACE. To date, there has been no reported case of ischemic colitis after TACE. This presentation of ischemic colitis in our patient may be due to regurgitation of embolized particles into superior mesenteric arterial circulation leading to hypoperfusion of the colon, resulting in ischemic colitis. One should consider this presentation on the differential diagnosis in a patient with hematochezia after TACE.Figure 1.: Ascending and transverse colon demonstrating multiple ulcers and erythema suggestive of ischemic colitis on colonoscopy.

S2579 Colonic Varices: What Are the Therapeutic Options?

Introduction: Colonic varices are a rare case of lower gastrointestinal bleeding (LGIB) with an incidence of 0.07%. The most common sites of colonic varices are the rectum and cecum. Colonic varices are diagnosed on colonoscopy, mesenteric angiography, or computed tomography (CT) scans. Currently, there are no standardized treatments for treatment of colonic varices due to the heterogeneity in localization and vascular anatomy. We present a case of LGIB due to an ascending colon varix. Case Description/Methods: A 38 year-old-man with a history of decompensated alcoholic cirrhosis complicated by esophageal and gastric variceal bleed requiring balloon-occluded retrograde transvenous obliteration one month ago was transferred from an outside hospital (OSH) for liver transplant evaluation and hematochezia. He underwent a colonoscopy at the OSH which showed an ascending colon varix with white nipple sign. His vital signs were normal. His physical exam was benign except for scleral icterus with spider angiomas on his chest. His labs were pertinent for a hemoglobin of 8.0, hematocrit 24, platelet 50,000, alanine aminotransferase 50, total bilirubin 3.0, and international normalized ratio 2.0. The patient was treated with octreotide infusion and antibiotics for spontaneous bacterial peritonitis prophylaxis. A CT three phase abdominal imaging was revealed significant perisplenic and ascending colon varices with smaller varices supplying the descending colon. The case was reviewed with interventional radiology and hepatology and the patient underwent transjugular intrahepatic portosystemic shunt (TIPS) placement with coil and plug embolization of the splenic varix and gonadal varix feeding into the ascending colon varix. The patient did not have any further episodes of hematochezia and his hemoglobin stabilized. A few days later, the patient underwent an orthotic liver transplant. His post-operative clinical course was uncomplicated. Discussion: This is a rare case of a colonic varix resulting in a clinically significant LGIB. There is no standardization of therapy for ectopic varices due to the heterogeneity in vascular anatomy. Therapeutic options include endoscopic variceal band ligation, cyanoacrylate injections, surgery, TIPS and coil embolization. This case highlights the importance of a multi-disciplinary approach with gastroenterologists, hepatologist, interventional radiologists, and surgeons for the treatment of colonic varices.

S1852 Colonic Varices Due to Alcoholic Cirrhosis

Introduction: Ectopic varices (all varices outside the gastroesophageal region) account for 1-5% of all variceal bleeding episodes. Specifically, colon varices are rare, as incidence of colonic varices, irrespective of etiology, is around 0.07%. If colonic varices bleed, treatment is urgent, as delay in treatment can potentially be fatal. Case description/methods: A 55 year old male with a past medical history of complicated diverticulitis status post open sigmoidectomy and heavy alcohol abuse with history of deliriums tremens who was admitted due to having hematochezia with bowel movements for two days. He denied any hematemesis, abdominal pain, melena or NSAID use. Patient was hypotensive on arrival to the ED with MAPs in the 40s. On physical exam, scleral icterus along asterixis and tremors in his hands were noted. CTA Abdomen and Pelvis showed no signs of active gastrointestinal bleeding with signs of hepatic cirrhosis with extensive esophageal, gastric varices, and descending colon varices. Patient had two more episodes of hematochezia in the ED. Patient was given 2 units of emergent blood in the ED to help stabilize his blood pressure. Patient did not have a diagnosis of cirrhosis prior to presentation. He admitted to drinking a six pack of beer daily for the past thirty years. Last colonoscopy was five years ago which showed tubular adenomatous polyps in the rectum and ascending colon. Diverticulosis was also present in the ascending colon. Patient had EGD performed which showed some mild esophagitis and some portal hypertensive gastropathy (PHG) located in the antrum, body and fundus. Flexible sigmoidoscopy was then performed which showed a large amount of fresh and old blood coming from a sigmoid varix at 25 cm located in the sigmoid colon. Hemostasis was achieved with using a Bear claw clip (Figure 1). Discussion: Colonic varices can develop secondary to portal hypertension, congenital anomalies in venous outflow, mesenteric or splenic vein thrombosis, congestive heart failure, or formation of collateral vessels from previous abdominal surgeries. Patients with suspected bleeding colonic varices need immediate assessment, resuscitation, and hemodynamic stabilization. There are no evidence based guidelines for treatment for bleeding colonic varices, but options include medical, endoscopic, interventional radiological and surgical modalities.Figure 1.: Bear claw clip was used to achieve hemostasis.

Gastrointestinal bleeding from gangliocytic paraganglioma treated with palliative radiotherapy: a case report

: Gangliocytic paraganglioma (GP) is a rare neuroendocrine tumor typically found in the second part of the duodenum. The rarity of this tumor has not allowed development of treatment guidelines. The mainstay of treatment involves endoscopic or surgical resection. Adjuvant chemotherapy or radiation have been utilized in a few cases. Gastrointestinal bleeding from GP treated with radiotherapy has not been described in the literature. The case described is of a patient presenting with a 6-month history of hematochezia and a one week history of fatigue. An esophagogastroduodenoscopy (EGD) was performed demonstrating a 3-cm periampullary, non-obstructing mass with areas of ulceration and oozing. Pathology from biopsy samples showed trabeculae and cords of epithelioid cells bordered by S-100 positive spindled cells consistent with paraganglioma as well as scattered “large cells” without typical ganglion cell morphology. GP was favored versus other neuroendocrine carcinomas given its classic location in the second part of duodenum, presentation with bleeding, and the morphological pattern of paraganglioma. This patient was a poor surgical candidate and at high risk of perioperative mortality due to multiple chronic comorbidities and poor functional capacity. It was decided to administer fourteen courses of 35 Gray (Gy) palliative radiotherapy to control the patient’s gastrointestinal (GI) bleeding. Surveillance EGD was performed after his tenth treatment which showed no further areas of oozing along the mass. From his first to his last radiotherapy session, his hemoglobin improved from 7.5 to 8.9 g/dL without further episodes of hematochezia. One week after his discharge, the patient died from cardiac arrest. Radiotherapy may be useful in controlling GI bleed secondary to GP in a palliative setting.

S2157 An Unusual Cause of Hematochezia in a Patient with Chronic Pancreatitis

INTRODUCTION: Pancreatic pseudocyst formation can lead to fistulization with nearby vessels which can lead to melena and hemodynamic instability. We report a rare case of a patient with chronic pancreatitis who presented with hematochezia from a pancreatic pseudocyst eroding into the splenic artery, forming a splenic pseudoaneurysm (SPA) with simultaneous fistula formation with the descending colon. To our knowledge, this has not been reported in the literature. CASE DESCRIPTION/METHODS: A 46 year old male with a history of chronic pancreatitis presented to the hospital with epigastric pain for 1 month. He also reported three episodes of hematochezia over the past 2 days. He reported drinking Vodka daily for 20 years. Vital signs were stable. Rectal exam showed brown mixed with maroon colored stool. Lab values: Hg 9.7 g/dL (baseline Hg 15), MCV 96 fl, RDW 16.8%. EGD showed a white clean based duodenal ulcer, portal hypertensive gastropathy and no varices. Colonoscopy showed no blood in the ascending colon however with a large amount of blood and clots in the descending and sigmoid colon, with no identifiable source of bleeding (Figures 1–2). Given continuous bleeding, CTA abdomen pelvis was done and showed an actively bleeding SPA into the pancreatic pseudocyst that had fistulalized with the descending colon causing rectal bleeding. IR angiogram showed SPA which was embolized successfully (Figure 3). After embolization, he had no further episodes of bleeding and was discharged home. He was lost to follow up after discharge. DISCUSSION: Chronic pancreatitis cases can be complicated by pancreatic pseudocysts. Complications from pancreatic pseudocyst formation include fistulization, infection or bleeding. Commonly, patients with chronic pancreatic pseudocysts can form gastroduodenal pseudoaneurysms, which present as upper GI bleeding. In rare cases, vessels near the pancreatic pseudocyst such as the splenic artery have been known to form fistulas with the transverse colon, which presents as hematochezia. Our patient presented with hematochezia from a SPA that eroded into the pancreatic pseudocyst which also formed a fistula with the descending colon. To our knowledge, this has not been reported in the literature. Rupture of SPA into the pseudocyst with concomitant fistula creation to the left colon can lead to a massive gastrointestinal bleed. Once suspected, IR guided embolization of the involved vessel and/or endovascular repair can be life-saving.Figure 1.: Colonoscopy findings in descending colon.Figure 2.: Colonoscopy findings in sigmoid colon.Figure 3.: IR angiogram findings.

S2837 An Uncommon Diagnosis Presenting as Acute Blood Loss Anemia

INTRODUCTION: Cryptogenic Multifocal Ulcerous Stenosing Enteritis (CMUSE) is a rare disease that is difficult to diagnose because of the nonspecific clinical manifestations and vague radiological findings across multiple diagnostic modalities. This abstract aims to present a case of CMUSE, re-iterate how its presentation can mimic other common GI conditions, and emphasize the importance of its consideration when the common GI conditions do not align with a patient's presentation. CASE DESCRIPTION/METHODS: 78 year old male presents with two episodes of hematochezia. Pt denied prior history of anemia or melena and was not on oral anticoagulation. He completed a colonoscopy which revealed pan diverticulosis and internal hemorrhoids. He continued to have intermittent hematochezia with significant anemia. A pill cam was then completed and showed distal small bowel with active bleeding from unclear etiology. A distal small bowel stricture was noted to be present, and for this reason, the pill cam was unable to pass. CT enterography was then recommended; this did not reveal a colonic stricture as was seen on the pill cam study, but rather, it revealed a 1cm enhancing nodule in the distal small bowel. Surgery was consulted for small bowel laparoscopy with plan for resection of the nodule to obtain pathology. Two small bowel tumors were observed in the distal ileum approximately 10cm apart in addition to a jejunal diverticulum with thickened tissue. Pathology reported non-specific shallow ulceration confined to the mucosa and submucosa and no identifiable granulomas. Working differential diagnoses at that time included: Crohn’s Disease, CMUSE, and Drug Induced Ulceration with Stenosis. Immunological work revealed negative C-ANCA, P-ANCA, Saccharomyces Cerevisiae Antibodies: IgG 4.5, IgA 5.2 (Relative Ranges 0–24.9). After negative antibody titers, the working diagnosis in this patient is CMUSE. DISCUSSION: Although this patient did not present with an ileus as many patients with CMUSE do, the anemia 2/2 GI bleeding, ulcerations and capsule retention in the distal small bowel are consistent with the diagnosis. Tao et al reported in 2019 that the most effective form of treatment is immunotherapy and surgery, the reported patient receiving the latter. However, the recurrence rate is high, and some patients become steroid dependent. Increasing awareness of this condition can contribute to identification of the optimal treatment of this rare condition in an effort to improve the lives of those affected.Figure 1.: One centimeter enhancing nodule in the distal small bowel noted on CT enterography.Figure 2.: Active bleeding in distal small bowel noted on pill cam study.

S1749 Human Intestinal Spirochetosis: An Atypical Cause of Symptomatic Colonic Ulceration

INTRODUCTION: This case demonstrates an atypical presentation of intestinal spirochetosis in a patient with HIV on anti-retroviral therapy with adequate viral suppression. CASE DESCRIPTION/METHODS: A 56-year-old male presented with one day of hematochezia and abdominal cramping. He had a past medical history of HIV on Highly Active Antiretroviral Therapy with recent undetectable viral load and CD4 count of 1225. On initial assessment, he was tachycardic with frank blood on rectal examination. Hemoglobin was 11.8 with a baseline of 14.7. Computed Tomography scan of the abdomen and pelvis was significant for contrast extravasation in the cecum consistent with active gastrointestinal bleed. His hemoglobin further downtrended to 9.4, but he remained hemodynamically stable. Colonoscopy revealed a solitary twenty mm ulcer in the cecum without active bleeding. Biopsy obtained from the ulcer edge demonstrated intestinal spirochetosis (Warthin-Starry stain positive) and focal acute colitis with lamina propria hemorrhage. Patient remained clinically stable without further episodes of hematochezia and was discharged before biopsies resulted. Unfortunately, he was lost to follow-up. DISCUSSION: Human intestinal spirochetosis is rare in developed countries but when present, they are often found in homosexual males and those with HIV. Stool colonization rates in homosexual men in the US have ranged between 20.6 and 62.5%. It is most commonly caused by Brachyspira aalborgi or Brachyspira pilosicoli. Patients are often asymptomatic but can present with abdominal pain and watery diarrhea. Endoscopic findings are usually non-specific since mucosa may be normal, polypoid, or mildly erythematous. There are only case reports of colonic ulceration. Diagnosis is made by histology with hematoxylin-eosin and Warthin-Starry silver stains which demonstrate spirochetal adhesion along the border of the intercryptal epithelial layer. Treatment is reserved for immunocompromised and symptomatic patients and consists of metronidazole for 10 days with resolution of symptoms. Complete mucosal healing has been observed for those who opt for repeat endoscopy. Our patient is unique since he had sudden large-volume hematochezia without diarrhea and a rather discrete endoscopic finding despite viral suppression and a robust CD4 count. Therefore, clinical suspicion for intestinal spirochetosis should be moderately high in patients with these specific risk factors.Figure 1.: Clean-based cecal ulcer.Figure 2.: Warthin-Starry silver stain of cecal ulcer edge biopsy highlighting spirochetes on the surface epithelium.

S2830 Hematochezia of Unknown Origin

INTRODUCTION: The estimated incidence of neuroendocrine tumors in the United States ranges from 2.5 to 5 cases per 100,000. Although relatively rare, the most common location for them is the small bowel, specifically the ileum. Rarely do they present with hemodynamically significant bleeding or at a young age. The following case is a rare presentation of substantial hematochezia from a small bowel neuroendocrine tumor in a young, otherwise healthy male. CASE DESCRIPTION/METHODS: The patient is a 26 year old male who presented to hospital complaining of bloody stools.His hemoglobin on admission was 6.9 dg/L. Patient underwent a CTA that was read as 1.6 cm mesenteric mass and right colon extravasation, but subsequent angiography was negative for active bleeding. A follow-up Meckel’s scan was also negative. Within 3 days, the patient had 12 bloody stools and required transfusion of 6 units of blood. An EGD and colonoscopy revealed no sources of acute bleed. Decision was then made to transfer the patient to a higher acuity facility for push enteroscopy and video capsule endoscopy. VCE on transfer was remarkable for 3 areas of fresh blood mixed with mucosa in the distal small bowel. Decision was made for a push enteroscopy the next day, however it revealed a normal small bowel from the ileocecal valve to about 100cm into the ileum. The patient was stabilized and a few weeks later underwent an exploratory laparotomy where a mesenteric mass and 2 lymph nodes were biopsied. There was also appreciable denseness to the mid and distal jejunum. Subsequent biopsies were remarkable for a well-differentiated, G2 neuroendocrine tumor likely representing a metastatic tumor from the adjacent small intestine. Since surgery, the patient reports no further episodes of hematochezia. DISCUSSION: The most common site of small bowel neuroendocrine tumors is the ileum, approximately 60-100cm from the ileocecal valve. While abdominal pain is the most common presentation, GI bleeding is the initial symptom in 23-29 percent of cases. One study of neuroendocrine tumors found it took an average of 2.3 tests before a diagnosis was determined. In this case, the patient underwent multiple imaging and endoscopic evaluation before ascertaining a cause for his bleeding. These tumors are typically found in the 6th or 7th decade of life, which is one of the unusual facets of this case. For a tumor of this size, surgery with extensive lymph node resection is associated with low local recurrence.Figure 1.: Mesenteric tumor pathology report.

S1685 Cocaine-Associated Ischemic Colitis: A Rare Form of Lower Gastrointestinal Bleeding

INTRODUCTION: Cocaine is a commonly abused stimulant drug. It causes vasoconstriction through stimulation of alpha-adrenergic receptors. The majority of adverse effects are cardiovascular. Gastrointestinal complications occur less frequently – but include ischemia, ulceration, gangrene and perforation. CASE DESCRIPTION/METHODS: A 37-year-old Hispanic woman with history of post-traumatic stress disorder presented with two days of crampy LLQ abdominal pain. She also reported non-bloody diarrhea followed by episodes of hematochezia and a fever of 103 degrees F. She admitted using cocaine the day prior to symptom onset. She denied use of oral contraceptives. On examination, she had LLQ tenderness but no guarding or rigidity. Laboratory studies revealed WBC 11.9 (×103/uL), ESR 29 mm/hr, CRP 3.99 mg/dL. Urine toxicology was positive for cocaine. CT abdomen showed circumferential thickening of the transverse and sigmoid colon (Figure 1). MR Venogram showed no acute mesenteric thrombosis. Stool studies including Clostridium Difficile toxin were negative. A subsequent colonoscopy located moderate inflammation characterized by congestion, erythema and linear ulcerations in the transverse colon (Figure 2). Biopsies revealed acute inflammation. Given the clinical presentation, the patient was diagnosed with acute ischemic colitis (IC) due to cocaine use. She was treated with intravenous hydration and antibiotics (ciprofloxacin and metronidazole). Her gastrointestinal bleeding and abdominal pain resolved after two days, with no recurrence of symptoms. DISCUSSION: We present a case of IC related to cocaine use. IC occurs more commonly in the elderly due to risk factors including atherosclerosis. However it can occur in younger populations due to intestinal arteriolar vasospasm related to cocaine use. Cocaine related gastrointestinal complications are rare. The interval from drug ingestion to symptom onset varies from 2 hours to upto 2 days. Patients can present with fever, nausea, vomiting, severe abdominal pain and hematochezia. The majority of cases reported in the literature have shown ischemia of the small bowel, with large bowel involvement less common. Physicians should have an index of suspicion for cocaine associated IC in younger populations, especially those with a history of substance abuse. It is important to rule out hypercoagulable states and thrombo-embolic events. A thorough history together with contrast imaging and colonoscopy can aid in diagnosis and prognostication.Figure 1.: Computerized tomography (CT) of the abdomen showed circumferential thickening of the transverse colon consistent with colitis.Figure 2.: Colonoscopy revealed moderate inflammation characterized by congestion, erythema and linear ulcerations in the transverse colon. Biopsies revealed acute inflammation on pathology.

A case of a patient in whom the cause of three episodes of hematochezia was different each time

A case of a patient in whom the cause of three episodes of hematochezia was different each time

P098 Worsening Colitis and Congestive Heart Failure Related to Mesalamine Use

BACKGROUND: Five-amino salicylic acid derivatives are generally well-tolerated agents commonly used to treat ulcerative colitis. Serious reactions are rare. We present a case of paradoxical worsening of ulcerative colitis and acute heart failure in a young woman on mesalamine therapy. CASE: A 37-year old white female with a history of sleeve gastrectomy and recently diagnosed mild to moderate extensive ulcerative colitis (UC) had been on oral mesalamine for 1 month. She endorsed worsening symptoms, with 10-12 watery bowel movements daily along with 3-4 episodes of hematochezia and generalized abdominal cramps. Lack of response to prednisone prompted admission. She was found to be severely dehydrated, hyponatremic with a sodium of 132 mEq/L, and anemic with a hemoglobin of 10.2 g/dL (from normal three months earlier). Albumin was decreased at 3.1 g/dL and C-reactive protein (CRP) was elevated at 4.2 mg/dL. Stool tests for Clostridioides difficile, other bacteria, and viruses, were negative. Flexible sigmoidoscopy showed Mayo 3 colitis despite 3 days of IV methylprednisolone. Her hospital course was complicated by acute heart failure presenting as leg edema and shortness of breath. Brain natruretic peptide level was elevated at 550 pg/mL. Echocardiogram revealed global hypokinesis of the left ventricle and an estimated ejection fraction of 30-35%. Given this contraindication to anti-tumor necrosis factor agents, she was started on tofacitinib 10 mg thrice daily. Surgical consultation was also obtained. After three doses her abdominal pain improved, diarrhea decreased to 5 bowel movements daily, and CRP decreased to 1.9 mg/dL. After three days, the dose was decreased to 10 mg twice daily. On clinic follow-up 3 weeks later, she was pain-free and bowel movements were back to baseline with no blood and no diarrhea. CRP and albumin normalized. Her shortness of breath and leg edema had also resolved. Multigated acquisition scan 3 months after discharge showed resolution of left ventricle wall motion abnormalities, and a normal ejection fraction of 61%. DISCUSSION: Five-amino salicylic acids (5-ASA) are relatively safe medications. Serious reactions including pancreatitis, interstitial nephritis, blood dyscrasias, pneumonitis, and Stevens Johnson syndrome, are rare. Infrequently, paradoxical worsening of colitis is seen. This phenomenon is not well understood and there is no consistency in the presence of inflammatory markers. Confirmation requires a mesalamine challenge, which is not often feasible. Acute cardiac side effects from mesalamine are extremely uncommon, potentially serious, and appear dose-independent. The exact mechanism by which it might induce myocardial inflammation and heart failure is unclear. Existing hypotheses include: a hypersensitivity reaction due to inhibition of COX enzyme and subsequent acceleration in metabolism of arachidonic acid to lipoxygenases, humoral-mediated hypersensitivity wherein antibodies against mesalamine cross-react with the myocardium, cell-mediated hypersensitivity, and immunoglobulin E-mediated allergic reaction. Symptoms usually manifest within 2-4 weeks of starting the drug. CONCLUSION: The temporal relationship between our patient’s symptom onset and initiation of mesalamine indicates a causal relationship. Mesalamine should remain on the differential of worsening UC, and acute heart failure, after evaluating for more common causes.

2637 An Unusual Cause of Persistent Abdominal Pain and Hematochezia an Adult Male; Small Bowel Meckel’s Diverticulum Causing Intussusception

INTRODUCTION: Symptomatic Meckel’s diverticulum (MD) in adults is extremely rare. The prevalence of MD in the entire population ranges from 0.3%–-2.9% with a lifetime incidence of symptoms at 4.2%. The common presentations of symptomatic MD are obstruction, gastrointestinal (GI) bleed, and inflammation; these complications are significantly more frequent in childhood. This case report highlights direct observation by traditional colonoscopy of small bowel MD as a lead point of intussusception in an adult. CASE DESCRIPTION/METHODS: A 25-year-old male presented to the hospital with acute on chronic periumbilical abdominal pain worsening over several days. He reported intermittent watery diarrhea and an episode of hematochezia. He was also hospitalized earlier in the year for bowel obstruction of unknown etiology, but found to have intussusception status-post diagnostic laparotomy and partial ileal resection. His vital signs were stable and the physical exam revealed peri-umbilical tenderness. Laboratory data resulted with fecal calprotectin 517.7 mg/kg, hemoglobin 10.2 g/DL, WBC 11.6 × 10exp9/L, ESR 33 mm/h, CRP 78.51 mg/L, and a negative Clostridium difficile PCR test. A CT abdomen/pelvis revealed mild thickening and mucosal hyperenhancement of the terminal ileum. A colonoscopy was performed due to concern for GI bleed and inflammatory bowel disease. On colonoscopy, the colon was normal, but a partially obstructing, mobile, villous mass was noted in the ileum. Subsequently, an exploratory laparotomy found recurrent small bowel intussusception. The ileal mass was resected and pathology showed ectopic gastric and pancreatic tissue confirming MD. An ulcer and acute inflammation were noted on the mass. His follow-up course was unremarkable and the patient’s symptoms have since improved. DISCUSSION: The symptoms of MD are significantly more common in other etiologies. In addition, symptomatic MD is rarely diagnosed in adulthood which makes the diagnosis of MD in adults a challenge. MD is often diagnosed by imaging modalities or direct observation during surgery. Balloon-assisted enteroscopy and capsule endoscopy are other diagnostic measures being explored. Endoscopy is indicated in patients presenting with GI bleed and was completed in this patient. A large portion of this patient’s distal ileum was previously resected and his altered anatomy allowed the direct observation of MD by colonoscopy. This case highlights a unique endoscopic finding that endoscopists should be aware as the etiology for GI bleed.

2040 Where Can the Lesion Be? A Pelvic GIST With Both a Normal Upper and Lower Endoscopy

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumor of the GI tract; the age-adjusted incidence is 6.8 per million in the SEER data collected from 1992-2000 [1]. CASE DESCRIPTION/METHODS: An 80-year-old female with history of CVA, hypertension, diabetes, hyperlipidemia, diverticulosis, and mild antral gastropathy with negative H.Pylori presented to the hospital with syncope and two episodes of dark stools mixed with bright red blood. Physical exam revealed normoactive bowel sounds and tenderness to palpation in the left lower quadrant without rebound tenderness. A rectal exam was positive for melena but negative for any palpable masses or hemorrhoids. Initial laboratory workup showed a hemoglobin of 4.8 and elevated BUN to 60 from a baseline of 40. Patient was fluid resuscitated and given packed red blood cells with appropriate response to transfusion; the patient remained hemodynamically stable and had no further episodes of hematochezia. On endoscopic investigation, both upper and lower endoscopy were unremarkable and did not reveal any lesions; colonoscopy showed old blood but no active bleeding. An Abdominopelvic CT scan was performed which showed a 9.5 × 9.8 cm soft tissue mass in the right abdomen inferior to the liver and a 12.5 × 12.4 cm conglomerate soft tissue mass in the right pelvis as well as a 1.3 cm left hepatic hypodensity concerning for liver metastasis (Figure 1). Core biopsy of the pelvic mass revealed spindle cells and positive KIT (CD 117) consistent with GIST (Figures 1 and 2). DISCUSSION: GISTs are commonly are found in the stomach and proximal small intestine, but they can be found in any part of the gastrointestinal tract. GISTs are composed of spindle (70%) or epithelioid (30%) cells, and 10%-30% are malignant showing intra-abdominal spread or liver metastases. Most GISTs will be positive for a KIT protooncogene mutations leading to uncontrolled activation of KIT (CD 117), a receptor tyrosine kinase (RTK) [2]. The likelihood of metastasis increases when the tumor reaches a size of 10 cm. Tumors located in the small intestines have more potential of metastasis than gastric tumors due to delay in onset of symptoms. While endoscopic investigation is a significant diagnostic method, some cases may yield unremarkable findings. Our case highlights the importance of obtaining further imaging studies when no source of gastrointestinal bleed or mass can be identified on initial endoscopy.

2587 Never Too Old for Meckel's: A Unique Presentation of an Uncommon Source of Gastrointestinal Bleeding in Adults

INTRODUCTION: Meckel's diverticulum is a common gastrointestinal congenital malformation, affecting approximately 2% of the population. Related complications such as bleeding commonly occurs in the pediatric age group; although, in adults it is often missed. We present a case of recurrent obscure-overt gastrointestinal (GI) bleeding secondary to a Meckel's diverticulum which remained elusive after multiple diagnostic studies. CASE DESCRIPTION/METHODS: 30-year-old male with history of recurrent GI bleeding, presents to the outpatient GI clinic for further evaluation after being admitted to the intensive care unit (ICU) 3 weeks prior with massive hematochezia requiring several blood transfusions for a drop-in hemoglobin from 14 gm/dL to &lt;7 gm/dL. The patient had undergone endoscopy, colonoscopy, and video capsule endoscopy (VCE) three years prior for similar symptoms without an identifiable source. A nuclear tagged red blood cell scan was performed showing bleeding in the proximal colon. CT angiography following showed contrast extravasation in the distal jejunum and ileum which was treated with gel foam. The patient had no further episodes of hematochezia and was discharged. After the clinic visit, the patient underwent a Meckel's scan which did not show ectopic gastric mucosa but revealed colonic bleeding proximal to the hepatic flexure. Ileocolonoscopy was normal. Subsequent VCE showed abnormal mucosa in the distal small bowel. He finally underwent a retrograde balloon enteroscopy which revealed a distal small bowel diverticulum with a single adjacent, nonbleeding ulcer (Figure 1). Biopsies of the ulcer showed gastric foveolar metaplasia. Based on the findings, he was referred for a small bowel resection which revealed a jejunal Meckel's diverticulum with gastric oxyntic heterotopia on histology (Figures 2 and 3). DISCUSSION: This case highlights the potential morbidity and possible mortality of Meckel's diverticulum as a source of lower GI bleeding. Recent studies have recommended against prophylactic surgical resection in the absence of certain risk factors including age less than 40, male gender, and macroscopic mucosal alteration. Given this patient's significant hematochezia, transfusion requirements, and gross peri-diverticular ulceration, we opted for small bowel resection. Meckel's diverticulum should always be included in the differential for occult or overt GI bleeding, especially in young patients when no other sources of bleeding are readily identifiable.

2633 A Challenging Case of Ileo-cecal Intussusception in Pregnancy

INTRODUCTION: Intussusception is an extremely rare cause of intestinal obstruction in adults; being reported in up to 1% of cases of obstruction and in contrast to children almost always is secondary to an identifiable lesion forming a lead point. Its incidence is even lower in pregnancy with studies reporting incidence rates ranging from 0.067% to 0.0015%. Rarity of the condition combined with non-specific clinical presentation make diagnosis difficult in adults. This is particularly challenging in pregnant patients due to the overlap of symptoms with pregnancy and limited findings on abdominal examination. High morbidity and mortality for both mother and child warrant prompt investigation and surgery. CASE DESCRIPTION/METHODS: We describe the case of a 39-year-old female who presented in the third trimester with abdominal pain and an episode of hematochezia. Ultrasound findings were suggestive of ileo-colic intussusception that was confirmed with subsequent magnetic resonance imaging. The lead point was formed by an adenocarcinoma of the colon measuring 4 cm. Our patient underwent a right-sided colectomy with primary ileocolostomy. The postoperative course was uneventful for both mother and fetus, and the patient was discharged a week after the surgery. DISCUSSION: Intussusception very rarely presents during pregnancy. Ultrasonography of the abdomen is the initial test of choice in most cases and the findings of single or double anechoic rings surrounding a central echogenic focus is the classic hallmark. CT scanning is considered to be superior in adults with a reported diagnostic yield of over 50%. MRI, however, is the preferred imaging modality in pregnancy as it helps avoid the risk of radiation to the fetus and has comparable sensitivity to CT. Most cases are diagnosed by exploratory laparotomy which itself is associated with a high risk of miscarriage and pre-term birth, with some studies reporting miscarriage rates as high as 8%. Adults almost always require surgery as untreated bowel obstruction carries a maternal mortality of up to 6% and fetal mortality as high as 26%. Surgical reduction of intussusception can be tried but most patients require bowel resection, which is also the procedure of choice if a mass is identified at the leading point. Nearly 50% of these masses will be malignant. This report highlights the importance of abdominal imaging and urgent intervention in suspected cases of intussusception in pregnancy.

3084 A Case of CMV Colitis: Both a Cause and Consequence of Acute Renal Allograft Rejection

INTRODUCTION: Cytomegalovirus is an extremely common pathogen that usually causes a mild, self-limiting disease in the immunocompetent host. The risk of active CMV disease increases in states of immunosuppression (AIDS, transplant recipients, cancer, IBD, use of immunosuppressive agents). CMV infection in transplant recipients has a predilection for the gastrointestinal tract. CASE DESCRIPTION/METHODS: A 46 yo African American male with history renal transplant in 2002 presented to the hospital for worsening creatinine. He was previously doing well on immunosuppression with sirolimus, cyclosporine, and prednisone. His baseline creatinine was 2.2-2.6 mg/dL. On admission his Cr was 5.8. He underwent a renal biopsy that was suspicious for antibody-mediated rejection. He received high dose IV steroids, plasmapheresis, and IVIG. His Cr improved to 4 and he was discharged on tacrolimus, mycophenolate, and a tapering prednisone dose. He returned to the hospital 3 weeks later with dyspnea and peripheral edema. He also had 2 episodes of hematochezia the day prior. His Cr increased to 7.2 and his hemoglobin dropped from 8.9 g/dL to 6.9. He was started on dialysis. His hemoglobin initially improved with a transfusion but 3 days later dropped to 6.9. GI was consulted. Colonoscopy revealed a 7 × 7 mm ulcer at the ileocecal valve. Biopsies confirmed CMV colitis. He was evaluated by infectious disease for treatment. DISCUSSION: CMV infection of the GI tract is relatively common in organ transplant recipients and can involve the upper or lower GI tract. It can result in mucosal injury, ulcerations, hemorrhage, GI dysmotility, or perforations. CMV colitis can present with fever, abdominal pain, diarrhea, hematochezia, toxic megacolon, or perforation. Lower GI bleeding is the most common initial presentation. Endoscopic findings of CMV colitis are categorized into 3 groups: well-demarcated ulcers, diffuse infiltrative ulcers, and pseudomembranous patterns. Sometimes hemorrhagic colitis is seen with multiple punctuate lesions. CMV reactivation can be elicited by high intensity immunosuppression and disease can lead to allograft dysfunction and rejection. Patients at risk for CMV infection should be started on antiviral prophylaxis. With symptoms of disease, a prompt diagnosis is necessary in order to start antiviral therapy with IV ganciclovir or oral valganciclovir. A delay in treatment can result in high morbidity and mortality and therefore clinicians need to have a high index of suspicion.