Hemoccult-positive Stools Research Articles

Abstract 4808: Small intestinal leiomyosarcoma in a young adult

Abstract Objectives: • Outline the epidemiology of leiomyosarcoma•Identify the immunohistochemistry of a leiomyosarcoma Introduction: Primary small intestinal malignancies are rare malignancies as compared with other malignancies of the gastrointestinal tract. Here, we present a case of a jejunal leiomyosarcoma in a young adult. Case Presentation: A 23-year-old Caucasian male with GERD presented with five months of abdominal pain, intermittent nausea with non-bloody emesis, and a 20-pound weight loss. Presenting vital signs were within normal limits. Physical exam revealed conjunctival pallor with epigastric tenderness to palpation. Serology demonstrated iron deficiency anemia, hemoccult positive stool, negative CEA, CA19-9, and AFP tumor markers. HIV antigen antibody and EBV-PCR were non-reactive. CT of the abdomen and pelvis revealed markedly thickened heterogenous jejunal loop in the left hemiabdomen with associated mesenteric adenopathy and small volume pelvic ascites. EGD with push enteroscopy revealed a single, malignant appearing and ulcerated mass in the proximal jejunum. PET-CT showed a hypermetabolic, multilobulated, ill-defined mass involving multiple loops of jejunum. He underwent exploratory laparotomy with resection of a proximal jejunal mass (10x8 x7 cm), mesenteric lymphadenectomy, and a jejunojejunostomy creation. Pathology demonstrated leiomyosarcoma (pT2aN0MoG3), and he was initiated on cyclophosphamide and doxorubicin. Discussion: Primary small intestinal malignancies are rare malignancies with an incidence of less than 5% of all GI malignancies. 56 cases of GI leiomyosarcoma in adults were identified between 2000-2012 with a peak incidence between 55-59 years of age (Aggarrwal 2012). Leiomyosarcomas are soft tissue sarcomas arising from bones, tendons, blood vessels, or muscles with a spectrum of disease ranging from low-grade cutaneous lesions to aggressive lesions of internal organs with significant potential for metastasis (Pipe 2002). Diagnosis is based on immunohistochemical positivity for SMA, desmin, and h-caldesmon, and negativity for CD117, CD34, and DOG1.1, notably lacking KIT and PDGFRA mutations (Aggarwal 2012). Treatment involves surgical resection and a cost benefit analysis of adjuvant chemotherapy with (Reynolds, 2014). This case of a 23 year old, without significant risk factors, diagnosed with a jejunal leiomyosarcoma presents as one of the youngest cases ever to be reported and emphasizes the importance of recognizing the cancer in a broader range of the adult population. Citation Format: Alyssa A. Guo, Blake H. Bentley, Abigail L. Ellington, Haiyan Lu, William C. Lippert. Small intestinal leiomyosarcoma in a young adult [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4808.

S2563 Upper GI Bleed Caused by Ampullary AVM

Introduction: GI bleed (GIB) is responsible for 1,000,000+ hospitalizations every year, and a mortality rate of 2-10%. Ampullary AVMs are an uncommon etiology of GIB and difficult from a diagnostic standpoint. We present a case of 77-year-old man presenting to emergency department (ED) with acute shortness of breath (SOB) and chest pain (CP), and dark stools for 4 days, found to have acute GIB caused by ampullary AVM. Case Description/Methods: 77-year-old white male presented to ED with acute SOB and CP. Past medical history included aortic regurgitation s/p valve replacement, atrial fibrillation s/p ablation and watchman, chronic anemia with baseline Hgb of 9, HTN, HFpEF, and ulcerative colitis s/p curative total proctocolectomy and ileostomy with modified Kock pouch procedure. Physical exam was unremarkable aside from dark-appearing ileal pouch output. He was not on anticoagulation and denied Pepto-Bismol use. Abnormal labs included Hgb/Hct of 5.1/16.4, BUN:Cr 37:1.93, and hemoccult positive stool from ileal pouch. Presenting symptoms of anemia (CP, SOB) were consistent with lab findings, concerning for GIB in setting of hemoccult positive stool. He received IV Protonix, Rocephin, and 1u pRBCs for acute blood loss anemia secondary to suspected GIB and was admitted to hospitalist. GI was consulted to do EGD, which showed active bleeding around major papilla, suggesting hemobilia. Subsequent CT A/P with contrast showed no clear etiology of bleed, so nuclear medicine bleeding scan was performed. The scan was unremarkable, and he continued to have melena, requiring 2u of pRBCs. Finally, ERCP was pursued to evaluate for potential biliary source. A normal bile duct (BD) was identified via cholangiogram, measuring 10mm without filling defect. Sphincterotomy was performed, followed by BD sweeping using a stone extraction balloon. No blood clots were noted, making hemobilia less likely. However, slow bleeding from inferior aspect of ampulla was visualized. The site was lavaged and appeared to be ampullary AVM (see Figure). Before ablation of AVM, a PD stent was placed to reduce likelihood of post-ERCP pancreatitis. Following procedure, his Hgb normalized, and he stopped having melenic stools. He continued PPI treatment outpatient and is doing well. Discussion: To our knowledge, no case of GIB caused by ampullary AVM is found in the literature. Thus, this case reports a rare finding of ampullary AVM and provides support for endoscopy as diagnostic approach in such patients.Figure 1.: Ampullary AVM.

1961 Everolimus-Associated Gastric Antral Vascular Ectasia in a Patient With Advanced Breast Carcinoma

INTRODUCTION: Targeted cancer therapies have led to improvement in survival time and quality of life for patients with various cancer types, including advanced breast cancer. Everolimus is a mammalian target of rapamycin (mTOR) inhibitor approved for use in combination with exemestane for advanced hormone-receptor positive, HER2-negative breast cancer in post-menopausal women. While typically well-tolerated, a few cases of upper gastrointestinal bleeding from gastric antral vascular ectasia (GAVE) associated with everolimus have been described, primarily in oncology literature. In our patient, we present a case of gastrointestinal bleeding due to GAVE during treatment with everolimus. Given the clinical consequences of this adverse effect, gastroenterologists must maintain awareness of the associated risk of gastrointestinal hemorrhage and approach to treatment in patients treated with this agent. CASE DESCRIPTION/METHODS: Our patient is a 64-year-old female with stage III left breast invasive ductal carcinoma (HER2-negative, estrogen receptor positive, progesterone receptor positive). She underwent left lumpectomy, adjuvant doxorubicin and cyclophosphamide, paclitaxel, and radiation. Follow-up revealed bony metastases and right upper lobe pulmonary metastatic disease. She was initiated on exemestane and everolimus. Three weeks later, she presented with severe weakness and dyspnea. Rectal examination with dark hemoccult positive stools. Laboratory findings revealed Hgb of 6.0 g/dL. An upper endoscopy showed no source of bleeding. The patient responded to blood transfusions and Hgb stabilized. One month later, the patient represented with symptomatic anemia. A repeat upper endoscopy revealed blood with diffuse gastric antral oozing consistent with GAVE. She was treated with argon plasma coagulation (APC), and everolimus was discontinued. The patient stabilized after endoscopic therapy and was discharged after recovery. DISCUSSION: Gastrointestinal bleeding due to GAVE while undergoing treatment with everolimus is an uncommon event with an unknown mechanism. Review of current literature shows that few similar cases have been previously reported. Our patient responded well to therapy with APC. However, progression to life-threatening bleeding with poor response to endoscopic therapy has been described. As use of everolimus increases, we are more likely to encounter gastrointestinal bleeding due to GAVE. Clinicians should remain alert to the risk of severe bleeding and the utility of APC in these patients.

Preoperative Right-Sided Cardiac Congestion Is Associated with Gastrointestinal Bleeding in Patients with Continuous-Flow Left Ventricular Assist Devices.

Large scale data on preoperative risk stratification for gastrointestinal bleeding (GIB) following continuous-flow left ventricular assist device (CF-LVAD) implantation are scarce. To identify independent predictors for GIB following CF-LVAD implantation. We conducted a retrospective cohort study of consecutive 243 patients who underwent CF-LVAD implantation (HeartMateII) from January 2009 to March 2015 at the University of Chicago Medical Center. GIB was defined as the presence of overt bleeding or occult GIB with ≥2g/dl drop in hemoglobin (Hgb) from recorded baseline values and hemoccult-positive stool. The preoperative and postoperative data were reviewed. Within a median follow-up duration of 408 (IQR 113-954) days, 83 (34%) patients developed GIB after a median of 149 (IQR 27-615) days after implantation of CF-LVAD. There were no significant differences between the groups of GIB and non-GIB with respect to preoperative demographics and comorbidity except for ethnicity. The source of bleeding was identified in 39 (47%) patients and arteriovenous malformation or submucosal streaming vessel was the most frequent cause of bleeding (18/39, 46%). Multivariate-adjusted analysis demonstrated preoperative central venous pressure (CVP)≥18mmHg (HR 3.56; 95% CI 1.16-10.9; p=0.026), mean pulmonary artery pressure (mPA)≥36mmHg (HR 4.14; 95% CI 1.35-12.7; p=0.013), and the presence of moderate/severe tricuspid valve disease (HR 1.01; 95% CI 1.01-3.86; p=0.046) were associated with the risk of GIB. In this study, preoperative right-sided cardiac congestion (i.e., increased CVP, mPA and the presence of moderate/severe tricuspid valve disease) was associated with GIB in patients with CF-LVAD.

Massive Pulmonary Bleed from Undiagnosed Hepatitis C Infection

A 14 year-old previously healthy female patient presented with back pain, halitosis, and hemoccult positive stool.She was ultimately diagnosed with Takayasu’s Vasculitis and thrombo-angiitis vasculitis as well as a post-mortemdiagnosis of Hepatitis C. The two vasculitides created a pulmonary arterial-esophageal fistula with a necrotic areaand a ruptured pulmonary artery, which led to the patient’s death. Further discussion with the familyindicated thatthey were unaware of the patient’s Hepatitis C status and they denied any risk factors the patient may have had thatlead to Hepatitis C infection. Obtaining a history in pediatric patients is often limited by what the family knows anddiscloses, but when a patient presents with elevated inflammatory markers, halitosis, and hemoccult-positive stool,an esophageal fistula should be considered in one’s differential diagnosis.

Portal Hypertensive Polypoid Enteropathy Without Overt Endoscopic Features of Portal Hypertension: A Case Report

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 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.Figure: Upper DBE showed small bowel findings consistent with portal enteropathy without discrete AVM.Figure: Histopathology of the polypoid specimen showed numerous ectatic vessels and ulcerations.Figure: Histopathology of the polypoid specimen showed numerous ectatic vessels and ulcerations.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.

Exploring signet-ring cells in pregnant female.

Primary signet-ring cell carcinoma (SRCC) of the colon and rectum are rare form, which present at an advanced stage and have poor prognosis. Different treatment policies of SRCC during different gestational age of pregnancy are explored from the literature. A 26-year-old young pregnant female with 10-week gestation presented with constipation and blood in stools and on per rectal examination a tender circumferential stricture was present 2 cm above the anal verge. Magnetic resonant imaging (MRI) pelvis of the patient revealed rectal thickening, the biopsy of which revealed characteristic appearance of "linitis plastica" and diagnosed as poorly differentiated adenocarcinoma with signet ring morphology with wide spread positivity for cytokeratin & p53. With this diagnosis, patient underwent medical termination of pregnancy (MTP). SRCC of the colon comprises about only 1% of all cases of colon cancer. When compared with other types of adenocarcinoma, patients with SRCC in the colon are younger and more likely to experience lymph node metastasis. Its incidence in pregnancy is estimated to be less than 0.1%. Certainly, any pregnant patient who reports rectal bleeding or has hemoccult positive stool on examination deserves careful evaluation to rule out cancer. The complex treatment of colorectal cancer in pregnancy is based on the gestational age of the fetus, tumor stage and need for emergent vs. elective management.

Esophageal Inlet Patch: A Rare Cause of Melena

Purpose: Esophageal inlet patches are congenital anomalies of heterotopic gastric mucosa occurring in the proximal esophagus. They are infrequently seen, generally asymptomatic and typically do not warrant intervention. While rare complications may occur, there is only one documented case of bleeding from an inlet patch. We report an unusual case of melena resulting from an esophageal inlet patch. A 41-year-old woman with a past medical history of gastric bypass surgery was referred for evaluation of melena. She had a history of gastroesophageal reflux which was self-managed with intermittent antacids or over-the-counter lansoprazole. She denied nausea, vomiting, dysphagia, odynophagia, melena, and hematochezia. Her exam revealed stable vital signs, a benign abdomen with healed surgical scars and hemoccult positive stool. A colonoscopy revealed no abnormalities. An UGI with small bowel follow-through was normal. An EGD showed a 1-cm, irregular area of salmon-colored mucosa in the proximal esophagus with a central dark spot consistent with recent bleeding. No hemostatic intervention was required. Biopsies of the area revealed gastric mucosa with chronic inflammation. The gastric pouch, anastomosis, and small bowel mucosa was without abnormality. She was treated with omeprazole with resolution of her melena. There is limited available information in the literature on esophageal inlet patches. Endoscopy reveals salmon-colored mucosa distinct from the surrounding esophageal mucosa. Definitive diagnosis is made by histologic evaluation revealing gastric mucosa. Clinical manifestations are unusual, ranging from acid-related manifestations to dysplastic changes. The relationship with Helicobacter pylori is unclear. However, there has been only one previously reported case of bleeding associated with an inlet patch. This case illustrates the importance of careful endoscopic assessment and high level of suspicion in the appropriate clinical circumstances.

Importance of Examining Distal Duodenum on Standard Upper Endoscopy

Objective: Encourage endoscopists to examine beyond the second portion of the duodenum with upper endoscopy. Case Presentation: A 47-year-old, African-American female, presented to the emergency room with shortness of breath and fatigue. She had received oral iron supplementation for 6 months for iron deficiency anemia, attributed to menorrhagia. There was no history of nausea, vomiting, abdominal pain, difficulty swallowing, hematemesis, melena, or rectal bleeding. She reported a 15-pound weight loss over the last 3 months and vague back discomfort. She admitted to occasional NSAID use for joint pains. Past medical history revealed fibroadenoma of the breast. There was no significant family history of gastrointestinal disease or malignancy. Vital signs were stable. Examination was notable for pale skin and brown, hemoccult positive stool. The remainder of the examination was negative. Labs showed hemoglobin 6 g/dL, hematocrit 19.5%, MCV 79 and low iron, ferritin, and transferrin saturation. Platelet count, INR, LFTs and CHEM-7 were normal. On upper endoscopy, the esophagus, stomach, duodenal bulb and second portion of the duodenum were normal. Upon entering the third portion duodenum a large circumferential necrotic mass with ulceration and oozing on contact was identified. Biopsy returned moderately differentiated adenocarcinoma. CT scan was negative for pancreatic, lymphatic or liver involvement. She underwent a Whipple procedure with an uneventful post-operative course. Conclusion: Examining the third portion of the duodenum is recommended since lesions may be present beyond the proximal duodenum. Though small bowel cancer currently represents less than 5% of GI cancers, demographic studies suggest its incidence may be on the rise1. Furthermore, about 45% of duodenal adenocarcinomas occur in the third and fourth portions2. Depth of insertion for upper endoscopy is not clearly standardized, but the exam is often limited to the second portion of the duodenum. In our hospital, we have recently encountered cases of tumors in the third and fourth portions of the duodenum which would have been missed without careful examination of this region. Therefore, we encourage endoscopists to examine beyond the second portion of the duodenum. In this case, patient was spared additional endoscopic procedures and delay in diagnosis.

Factors Associated With Bowel Resection Among Infants With Intussusception in the United States

Intussusception is the most common cause of infant bowel obstruction. Because delays in diagnosis can lead to severe outcomes, differentiating milder cases from those with potentially serious outcomes is important. The objective of this study was to identify factors associated with bowel resection among intussusception cases using data from a large nationwide study, which investigated the association between intussusception and Rotashield. We examined characteristics of 376 intussusception cases not associated with Rotashield use. Cases were confirmed by a radiologic procedure, surgery, or autopsy. Clinical characteristics of infants with and without bowel resection were compared. During the week before hospitalization, 93% of the 376 infants with intussusception had vomiting, 72% reported bloody stool, 63% had hemoccult positive stool, 51% had diarrhea, 43% reported fever, and 14% had documented fever. Surgery was performed on 209 cases (56%). Of these 209 cases, 33% (67/209) required bowel resection. Documented fever on admission significantly increased the risk of bowel resection (odds ratio, adjusted for race and sex, 2.7; 95% confidence interval, 1.2-6.0). Among infants with intussusception, the presence of a reported symptom for at least 2 days before hospital admission was also an independent predictor of bowel resection (adjusted odds ratio, 2.7; 95% confidence interval, 1.5-4.8). Bowel resection appears to be more likely among intussusception patients with documented fever and symptoms for at least 2 days. However, because resection also occurred among those without fever or prolonged symptoms, severe disease must also be considered in absence of these symptoms.

Identification of Meckel Diverticulum by Capsule Endoscopy

A 5-year-old white boy with a medical history of constipation presented with a 1-day history of painless hematochezia. He had 2 episodes of bright-red blood in his stool with clots. Initial laboratory evaluation was positive for hemoglobin of 7.9, hemoccult-positive stool, and 2 negative Meckel scans after 5-day pretreatment with ranitidine (1). An upper endoscopy and colonoscopy were visually and histologically normal. Capsule endoscopy showing 2 lumens within the ileum was consistent with Meckel diverticulum (MD) (Fig. 1). The patient underwent an exploratory laparoscopy; an MD was found and removed (2). The presence of the enteric wall biopsy showing a layering architecture composed of villiform small intestinal mucosa and gastric oxyntic mucosa with focal ulceration on histological evaluation confirmed an MD. Capsule endoscopy, which is not the conventional method of detecting MD, can aid in identifying MD in patients whose previous evaluations are negative. Definitive treatment for MD is surgical removal in the symptomatic patient.FIGURE 1: Meckel diverticulum.

Multiple Granular Cell Tumors of the Ascending Colon: A Case Report and Review of the Literature

Purpose: Introduction: Granular cell tumor (GCT) is a very uncommon entity that rarely affects the GI tract. It is usually detected incidentally on routine colonoscopy in asymptomatic patients. Because of its morphological pattern and its submucosal location, it can often be mislabeled as a malignant lesion. Due to its low incidence no clear standards of therapy have been described. We report an unusual form of GCT of the ascending colon diagnosed and treated by endoscopic ultrasound (EUS) resulting ultimately in right hemicolectomy. Case: A 32 year-old woman presented with crampy abdominal pain, diarrhea and hemoccult positive stools. Initial colonoscopy revealed four firm submucosal nodules in the cecum and ascending colon. Chase biopsies reported nonspecific chronic mucosal inflammation without visualization of submucosal tissue. Due to the submucosal location of the masses a full workup for carcinoid was sent with negative results. A follow up colonoscopy six months later showed no changes in the submucosal nodules. Repeat biopsies with jumbo forceps were non-diagnostic. EUS revealed 5 well defined hypoechoic nodular structures in the right colon. Submucosal resection of the two smaller and most distal lesions was performed. The same evening, the patient is diagnosed with acute ruptured viscus. Exploratory laparotomy with right hemicolectomy was performed identifying perforation points at one of the mucosectomy sites. Pathology reports from EUS revealed a submucosal mass strongly positive for S-100 with no clear necrosis or mitotic activity clearly suggestive of GCT. Surgical pathology confirmed the same diagnosis. Discussion: GCT are rare and typically benign tumors. Schwan cells are currently the most acceptable derivation site. It might occur anywhere in the body with a GI incidence close to 1%. The most common site in the GI tract is the esophagus, followed by the stomach, colon and perianal region. With < than 2 cm in diameter, and frequently reported as solitary masses, GCTs are often diagnosed as incidental findings during routine endoscopy. Positive immunohistochemical markers such as S-100 and Neuron Specific Enolase strongly suggest the diagnosis. Rate of malignancy depends on tumor size (usually > 4 cm) and adjacent tissue spreading (muscularis propia). EUS is a very effective tool in evaluating submucosal lesions. Although endoscopic resection is the preferred treatment, surgery has also been considered for cases where malignant features are present. It is imperative for the gastroenterologist to include GCT in the differential diagnosis of submucosal tumors of the colon.

A Case of FVII Inhibitor.

AbstractAbstract 3655Acquired inhibitors of coagulation are bleeding disorders that require prompt recognition, diagnosis, and management. Antibodies against factor VII are extremely rare with only a few cases reported in the literature. We present a case of a patient with an acquired Factor VII inhibitor. This is an 87 year old female with a past medical history of breast cancer, hypertension, and hyperlipidemia who presented to the emergency room with right flank pain and hematuria. A CT scan of the abdomen and pelvis showed bilateral hydronephrosis with no evidence of nephrolithiasis. The patient denied hematemesis or hematochezia but was noted to have hemoccult positive stools. The patient denied any anticoagulant use. Admission laboratories revealed a coagulopathy with a normal partial thromboplastin time (PTT) of 28 seconds and prolonged prothrombin time (PT) of greater than 50 seconds and INR of 19.59. The patient received vitamin K without improvement in coagulation parameters. A mixing study revealed a markedly prolonged PT that did not correct with 1:1 (18.9 seconds) and 4:1 (27.3 seconds) mix normal plasma. Factor assays shows an abnormal Factor VII level of less than 1%, and normal Factor II 121%, Factor V 140%, Factor VIII 201%, Factor IX 99%, and Factor XI 126% levels. A FVII inhibitor was 1.66 Bethesda units per milliliter. Immunosuppressive treatment was initiated with prednisone 1 milligram per kilogram daily and cyclophosphamide 200 milligrams daily. Factor VII levels normalized without evidence of inhibitor. The patient clinically improved and immunosuppressive medications were gradually tapered off. This case emphasizes the importance of prompt recognition in a patient with a rare acquired inhibitor of coagulation. Treatment with immunosuppressive therapy consisting of corticosteroids and cyclophosphamide resulted in normalization of factor VII levels and resolution of bleeding symptoms and should be considered as first-line management for such patients. [Display omitted] Disclosures:Philipp:Baxter: Research Funding; Wyeth: Research Funding; Octapharma: Research Funding.

A Rare Cause of Failure to Thrive: A Case of a Primary Gastric Cancer in a Patient with Metastatic Renal Cell Carcinoma and a Review of the Literature on Management

Purpose: Renal cell carcinoma(RCC) accounts for approximately 3% of all adult malignancies. Papillary carcinoma, which is the second most common type of RCC, accounts for approximately 15% of RCC. RCC has a metastasis rate of approximately 25%, which is most commonly to the lungs (>50%). On the contrary, RCC metastasis to the GI (Gastrointestinal) tract (excluding liver) is very uncommon and ranges from 0.2-0.7%. Thus, a gastric cancer in a patient with known metastatic RCC would most likely secondary to metastasis. We present the first reported case of a metastatic RCC coexisting with a new onset primary gastric cancer and a review of management. A 82-year-old male with Papillary RCC status post left nephrectomy with recurrence of liver metastasis presented with failure to thrive shortly after his third cycle of chemotherapy despite stable disease by imaging studies. He had received 7 chemotherapy cycles of Gemzar®, Nexavar®, and Avastin® prior to admission. Catheter related infection was suspected due to a leukocytosis of 19,000. However, he had no evidence of infection. He subsequently dropped his Hct and was found to have Hemoccult positive stool in the setting of having received Avastin®. Endoscopic evaluation of his anemia showed a 3 cm ulcerated mass in the cardia, which was subsequently biopsied. The biopsy showed invasive and poorly differentiated gastric adenocarcinoma unrelated to his RCC. H. pylori was considered negative. The patient subsequently underwent partial gastrectomy with loop gastrojejunostomy for resection of his Stage 1 primary gastric adenocarcioma. The patient did not receive adjuvant chemoradiation for his Gastric cancer due to his comorbidities at the time and did well at a 1 month follow-up. There are no guidelines to manage a primary gastric cancer coexisting with a metastatic RCC. Review of the literature shows that the management of a solitary gastric cancer secondary to RCC metastasis without adjacent organ involvement is ideally surgical (gastrectomy) if the tumor is greater than 2 cm. There is a role of endoscopic resection for non-surgical candidates and for early gastric cancer with differentiated tumors that are slightly raised and less than 2 cm in diameter, or in differentiated tumors that are ulcerated and less than 1 cm in diameter. In our patient, the gastric cancer was 3 cm in size without nodal involvement, thus, not a candidate for endoscopic mucosal resection. Surgical management was the therapy of choice due to the patient's clinical presentation as well as future consideration of RCC chemotherapy. Conclusion: Metastatic RCC and primary gastric cancer can coexist and surgical management can still be considered for the primary gastric carcinoma.

Multiple Recurrences of Colonic Adenocarcinoma at an Anastomosis Site

Purpose: Introduction: Colorectal cancer (CRC) is a common disease which accounts for nine percent of all cancer deaths in the United States. Age is the dominant risk factor for sporadic CRC, with 90% of cases occurring after age 50. Treatment for nonmetastatic CRC is surgical resection, +/− adjuvant chemotherapy and radiation. Despite aggressive regimens, 40% of patients have disease recurrence. However, recurrence at the anastomosis is a rare entity with potential devastating outcome. Case Report: A 67 yo male without prior medical history presents with intermittent rectal bleeding and hemoccult positive stool. Physical exam, CBC, Chem7, LFT: unremarkable. Colonoscopy revealed malignant sigmoid polyp with submucosal venous invasion. Patient underwent left colectomy; pathology notable for a single tumor nodule in pericolic fibroadipose tissue. Postoperative adjuvant chemotherapy was initiated. Patient was asymptomatic for 6 years, with unremarkable surveillance colonoscopies. At 7 years, rising CEA levels triggered a CT abdomen/pelvis, which was notable for soft tissue mass adjacent to descending colon; fine need aspiration was positive for metastatic colonic adenocarcinoma. Patient underwent local resection, chemotherapy and postoperative radiation. Post-operative colonoscopy initially revealed normal appearance of end to side left hemicolectomy of distal sigmoid colon. However, one year later an ulcerated 3cm mass was found at the anastomosis; pathology consistent with colonic adenocarcinoma. Patient underwent a third surgery, left retroperitoneal resection with partial left colectomy. One year after the third surgery, CEA levels rose. At ten years from initial surgery, repeat colonoscopy demonstrated an ulcerated and fungating mass at the anastomosis, consistent with a second anastomosis recurrence. Discussion: CRC ranks as the third most common cancer death in the United States. Despite surgery, chemotherapy and radiation treatment, recurrence rates are as high as 40%. Recurrence at the anastomosis is very rare. Intraluminal anastomosis lesions account for 2-8% of all recurrent tumors; are far more common in rectal versus colonic anastomosis sites, and usually occur by 2.5 years from primary treatment. Our patient presents an unusual case of multiple recurrences at the anastomosis site despite several years of normal surveillance colonoscopies. The importance of monitoring CEA levels, in addition to serial colonoscopies, as a surrogate for tumor burden is highlighted by this case.

Sodium arsenite reduces severity of dextran sulfate sodium-induced ulcerative colitis in rats

The histopathological features and the associated clinical findings of ulcerative colitis (UC) are due to persistent inflammatory response in the colon mucosa. Interventions that suppress this response benefit UC patients. We tested whether sodium arsenite (SA) benefits rats with dextran sulfate sodium (DSS)-colitis. The DSS-colitis was induced by 5% DSS in drinking water. SA (10 mg/kg; intraperitoneally) was given 8 h before DSS treatment and then every 48 h for 3 cycles of 7, 14 or 21 d. At the end of each cycle rats were sacrificed and colon sections processed for histological examination. DSS induced diarrhea, loose stools, hemoccult positive stools, gross bleeding, loss of body weight, loss of epithelium, crypt damage, depletion of goblet cells and infiltration of inflammatory cells. The severity of these changes increased in the order of Cycles 1, 2 and 3. Treatment of rats with SA significantly reduced this severity and improved the weight gain.

The endoscopic appearance of a gastrointestinal stromal tumor in a pediatric patient

Gastrointestinal stromal tumor (GIST) is a mesenchymal tumor that is rare in children. We report a case of GIST in a pediatric patient. A 16-year-old adolescent girl presented after an episode of syncope preceded by one episode of melena. Physical examination results were normal except for Hemoccult-positive stool. Laboratory studies included a hemoglobin level of 6.1 g/dL; complete metabolism profile and coagulation studies revealed normal results. She was transfused with 2 units of packed red blood cells, and an urgent esophagogastroduodenoscopy was performed. Esophagogastroduodenoscopy demonstrated 3 submucosal sessile masses in the gastric antrum ranging from 1 to 3 cm with normal overlying mucosa except for one of the lesions, which was ulcerated. Endoscopic biopsies stained positive for CD117 and were consistent with GIST. Radiologic imaging demonstrated the endoscopically visualized masses and also showed a solitary 1-cm lesion within the liver. She underwent partial gastrectomy and open biopsy of the hepatic lesion. Histologic examination confirmed GIST with hepatic metastasis. Typically with GIST, esophagogastroduodenoscopy will demonstrate a normal surface mucosa and a firm, smooth yellowish submucosal mass, which can be ulcerated. In some cases these tumors can be missed because of their frequent submucosal and extraluminal growth. This case, to our knowledge, is one of the first reports of the endoscopic appearance of GIST in a pediatric patient. Although a rare entity in children, GIST should be considered in pediatric patients with endoscopically visualized submucosal gastric masses.

The Endoscopic Appearance of a Gastrointestinal Stromal Tumor in a Pediatric Patient

Gastrointestinal Stromal Tumor (GIST) is a mesenchymal tumor that is rare in children. We report a case of GIST in a pediatric patient presenting with melena, anemia and gastric submucosal masses. A 16 year old female presented after an episode of syncope preceded by one episode of melena. Physical exam was normal except for hemoccult positive stool. Labs included a Hg of 6.1 g/dl; CMP and coagulation studies were normal. She was transfused with 2 units of PRBC and emergent EGD was performed. EGD demonstrated 3 submucosal sessile masses in the gastric antrum ranging in size from 1–3 cm with normal overlying mucosa except for one of the lesions, which was ulcerated. Endoscopic biopsies stained positive for CD 117 and were consistent with GIST. Radiologic workup with CT, MR, and PET imaging demonstrated the endoscopically visualized masses. MRI and PET imaging also revealed a solitary 1 cm lesion within the liver. She underwent partial gastrectomy and open biopsy of the hepatic lesion. Histology confirmed GIST with hepatic metastasis. She received postop chemotherapy consisting of Imatinib Mesylate, and has done well without disease recurrence with a follow up of nine months. Typically with GIST, EGD will demonstrate a normal surface mucosa and a firm, smooth, yellowish submucosal mass, which can be ulcerated. In some cases these tumors can be missed because of their frequent submucosal and extraluminal growth. This case, to our knowledge, is one of the first reports of the endoscopic appearance of GIST in a pediatric patient. Endoscopic ultrasound (EUS) is an important aid to differentiate submucosal masses seen by EGD. By EUS GISTs will typically have a hypoechoic appearance and will originate from the muscularis propria. EUS was unnecessary in our patient because the biopsies obtained by EGD were deep enough to provide a pathologic diagnosis. Although a rare entity in children, we conclude that the possibility of GIST should be considered in pediatric patients with endoscopically visualized submucosal gastric masses.

Metastatic Melanoma Initially Diagnosed with Double-Balloon Enteroscopy in a Patient with Recurrent Gastrointestinal Bleeding

Evaluation of the small bowel has drastically improved with the introduction of capsule endoscopy, which is helpful in identifying small bowel pathology. However, capsule endoscopy is limited as it doesn't allow biopsy or interventions. Double-balloon enteroscopy (DBE) is able to reach most abnormal areas seen on capsule endoscopy, and has the benefit of allowing diagnostic and therapeutic interventions. We report a case of metastatic melanoma initially diagnosed with biopsy of a small intestine mass during DBE. Case: A 73 year old man presented with 5 days of melena and hemoglobin (Hb) of 11.9g/dl, one month after having a normal physical exam, Hb, and screening colonoscopy. His bowel movement returned to normal and the bleeding appeared to have stopped, and no further evaluation was done. 8 weeks later he had another episode of melena and the Hb was 10.8 g/dl. Upper endoscopy showed antral gastritis and duodenitis, but no signs of bleeding. Capsule endoscopy showed bleeding in the distal small intestine, without a definite source. Physical exam was normal, except for hemoccult positive stool. Because capsule endoscopy suggested the bleeding source was in the distal small intestine, DBE was performed through the colon and ileocecal valve, using the Fujinon EN-450T5 system. 70cm proximal to the ileocecal valve a hemorrhagic mass (3–4 cm diameter) was identified. Biopsies were obtained, and showed a malignant neoplasm. Special stains were positive for S100 and HMB45, consistent with a metastatic melanoma. The patient underwent a laparoscopy with partial small bowel resection to remove the bleeding tumor. Despite careful skin examination, a primary lesion was not found. Staging evaluation showed other metastases in the liver, chest, bones, and brain. He was treated with chemotherapy. Discussion: Malignant melanoma involving the GI tract may be primary or metastatic, the latter being more common. Melanoma is the most common tumor with metastatic spread to the GI tract. Clinical presentation varies and can include bleeding, weight loss, obstruction, or malabsorption. In the past the diagnostic test of choice was enteroclysis, which is limited since histopathology can't be obtained and surgery would be the next step for definitive diagnosis. This case illustrates the usefulness of DBE in diagnosing small intestine pathology that is not accessible to conventional endoscopy.

Treatment of watermelon stomach

Watermelon stomach (WMS), or gastric antral vascular ectasia, is an uncommon but clinically important cause of chronic occult or overt gastrointestinal (GI) blood loss. Patients typically present with symptomatic anemia and hemoccult positive stools. Although the diagnosis is based primarily on the typical endoscopic appearance, the lesion may be overlooked on initial evaluation or interpreted as "gastritis." Gastric biopsy may be helpful in confirming the diagnosis by showing vascular ectasia, typically without inflammation. WMS is idiopathic but is often associated with autoimmune diseases or cirrhosis of the liver. The majority of patients with classic WMS are elderly and female. In contrast, there is no gender predominance with the diffuse pattern associated with cirrhosis. General supportive care includes transfusion of blood products as necessary to control symptomatic anemia and coagulopathy, iron replacement therapy by oral or parenteral routes, identification and treatment of iatrogenic (eg, warfarin) or hereditary (eg, von Willebrand's disease) coagulopathy, and avoidance of substances that might cause gastric mucosal damage and/or bleeding (eg, aspirin, NSAIDs, alcohol). The goals of therapy are to eliminate or decrease the need for blood transfusions, hospitalization, office visits, and endoscopic therapy sessions aimed at cessation of GI blood loss and resolution of symptomatic anemia. Multipolar electrocoagulation is our preferred technique for endoscopic ablation of WMS. A 10-Fr probe (3.2 mm in diameter) is used at a generator setting of 12 to 16 W. Pulse duration can be as short as 1 to 2 seconds if a pinpoint coagulation technique is used, or continuous if a paint-stroke technique is used to coagulate all vascular stripes in the classic WMS pattern or as many small lesions as possible in the diffuse type. Other techniques we currently use are argon plasma coagulation (APC) or heater probe. In the past, lasers (neodymium: yttrium-aluminum-garnet , KTP, or argon) were successfully used for such treatments. An initial treatment interval of 4 to 8 weeks should allow for interim healing of iatrogenic ulcers. Patients are routinely given standard doses of available proton-pump inhibitors (PPIs) to facilitate healing of iatrogenic ulcers and to prevent secondary bleeding. The treatment interval can be gradually lengthened as the long-term goals of obliteration of angiomata and resolution of anemia are reached. Side effects may include iatrogenic ulceration at the site of treatment, bleeding, and transient abdominal pain. Antral scarring (after APC or Nd:YAG laser) and hyperplastic polyps have also been reported after endoscopic treatment of classic WMS. Surgical antrectomy is very effective in the prevention of bleeding but has substantial (5% to 10%) mortality in older patients with comorbidity and is now reserved for endoscopic failures.