Jejunal Mass Research Articles

Effects of Bacillus subtilis, butyrate, mannan-oligosaccharide, and naked oat (ß-glucans) on growth performance, serum parameters, and gut health of broiler chickens

Four nonantibiotic alternative growth promoters for broiler chickens were evaluated. Ross 308 chicks were fed a control diet (mainly corn and soybean meal) or a diet supplemented with a probiotic (Bacillus subtilis Gallipro DSM 17299), encapsulated butyric acid (Novyrate C), mannan-oligosaccharide (Actigen MOS) or formulated with 20% naked oat (starter diet) and 30% naked oat (grower and finisher). The study was carried out as a complete random blocked design with 10 pens for each diet, 45 birds per pen. Compared to the control, the naked oat diet improved the average daily gain by 16% during the starter phase (up to d 10). The probiotic did so during the grower phase as did butyric acid in the finisher phase (up to d 34). For the experiment overall, the probiotic decreased average daily gain slightly. The best improvement in feed conversion ratio was obtained in the butyrate group (5%). No significant treatment effect on crop pH or on mortality was observed. The naked oat diet gave a slightly lower cecum pH on d 34. The MOS supplement decreased jejunal mass on d 34 and increased villus length (34%) and villus height/crypt depth ratio (32%) measured on d 10. Naked oat, butyric acid and MOS diets all reduced serum endotoxin levels. The probiotic increased serum C-reactive protein. All noncontrol diets reduced serum malondialdehyde. The naked oat diet reduced d 34 litter pH by about 0.3. Some effects of the proposed non-antibiotic growth promoters have been observed and could contribute to livestock performance. Their exact modes of action remained to be defined.

Small Bowel Adenocarcinoma Simulating Superior Mesenteric Artery Syndrome (SMAS): A Case Report

The adenocarcinoma of the small intestine is a rare tumor of all gastrointestinal cancers often occurs on a predisposing ground we report the case of a 40-year-old patient chronic smoker has 1 pack year weaned 2 years ago, alcoholic weaned 5 years ago whose symptomatology dates back to 3 months by the appearance of epigastralgia and vomiting post prandial, Complicated by a high occlusive syndrome made of post prandial vomiting with abdominal pain all evolving in a context of alteration of general state made the patient was addressed to the service of digestive cancer surgery and liver transplantation of CHU Ibn Rochd Casablanca.
 The patient had an abdominal CT scan which showed duodenojejunal distension with incarceration of an undistended loop at the level of the aorto-mesenteric clamp.
 The patient was sent to the operating room in emergency, he underwent a segmental Greco-Resection of 15 cm taking away a jejunal mass under laparoscopy with extra corporal anastomosis latero-lateral jejuno-jejunal with at the exploration one notes the presence of a tumoral mass of 3cm mobile at the level of the 2nd loop jejunal stenosing responsible for a jejunal distension upstream measuring 4cm in diameter.
 The anatomopathological study of the specimen showed a moderately differentiated and invasive adenocarcinoma, classified as pT3N1Mx.
 The postoperative follow-up was marked by a deep venous thrombosis involving the ileo-femoral-popliteal axis of the ilio-femoral-popliteal trunk on day 2 postoperatively, for which the patient was put on low molecular weight Heparin at a curative dose with compression stockings and monitoring.
 The patient had resumed transit in the form of gas on postoperative day 3, with a correct assessment, and was declared discharged on postoperative day 6.
 The patient's file was discussed in a multidisciplinary consultation meeting and the decision was to undergo adjuvant chemotherapy and oesogastroduodal fibroscopy (FOGD) and colonoscopy to look for predisposing diseases.

Bezoar as a cause of jejunal afferent loop mass after pylorus preserving pancreaticoduodedectomy: A case report.

Introduction and importanceBezoars may occur in patients after undergoing gastric surgery. Most bezoars are discovered due to small intestine obstruction, causing acute abdomen.Case presentationA 44-year-old woman with a history of intraductal papillary mucinous tumor of the pancreas was initially treated with pylorus-preserving pancreaticoduodenectomy. Two years ago, she had intermittent abdominal pain with no noted abnormality on computed tomography (CT) scan and gastroscopy. During her follow-up, an abdominal CT scan revealed a 1.8-cm low-enhancing nodular tumor with minute central calcification at the afferent loop of the jejunum, later diagnosed as a jejunal tumor. Endoscopy helped determine the location and characteristics of the tumor. Endoscopic findings revealed a bezoar approximately 3 cm below the pancreaticojejunostomy and hepaticojejunostomy, at the end of the afferent loop of the jejunum. Removal using an endoscopic basket failed as the bezoar broke halfway. Residual suture material was found inside the bezoar. Since the size of the bezoar decreased, the procedure was discontinued to allow it to dislodge naturally.Clinical discussionBezoars may be caused by gastric surgery, increased fiber diet, and psychiatric illness. As seen in this case, residual suture material caused bezoar formation. Bezoars mainly occur in the stomach and small intestines, but they can also occur in the afferent jejunal loop, as seen in this case.ConclusionSurgeons should be careful not to leave behind suture material during gastric surgery. However, bezoar formation should be considered in patients complaining of abdominal pain even if they did not undergo gastrectomy.

Metastatic choriocarcinoma presenting as intracranial hemorrhage and intussusception

Extrauterine choriocarcinoma is a rare entity. The criteria used for its diagnosis are as follows: (1) Absence of disease in the uterine cavity, (2) pathologic confirmation of diagnosis, (3) exclusion of molar pregnancy, and (4) absence of a coexistent intrauterine pregnancy. Delay in the diagnosis can be attributed to its nongynecologic manifestations such as bleeding from any organ system, unexplained systemic symptoms, and metastatic foci from an unknown primary malignancy. This is an unusual case of 27-year-old G3P3 (3-0-0-3) who underwent emergency left parietal craniotomy excision due to increased intracranial pressure symptoms secondary to left parietal tumor. Histopathology revealed metastatic adenocarcinoma. About a month later, she underwent exploratory laparotomy for acute abdominal symptoms secondary to a jejunal mass. Jejuno-jejunal resection anastomosis was done and histopathology revealed choriocarcinoma.

Small Bowel Adenomyoma: An Incidental Intraoperative Finding While Performing Hepaticojejunostomy for CBD Injury

Adenomyoma is a benign lesion that is most commonly seen in the gallbladder, however, rare cases have been reported where this pathology was encountered in the vicinity of the gastrointestinal tract. The pathogenesis of this lesion is still a controversy, with the previous reports suggesting it to be either a form of hamartoma or incomplete heterotopic pancreas. Jejunal and ileal adenomyoma have been rarely reported, and as of 2016 less than 30 cases were reported in the English literature. The clinical presentation is variable depending on the location of the lesion. Although there are no specific management guidelines for this pathology, a surgical resection is sufficient. However, aggressive surgical approaches, such as pancreaticoduodenectomy for periampullary adenomyoma, have been undertaken in the previous reports due to the misdiagnosis with carcinoma preoperatively. We report a case of a 58-year-old gentleman who was referred to our Hepato- Pancreato-Biliary facility with common bile duct injury post laparoscopic cholecystectomy for hepatico- jejunostomy. Intra-operatively, an intra-luminal, jejunal mass was found measuring 2x2 cm and was about 95 cm from the DJ junction. The lesion was resected with safety margins, and primary anastomosis was done. The final histopathology of the specimen was consistent with adenomyoma, and all of the surgical margins were free.

Clinical outcome after surgical resection of small bowel cancer

Background: Small bowel cancer (SBC) is rare, however there is recent trend toward increased incidence.Methods: Retrospective evaluation of the clinical presentation, diagnosis, management and clinical outcome of adult patients with primary SBC who were admitted at Sohag University Hospital during 2014-2019.Results: Twenty-one patients with SBC were enrolled (14 males and 7 females) with median age of 56 (range 32-83) years. Small bowel mass was identified preoperatively in 13 patients (62%). Thirteen patients (62%) presented with abdominal emergencies after failure of prompt diagnosis of non-specific abdominal pain of variable durations (median: 4, range: 2-11 weeks). Apart from duodenal tumors, histopathological diagnosis for jejunal and ileal tumors was not achieved preoperatively. Tumor types were gastrointestinal stromal tumors, GISTs (9, 43%), lymphoma (8, 38%) and adenocarcinoma (4, 19%). Patients with jejunal and ileal masses were managed by resection and primary anastomosis. Duodenal tumors required local resection in 2 and pancreatico-duodenectomy in 4 patients. Increased risk of aggressive behavior in GISTs, advanced stage and incomplete resection in lymphomas and adenocarcinomas were associated with higher recurrence rates and diminished survival. Follow-up ranged from 5 to 48 months, with survival rate of 76% (16 patients alive).Conclusions: The diagnosis of SBC is difficult and delayed. Appropriate surgical management, even during emergency, could achieve prolonged survival.

CONCURRENT PULMONARY AND JEJUNAL SARCOMATOID CARCINOMA WITH BRAIN METASTASES

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary sarcomatoid carcinoma (SCA) is a poorly differentiated, aggressive type of non-small cell lung cancer accounting for 0.1-0.3% of all lung cancers1-3. It is commonly seen in male smokers in their sixties. We present a rare case of concurrent pulmonary and jejunal SCA with brain metastases. CASE PRESENTATION: 75-year-old male with 40-pack year smoking history presents to the hospital with two weeks of nausea, vomiting, weight loss and dyspnea. CXR revealed a 10.1 x 7.4 cm right perihilar mass. Subsequent chest CT showed a 7.8 x 6.6 x 8.7 cm mass involving the posterior segment of right upper lobe, right middle lobe, and right lower lobe. PET scan showed avid lesions involving jejunum, brain, and adrenal glands. Endobronchial biopsy of the lung mass obstructing the lumen of posterior segment of right upper lobe revealed SCA with focal pleomorphism. Immunohistochemical staining was positive for Keratin AE1/AE3 and vimentin. A subsequent jejunal mass biopsy was also consistent with SCA with staining positive for keratin CAM5.2 and ß-hCG. Patient underwent whole brain radiotherapy as well as palliative pembrolizumab therapy. DISCUSSION: SCA is an aggressive cancer with average survival of 8.8 months and 13 months when involving small intestine and lung respectively. 5,7 Immunohistochemical staining is crucial in differentiating metastases versus primary SCA. In our case, TTF-1, Napsin-A, and CK7 staining of the jejunal mass were negative, which contradicts lung derivation. 4 This is a rare case of primary pulmonary SCA and concurrent primary jejunal SCA with brain metastases. Most SCA tumors involving small intestine are polypoid with central ulceration and frequently necrotic and hemorrhagic. 6,7 In contrast, pulmonary SCA usually arises as a solitary central airway mass with an average size of 7 cm.3 Symptoms in pulmonary SCA are non-specific such as chest pain, dyspnea and weight loss.1,4 This makes early diagnosis challenging. Patients often present in advanced stages with extra-thoracic metastases.4 Findings of brain metastasis is rare due to aggressive course of disease with low survival time.3 Both pulmonary and jejunal SCA are resistant to traditional therapeutic methods. Novel therapies like immunotherapy appears promising. CONCLUSIONS: This case is unique as it has two concurrent primaries for SCA, lung and jejunum. It is imperative to perform a complete oncological evaluation to assess for metastases. Early diagnosis and proper adjuvant therapy could prolong survival and improve quality of life. Reference #1: Arshad, H., Dudekula, R., Niazi, M., Malik, S., and Khaja, M. (2017). A Rare Case of Sarcomatoid Carcinoma of the Lung with Spine Metastasis, Including a Literature Review. Am J Case Rep. 2017; 18: 760-765. Beasley, M., Brambilla, E., and Travis, W. (2005). The 2004 World Health Organization classification of lung tumors. Semin Roentgenol. 2005 Apr, 40 (2): 90-7. Reference #2: Oliveira MF, Watanabe SC, Andrade MP, Rotta JM, Pinto FC. Sarcomatoid carcinoma of the lung with brain metastases. J Bras Pneumol. 2013;39(6):753-756. doi:10.1590/S1806-37132013000600016 Jia J, Ren J, Gu J, Di L, Song G. Predominant sarcomatoid carcinoma of the lung concurrent with jejunal metastasis and leukocytosis. Rare Tumors. 2010;2(3):e44. Published 2010 Sep 30. doi:10.4081/rt.2010.e44 Reference #3: Huang, S., Shen, S., and Li, X. (2013). Pulmonary sarcomatoid carcinoma: a clinicopathologic study and prognostic analysis of 51 cases. World J Surg Oncol 2013; 11: 252. Kwok CM. Sarcomatoid carcinoma of the jejunum with gastric metastases: A case report and review of the literature. Int J Surg Case Rep. 2016;28:161-164. doi:10.1016/j.ijscr.2016.09.046 Zhang B, Cheng BO, Wang L, Zhao KE, Zhuo GZ, Ding JH. Primary sarcomatoid carcinoma of the jejunum with massive intra-abdominal hemorrhage: A case report and review of the literature. Mol Clin Oncol. 2016;4(5):811-816. doi:10.3892/mco.2016.809 DISCLOSURES: No relevant relationships by Kushagra Gupta, source=Web Response No relevant relationships by Anthony Loschner, source=Web Response No relevant relationships by Elizabeth McCaskey, source=Web Response No relevant relationships by Toribiong Uchel, source=Web Response

S2770 When Two Rarities Occur, the Bowel Cringes

INTRODUCTION: Intussusception is a rare cause of mechanical intestinal obstruction in adults and is more frequently observed in pediatric patients. It tends to occur in association with a pathologic lead point, in most cases, a malignancy. Malignancies that commonly cause intussusception include lymphoma, colonic adenocarcinoma, and metastatic melanoma. Primary intestinal melanoma, however, is extremely rare and here we describe a case that presented as intussusception. CASE DESCRIPTION/METHODS: A 64-year-old female with asthma, COPD, OSA, HTN, HLD, GERD presented with a one week history of abdominal pain and nausea that progressed to coffee-ground emesis and melena a few days prior to admission. She endorsed a 22 pound unintentional weight loss and initial exam showed a soft but diffusely tender abdomen with labs only significant for a normocytic anemia that was near baseline. Computed tomography (CT) of the abdomen revealed intussusception and wall thickening involving the proximal small bowel (Figure 1). A small bowel enteroscopy demonstrated a 3-4 cm ulcerated, non-circumferential, non-obstructing mass in the proximal jejunum (Figure 2). A few non-bleeding superficial jejunal ulcers in the surrounding area which were presumed ischemic from the intussusception were also noted. Biopsies were sent for pathology and revealed sheets of infiltrating malignant cells with moderate amphiphilic cytoplasm and enlarged nuclei, some with pseudo inclusions. Immunohistochemical staining was done and the tumor cells stained positive for S100 and MelanA/MART1 and negative for CK7, CK20, CDX12, and CD45 which was concerning for metastatic melanoma (Figure 3). Patient underwent exploratory laparotomy with excision of the jejunal mass with surgical pathology confirming a malignant melanoma. Extensive imaging and examination of all cutaneous surfaces did not reveal a primary source. The patient was deemed to have a primary small bowel melanoma. DISCUSSION: Primary small bowel melanoma is extremely rare and should always be on the differential for neoplasms that can cause intussusception. Most intestinal melanomas represent metastatic disease and definite diagnosis can only be made after thoroughly excluding a primary lesion. It is important to recognize primary mucosal melanomas, as they are more aggressive and carry a worse prognosis, partly due to late diagnosis. Early recognition and diagnosis may allow for curative resection of the tumor, which remains the treatment of choice.Figure 1.: Proximal jejunal intussusception.Figure 2.: Push enteroscopy showing proximal jejunal mass.Figure 3.: Top left, immunohistochemical stain positive for s100. Top right, immunohistochemical stain positive for MelanA. Bottom left, H&E stain showing malignant cells with lymphovascular invasion. Bottom right, H&E stain, high power showing amphophilic cytoplasm, pleomorphic nuclei, and numerous mitotic figures.

S2880 A Rare Cause of Melena

INTRODUCTION: Melanoma presenting in the gastrointestinal tract is commonly due to metastasis from a primary cutaneous or ocular lesion. There have been a few case reports of primary GI melanoma which is most commonly seen in the rectum and anus. We report a case of a 77 year old man who presented with GI bleeding and was found to have a primary small bowel melanoma. CASE DESCRIPTION/METHODS: A 77-year-old male presented with generalized weakness and a remote history of melena for the past week. Physical exam was unremarkable with no palpable masses or abdominal tenderness. Labs were significant for iron deficiency anemia with a hemoglobin of 8.9 from 13.1 and a ferritin of 14 ng/ml. Patient underwent bidirectional endoscopy which showed no clear source for iron deficiency anemia. A capsule endoscopy was performed, and a mass with overlying ulcerated mucosa was seen in the small bowel (Figure 1). Subsequent computed tomographic enterography demonstrated a 3.3 cm soft tissue mass in the jejunum (Figure 2). As the mass was unable to be reached endoscopically, the patient underwent laparoscopic removal of the mass, and pathology was most consistent with malignant melanoma. Histology showed solid nests of epithelioid cells with brisk mitotic activity, and immunohistochemistry staining was positive for SOX-10 (Figure 3), a marker of melanocyte differentiation. The patient underwent a skin exam showing no evidence of a cutaneous primary melanoma, and a fundoscopic exam showed no evidence of ocular melanoma. A PET scan did not identify an alternative site of primary malignancy or any other sites concerning for metastatic disease. As the patient had a solitary lesion in the small bowel without evidence of an alternative primary melanoma, the final diagnosis was primary malignant melanoma of the jejunum. At one year follow up, patient did not have any recurrence noted on imaging. DISCUSSION: While melanoma is the most common tumor to metastasize to the GI tract, small intestinal primary melanoma is extremely rare making up 2.3% of primary GI melanomas. In all cases where melanoma is found in the GI tract, a comprehensive evaluation for additional metastatic lesions and alternative primary site with a skin exam, fundoscopic exam and PET scan is indicated. Primary GI melanoma is a rare clinical entity with nonspecific symptoms that requires a high index of suspicion and a thorough workup for a primary source when diagnosed.Figure 1.: Mass with overlying ulcerated mucosa in the small bowel on capsule endoscopy.Figure 2.: 3.3 cm soft tissue mass in the jejunum on computed tomographic enterography.Figure 3.: Immunohistochemistry staining of jejunal mass was positive for SOX-10, a marker of melanocyte differentiation.

2577 Dysdiadochokinesia, Ataxia, and Anemia: A Sign of Intraluminal Malignant Mesothelioma in the Small Bowel?

INTRODUCTION: Malignant mesothelioma (MM) is a rare cancer of the serosal membranes, the pleura and peritoneum, and causes significant morbidity and mortality. While implants of the bowel wall are common, only two case reports on intraluminal involvement exist. We present a case of an elderly male with dysdiadochokinesia found to have abdominal lymphadenopathy, and a jejunal mass from peritoneal mesothelioma (PM). CASE DESCRIPTION/METHODS: An 87 year-old male with a family history (FH) of colon cancer in one first-degree relative presented with one month of unintentional weight loss, gait instability, and trouble performing alternating movements. Two months prior to admission, evaluation included a negative MRI of the brain but positive CSF analysis for neuron-restricted autoantibody treated empirically with five days of intravenous immunoglobulin (IVIG) and three days of pulse dose steroids. Physical examination was notable for ataxia and dysdiadochokinesia and a benign abdominal exam. He had normal electrolytes and liver chemistries, but was anemic. PET/CT revealed intensely FDG-avid abdominal and mesenteric lymph nodes, one inseparable from the small bowel (Figures 1 and 2). Lymph nodes were not accessible by IR-guided biopsy, so he underwent push enteroscopy and colonoscopy, in light of his FH, to evaluate for anemia. A large, oozing ulcerated mass was found in the jejunum and biopsied (Figure 3). Immunostaining was positive for cytokeratin, CK7, WT1, and calretinin consistent with PM. His neurologic decline was then linked to PNS secondary to PM. He was discharged with plans for carboplatin therapy. DISCUSSION: MM is strongly associated with asbestos exposure, and is four to five times more prevalent in men than women. PM limited to the small bowel is exceedingly rare. Only one previous case report describes a mass spanning the entire small bowel, identified as mucin-positive epithelial mesothelioma. PNS affects 1 in 10,000 patients with cancer; more than 85% of cases are linked to gynecologic and breast cancers causing cerebellar dysfunction via purkinje cell destruction by anti-Yo antibody (Ab). Two cases of PM associated PNS with anti-Yo Ab in the CSF have been reported; one was treated with IVIG and high dose steroids. The treatment of PM is key to stabilizing neurologic symptoms, such as dysdiadochokinesia. The prognosis of PM and associated PNS remains poor. Anemia with cerebellar symptoms should trigger a search for malignancy and rarer causes such as PM.

2585 Distant Uveal Melanoma Presenting as Jejuno-Jejunal Intussusception After 11 Years!

INTRODUCTION: Metastatic melanoma of cutaneous origin is known to affect the GI tract. The jejunum and the ileum are commonly involved sites. Metastatic melanoma of uveal origin affecting the GI tract has been rarely reported. CASE DESCRIPTION/METHODS: A 46 year-old male with a diagnosis of right-sided ophthalmic uveal melanoma (diagnosed in 2007, treated with brachytherapy, with no evidence of recurrent disease) presented to Emergency Department with complaints of abdominal pain, nausea, and vomiting of 2 days. The CT scan of the abdomen showed a small bowel mass, measuring 4.3 × 4.6 × 6 cm causing intussusception. The patient underwent laparoscopic small bowel resection, and was found to have a jejunal mass causing intussusception. The mass was reported as malignant melanoma invading through the muscular wall into subserosal adipose tissue, and two lymph nodes were positive for metastatic melanoma. Next generation sequencing showed GNAQ and SF3B1 mutations, confirming metastatic uveal melanoma. The patient was initially started on a chemotherapy regimen and is now undergoing treatment with immunotherapy. DISCUSSION: Malignant melanoma of cutaneous origin has high metastatic potential. The GI tract is one of the most common sites of metastasis, among which the jejunum and the ileum are the most common sites. Most metastases go unrecognized or do not present clinically with gastrointestinal symptoms. Uveal melanoma does not contain recurrent BRAF or NRAS mutations, which are present in metastatic cutaneous disease. Common sites of metastasis of uveal melanoma include the liver, lung, soft tissue, and bone, whereas cutaneous melanoma metastasizes to the lung, soft tissue, and the GI tract. Cutaneous melanoma metastases to the GI tract have been reported multiple times in the literature, while uveal melanoma metastases to small bowel causing intussusception have rarely been reported. In our case, the patient had no evidence of disease for 11 years before he suddenly presented with GI symptoms. In patients with a history of uveal melanoma, metastatic melanoma should be considered when presenting with unusual GI symptoms.

2568 A Unique Case Presentation of Small Bowel Intussusception

INTRODUCTION: Intussusception is a life-threatening condition and can cause ischemia of the small intestine if not intervened promptly. When present in adults, intussusception typically is caused by a neoplasm, adhesions of the small bowel, or resultant of weight loss surgeries. Below we describe a unique intervention provided to a case presentation of intussesception. CASE DESCRIPTION/METHODS: 21 y.o. year old female with a past medical history of chronic abdominal pain, PTSD, suicide attempts, gender dysphoria, gastroesophageal reflux disease, depression, presented to the emergency department with secondary to abnormally low hemoglobin, abdominal pain, nausea and vomiting. She described pain in the epigastric abdominal region. She had no known family history of colon cancer, colonic polyps or other malignancies. She was noted to have a hemoglobin of 4.4 with no overt bleeding. She was tested negative for celiac serologies. She was evaluated with a CT scan of the abdomen and pelvis with IV contrast which showed long segment of proximal jejunal intussusception with associated inflammatory changes. The surgical team approached the gastroenterology team to attempt to reduce the intussusception prior to surgical resection. As a result of which a push enteroscopy was performed where in a normal esophagus, with erythematous mucosa in the gastric fundus and gastric body were seen. The duodenum was normal. An intussusception was encountered after the C-loop of the duodenum, around the proximal jejunum. This was reduced with the scope. A vascular appearing jejunal mass was seen. Biopsy was not attempted given the vascular appearance. A tattoo was applied. The patient subsequently underwent jejunal resection with small bowel anastomosis. The pathology of the mass resulted as benign hamartomatous polyp with surface erosion and no dysplasia. The patient's symptoms and anemia resolved post operatively. In addition she was evaluated with an upper endoscopy and flexible sigmoidoscopy previously which were within normal limits. DISCUSSION: Hamartomatous polyps of the small intestine can be associated with Cowden syndrome, Bannayan-Riley Ruvalcaba syndrome (BRRS), and juvenile polyposis syndrome (JPS). The above mentioned patient is unique as she does not meet criteria for any of these syndromes. In addition the emergent symptom relief was provided by endoscopic reduction of the intussusception providing the surgeons for a planned elective procedure rather than an emergent procedure.

2038 Jejunal Lymphangioma: A Rare Cause of Gastrointestinal Bleeding

INTRODUCTION: Lymphangioma is a rare benign vascular tumor in adults. The etiology is not clear but is proposed to be from the anomalous development of the lymphatics or inflammation and obstruction of developed lymphatics (1). Although most cases are asymptomatic and thus detected incidentally, non-specific symptoms, including abdominal pain, nausea, vomiting and weight loss may be present (2). Here we present a case of such tumor presenting as obscure overt GI bleed. CASE DESCRIPTION/METHODS: A 76-year-old female with past medical history of DM, ESRD, CHF, AFib presented with SOB and hypotension. Three weeks prior, she had a cardiac arrest during dialysis and was found to be anemic on admission to outside hospital (Hb 5.9). She was diagnosed with PE and anticoagulation was started. This resulted in multiple episodes of melena. She was deemed clinically unstable for EGD/colonoscopy and was discharged (Hb 8.6). A week later, she was again found to be anemic (Hb 5.8) and continued to have multiple episodes of melena. Colonoscopy and EGD were unremarkable and she was eventually discharged again. Her symptoms recurred following discharge and she was hospitalized now with SOB and hypotension (Hb 6.4). She continued to have melena. Diagnostic tagged RBC scan showed possible focus of luminal hemorrhage in small bowel in left abdomen. A capsule endoscopy showed a jejunal mass with active bleeding. Subsequent single balloon enteroscopy revealed a 2.5 cm polypoid mass with active bleeding in the mid-jejunum. Biopsies were taken and hemostasis was achieved with argon plasma laser. Histology revealed this mass to be a lymphangioma. She was discharged with no further bleeding. At 2 months follow up, she still did not have any further bleeding. She elected not to pursue any further management. DISCUSSION: A lymphangioma is a rare benign tumor. For lymphangioma, intestinal tract involvement is very uncommon. GI bleeding, intestinal obstruction, intussusception and protein-losing enteropathy are very rare manifestations(5). Diagnostic tests include barium enema, CT scan and endoscopic evaluation (7-9). Surgical resection may be required to provide definitive diagnosis and treatment. The upper and lower GI endoscopies can sometimes miss the mass, as in our patient. In such cases, capsule endoscopy and push enteroscopy play an important role. In our case, conservative measure was chosen due to the surgical risks of the patient from multiple comorbidities.

2622 A Case of Metastatic Renal Cell Carcinoma to the Jejunum Presenting as Iron Deficiency Anemia

INTRODUCTION: Small bowel malignancies comprise only 0.35% of all malignancies and small bowel metastases only comprise 2% of malignancies, only 7.1% of which are from a primary renal cell carcinoma (RCC).This case demonstrates a rare metastatic RCC of the small bowel diagnosed through video capsule endoscopy (VCE) prompting an antegrade double-balloon enteroscopy (DBE). CASE DESCRIPTION/METHODS: A 53-year old male with hypertension, diabetes mellitus, and anemia presented with a rapidly worsening, necrotic right lower quadrant abdominal wall lesion. Dermatopathology from a wound edge biopsy demonstrated an ulcer with neutrophils and karyorrhectic debris, consistent with pyoderma gangrenosum (PG). He was found to have iron deficiency anemia (IDA) requiring multiple blood transfusions and iron infusions. Colonoscopy and esophagogastroduodenoscopy were unremarkable. VCE demonstrated markedly abnormal mucosa in the proximal jejunum, occupying at least 75% of the lumen with several satellite lesions. Antegrade DBE revealed a large ulcerated jejunal mass with leakage of serosanguinous fluid. Pathology showed poorly-differentiated carcinoma of unknown etiology. Pan-CT revealed a 5.6 × 5.4 cm solid mass in the right kidney with invasion of the right renal vein with thrombus extending into the inferior vena cava, liver masses, and pulmonary nodules consistent with metastatic renal cell carcinoma. DISCUSSION: This is a rare case of RCC metastatic to the small bowel. Only three other case studies report this in the literature. Approximately 25–30% of patients have metastatic disease at time of RCC diagnosis. The most common sites of metastasis for RCC include lymph nodes, lung, bone, liver and brain. Metastasis to the small bowel often originate from cancers of the breast, lung, esophagus, head and neck, and melanoma. While there have been case reports of jejunal metastases many years status-post nephrectomy, there have only been three reported cases of synchronous jejunal metastases from RCC. Metastatic RCC to the small bowel can present as gastrointestinal bleeding and intussusception. VCE and DBE were useful diagnostic tools in our particular case. CT or MR enterography may have also served as an appropriate diagnostic alternative, and in retrospect may have helped to make the diagnosis sooner. Overall, it is important to consider small bowel malignancy on the differential diagnosis in a patient who presents with IDA.

1999 Jejunal GIST: An Unusual Cause of Acute Massive Gastrointestinal Bleeding

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are rare, making up 0.1–3% of all gastrointestinal (GI) tumors. While most commonly found in the stomach, GISTs in jejunum are among the rarest subtypes. The majority of GISTs present with occult GI hemorrhage. Here we present a case of massive GI bleeding due to a jejunal GIST in a young woman with BRCA2 gene mutation. CASE DESCRIPTION/METHODS: A 30-year-old woman presented with 1 day of melena and symptomatic anemia. Medical history was notable for BRCA2 gene mutation. Family history was significant for colon cancer in her maternal grandfather and breast cancer in her maternal aunt. On admission, there was melena in the rectal vault and her abdomen was soft, non-tender with no palpable masses. She was anemic with hemoglobin 6.8 g/dL. Emergent EGD revealed no blood or source of bleeding identified. After a rapid bowel preparation, an urgent colonoscopy showed melena in the entire colon and examined terminal ileum, however no culprit lesion was identified. Patient was hemodynamically unstable subsequently so an urgent computed tomography angiogram was performed and revealed active GI bleeding from the jejunal artery. A 3.1 × 2.2 cm mass with peripheral hemorrhage in the left upper quadrant was seen. The patient then underwent emergent embolization of two jejunal branches. An exploratory laparotomy was subsequently performed with resection of a proximal jejunal mass. Histology confirmed a spindle-cell GIST with positive staining for c-kit (CD117). Given the size, low-grade, and mitotic rate of 1/50 high-power field, no adjuvant therapy was needed. Magnetic resonance imaging surveillance was recommended. DISCUSSION: Bleeding jejunal GIST is a rare cause of acute massive GI bleeding. GISTs can be particularly difficult to diagnose because of their endoscopic inaccessibility. The majority of GISTs are thought to be a result of activating mutations of proto-oncogenes c-KIT (CD117) or PDGFR-alpha. These then increase tyrosine kinase receptor activity and result in the proliferation of stem cells. No reports yet suggest a direct association between a BRCA2 germline mutation and small bowel neoplasms. This case highlights a dramatic presentation of massive hemorrhage from a GIST, especially when confined to the small bowel. Further studies are needed to establish whether an association exists between BRCA mutations and GIST as well as other small bowel neoplasms.

2611 An Unlikely New Home for Metastatic Melanoma

INTRODUCTION: Symptomatic gastrointestinal involvement from primary malignant cutaneous melanoma represents only 1–4% of melanoma cases but is found in 60% of autopsies in patients who have had a primary cutaneous melanoma. We present a case of metastatic melanoma with initial symptomatic cecal involvement as demonstrated by colonoscopy and subsequent jejunal involvement discovered using single balloon enteroscopy. Our case illustrates that presenting symptoms for metastatic lesions in the gastrointestinal tract are often nonspecific but despite this, metastatic melanoma with gastrointestinal involvement should be considered in any patient that’s been diagnosed with a primary cutaneous melanoma. CASE DESCRIPTION/METHODS: A 61-year-old male presented with one-week history of melena. An iron panel was obtained which revealed iron deficiency anemia. The patient’s past medical history was significant for previously excised cutaneous melanoma. Initial colonoscopy demonstrated a malignant appearing mass in the cecum with an immunoprofile consistent with metastatic melanoma on biopsy. Patient was unable to tolerate initial chemotherapy and continued to have chronic blood loss anemia. The patient had a follow up pill cam endoscopy which showed slow oozing lesion noted in the duodenum. Subsequent single balloon enteroscopy was performed showing a non-obstructive, polypoid and ulcerated appearing proximal jejunal mass which was found to be melanoma on biopsy. DISCUSSION: Malignant melanoma is the most common metastatic tumor to the gastrointestinal tract. The propensity of the primary tumor to metastasize is dependent on Clark staging. Detection of small bowel lesions is often difficult. Small bowel lesions may present diffusely, as mural nodules, or “target” lesions on radiograph. Endoscopically, lesions may appear as ulcerated melanotic nodules, submucosal masses with ulcerations, or mass lesions with necrosis and melanosis. However, if the lesions involve the serosa or mesentery they can be missed on endoscopy. Various treatment modalities exist for metastatic melanoma of the GI tract including but not limited to surgical resection, immunotherapy, and chemotherapy.

2548 Jejunal Perforation: A Very Rare Presentation of Jejunal Adenocarcinoma

INTRODUCTION: Small bowel malignancies constitute less than 5% of all gastrointestinal malignancies. The most common histological types of small bowel cancer are adenocarcinoma, neuroendocrine cancer, lymphoma and sarcoma. Adenocarcinoma represents 25-40% of primary small bowel malignancies, with the highest incidence in the duodenum and the incidence progressively decreasing down the small intestine. CASE DESCRIPTION/METHODS: A 69 year old previously healthy women presented with periumbilical pain for four weeks. She also reported early satiety but no weight loss. The night prior to presentation abdominal pain became severe with one episode of vomiting. There was no history of chronic NSAIDs use. She had a 40 pack-years smoking history. She had two cesarean sections and a total abdominal hysterectomy with bilateral salpingo-opherectomy. She did not have routine colorectal cancer screening. On abdominal examination she had a distended abdomen and mild periumbilical tenderness. Laboratory testing revealed leukocytosis of 15000/µL and a hemoglobin level of 10.2 g/dl with a low MCV 78.6 fl. Noncontrast CT of the abdomen showed wall thickening and focal perforation in a loop of jejunum. There was no bowel obstruction and no free intraperitoneal air seen. Exploratory laparotomy revealed a large inflammatory mass in the proximal jejunum densely adherent to the mid-transverse colon. There was a large perforation (3.5 cm of greatest dimension) of a jejunal mass. The mucosa surrounding the defect was hyperemic and thickened. Microscopic examination showed a well-differentiated adenocarcinoma invading into muscularis propria. There was no lymphovascular invasion and no metastasis were identified in 13 excised regional lymph nodes. Immunostains were negative for cytokeratin 7 (expressed in lung and pancreatic adenocarcinomas), focally positive for cytokeratin 20 (colorectal adenocarcinoma) and were positive for CDX2. CDX2 is a highly sensitive and specific marker of adenocarcinoma of intestinal origin. DISCUSSION: Jejunal adenocarcinoma is an extremely rare GI malignancy. The clinical presentation is often with abdominal pain and distension; only 10% present as a bowel perforation. Surgical resection is considered curative treatment for localized adenocarcinoma. Oxaliplatin-based adjuvant chemotherapy is suggested for patients with lymphovascular invasion. In our patient perforation per se was considered a high-risk feature and the patient was advised to have post-operative adjuvant chemotherapy.

2628 Incidental Isolated Small Intestinal Melanoma in a Patient With Newly Diagnosed Celiac Disease

INTRODUCTION: It is believed that patients with Celiac disease (CD) are at increased risk of certain malignancies. However, CD patients are not associated with cutaneous malignant melanoma and thus additional screening is not indicated. We report an unusual case of a patient with first diagnoses of simultaneous CD and isolated small intestinal melanoma. CASE DESCRIPTION/METHODS: A 55-year-old female without history of malignant melanoma (MM) presented with chronic diarrhea. Physical exam and laboratory results were unremarkable except a tissue transglutaminase IgA antibody was elevated at 126.4 units (normal 0.00–19.99.). An esophagogastroduodenoscopy was performed and demonstrated scalloping of the duodenal folds. A hyperpigmented mass was incidentally found in the proximal jejunum (Figure). Duodenal biopsies showed villous blunting, chronic inflammation and increased intraepithelial lymphocytes, which was consistent with CD. Biopsies of the jejunal mass revealed a densely pigmented nodule of atypical cells with large hyperchromatic nuclei, abundant cytoplasm, and mitoses. An immunohistochemical stain was positive for Melan-A and S100, which confirmed a diagnosis of MM of the small bowel.Additional imaging revealed no signs of metastatic disease. Subsequently, the patient underwent laparoscopic resection of the small bowel mass and the pathology showed malignant MM with negative margins. Then, she was started on Trametinib and Dabrafenib for about 5 months, but was discontinued due to side effects. Currently, the patient remains disease-free 36 months after surgery. Diarrhea is also much improved after starting a gluten free diet. DISCUSSION: Small bowel malignancies are rare, accounting for 3% of GI neoplasms and the majority of small bowel neoplasms represent metastatic disease. The small intestine is also considered the most common site of melanoma metastases to the GI tract. Primary small intestinal MM is characterized by MM of the small bowel without evidence of a primary extra-intestinal lesion. Whether this represents a true primary malignancy or a metastatic disease from an unrecognized or a regressed lesion elsewhere remains debatable. The main treatment of primary small intestinal melanoma is surgical resection. Although patients with CD in general have increased risk of malignancy, there is no known association between CD and MM. This case highlights a rare incidental primary small intestinal melanoma in the setting of a patient who is symptomatic from CD.

2542 Emerging Use of Hemospray in Lower Gastrointestinal Bleeding: Primary Mucosal Melanoma of the Jejunum

INTRODUCTION: Small bowel (SB) primary melanomas (PM) are extremely rare; around 30 cases are reported to date. Diagnosis is challenging due to difficult endoscopic access and dealing with its complications such as bleeding is even more difficult. We describe in this report a case of jejunal primary melanoma presenting with lower gastrointestinal (GI) bleeding controlled with Hemospray. CASE DESCRIPTION/METHODS: A 70-year-old man with coronary artery disease on aspirin presented with symptomatic anemia. He endorsed recurrent melena associated with weight loss. Vital signs were stable. Physical exam remarkable for melena on rectal exam. Computed tomography scan of the abdomen revealed a jejunal mass. The patient underwent a push enteroscopy, which showed a large ulcerated necrotic mass in the mid-jejunum that was actively bleeding. The entire mass was oozing from multiple foci with a large surface area. It was invading the jejunal wall with larger vessels exposed. Hemospray was used to achieve hemostasis. Pathology revealed malignant melanoma; a thorough skin and eye exam was negative for PM. The patient denied any history of excision of pigmented skin lesions. The final diagnosis was primary melanoma of the jejunum. DISCUSSION: Malignant melanomas are mostly cutaneous. Only 3-4% originate in mucosal membranes as primaries. The diagnosis is challenging due to nonspecific manifestations and difficult pathologic access. Radiological studies are the first diagnostic approach. Balloon enteroscopy allows histopathological diagnosis and management of complications such as bleeding. In our case, the jejunal tumor was ulcerated with an extensive surface area and multiple foci of actively bleeding vessels. Due to the abundant lymphovascular supply of the intestinal mucosa, SB melanoma is a highly vascularized tumor. Hemospray was the preferred initial modality in this particular scenario and was successfully used for hemostasis. It is an inorganic powder that provides hemostasis by acting as mechanical tamponade and increasing the local concentration of clotting factors. It is easy to use with an excellent safety profile, does not require precise targeting, and is efficacious in large surfaces. Mucosal tissues do not absorb it; thus, it has no risk of systemic toxicity. It is FDA approved for hemostasis of non-variceal GI bleeding. It is contraindicated in varices and fistulas. It was also used in cancer-related bleeding with promising results. It can be applied repeatedly as a bridge to other definitive modalities.

Adenocarcinoma of the Proximal Jejunum Misdiagnosed as Gastroparesis

The prevalence of small bowel cancer is relatively low. The abdominal pain that patients with small bowel cancer present as a symptom is non-specific and often interpreted as a normal finding on radiographic studies. To prevent delayed diagnosis of small bowel cancer, practitioners must maintain a certain level of suspicion. We report a case of delayed diagnosis of jejunal cancer as it was misdiagnosed as gastroparesis. A 69-year-old woman complained of recurrent nausea and vomiting. At the beginning of her hospitalization, we could not diagnose mechanical obstruction through esophagogastroduodenoscopy and abdominal computed tomography. A gastric emptying study revealed delayed gastric emptying. Although the patients received treatments, including administration of prokinetics and botulinum toxin injection, for gastroparesis, her symptoms aggravated. Subsequently, plain radiography of the abdomen revealed a double-bubble sign. Abdominal computed tomography was performed under the suspicion of small bowel obstruction; however, the diagnosis was not clear. Consequently, exploratory laparoscopy was performed. She underwent surgical management, including small bowel segmental resection and duodenojejunostomy, due to the jejunal mass with involvement of the stomach, pancreatic head, and mesentery of the transverse colon. The postoperative pathological results revealed a moderately differentiated adenocarcinoma of the jejunum. Key words: Gastric emptying; Gastroparesis; Jejunal neoplasms; Nausea