Left Lower Quadrant Abdominal Pain Research Articles

Colonoscopic removal of an intrauterine device with rectal perforation: A case report.

The intrauterine device is one of the effective, safe, convenient, economical, and reversible contraceptive methods. Although its contraceptive effect is definite, some female patients may experience complications such as expulsion, bleeding, and pregnancy with the device in place. Rectal perforation is one of the rare and serious complications, which can lead to complications such as abdominal infection and intestinal adhesions, severely affecting the quality of life of patients. A 34-year-old female was sent to the Department of Gastroenterology with noticeable left lower quadrant abdominal pain. She had presented with abdominal discomfort and anal tenesmus 1 year earlier. Two months ago, her abdominal pain had gradually worsened and she was presented to our hospital. Investigations, including colonoscopy and computed tomography scan, had revealed an intrauterine device migrated and perforated into the rectum. The patient underwent successful colonoscopic removal of the intrauterine device. She recovered well after the treatment. This case proves that endoscopic therapy can be considered the preferred method for removing intrauterine devices displaced into the digestive tract lumen.

A case report of lactobacillus bacteremia in a patient on chronic parenteral nutrition

Short bowel syndrome is a malabsorption disorder typically caused by the physical loss of a portion of the intestine, whereafter the body is unable to adequately absorb nutrients, fluids, and electrolytes. Many patients with short bowel syndrome are reliant on home parenteral nutrition through a tunneled or peripherally inserted central catheter to ensure sufficient hydration and nutrition. Central venous catheters are a nidus for bacteria, and patients are at risk for infections associated with high levels of morbidity and mortality. Lactobacillus is a ubiquitous microorganism that most frequently colonizes mucosal surfaces such as the gastrointestinal tract. Lactobacillus bacteremia is rare, with limited occurrence in current medical literature. Our patient is a 60-year-old female with a past medical history significant for multiple abdominal surgeries resulting in short bowel syndrome, with subsequent dependence on home parenteral nutrition via peripherally inserted central catheter. She had type III chronic intestinal failure, category D2, and stage 1 moderate malnutrition. She was originally admitted to the hospital for a presumed pulmonary embolism and was found to have a deep vein thrombosis in the setting of her peripherally inserted central catheter. On admission her abdominal exam was unremarkable, she denied abdominal pain, and her only gastrointestinal complaint was chronic stable diarrhea. During the hospitalization she developed severe left lower quadrant abdominal pain and noted decreased frequency of her bowel movements. A computed tomography scan of her abdomen revealed chronic stable intestinal distension and was concerning for obstruction. Clinically she remained without symptoms of acute obstruction or ileus. During the admission she became febrile, with blood cultures from her peripherally inserted central catheter and peripheral IV growing out gram negative rods determined to be lactobacillus bacteremia. The infectious disease team recommended removal of her peripherally inserted central catheter given their concern for a line infection. The patient was treated with broad-spectrum antibiotics, did well clinically, and was ultimately discharged following reinsertion of her peripherally inserted central catheter after negative repeat blood cultures. Though she initially did well in the outpatient setting, she ultimately passed away ten months later after re-presenting to the hospital in septic shock, secondary to bowel ischemia and suspected fungemia of her peripherally inserted central catheter. In this case report, we describe an unusual case of a patient with short bowel syndrome on chronic parenteral nutrition who developed catheter-associated lactobacillus bacteremia - the first reported case in an adult patient on parenteral nutrition.

Non-traumatic lower abdominal pain: ultrasonographic and clinical differential diagnosis.

Lower abdominal pain is frequently reported and has a diverse differential diagnosis. In cases with atypical presentation and nonspecific findings, further imaging evaluation is required to confirm the clinical suspicion and to distinguish between self-limiting disorders and those requiring immediate intervention. In line with European guidelines, transabdominal ultrasonography is recommended as a first-line imaging modality for clinically suspected acute appendicitis and acute diverticulitis, which respectively represent the predominant causes of right and left lower quadrant abdominal pain. It is similarly the preferred method for evaluating suspected obstetric/gynecologic and genitourinary diseases. Computed tomography is utilized as a secondary option when ultrasonography results are inconclusive. This pictorial essay illustrates the sonographic features of the most common conditions associated with lower abdominal pain and outlines the clinical characteristics of each entity.

Non-Mass-Forming Myeloid Sarcoma of the Colon Presenting With Diarrhea

ABSTRACT A female patient in her mid-70s, with a history of diverticulosis, presented with a 2-month history of severe diarrhea, left lower quadrant abdominal pain, decreased appetite, and fever. She was treated for diverticulitis, but did not improve. Subsequent workup revealed leukocytosis and circulating myeloblasts on a peripheral blood smear. Bone marrow evaluation and flow cytometry confirmed the diagnosis of acute myeloid leukemia. Abdominal computed tomography and sigmoidoscopy were performed for her persistent diarrhea. While both failed to show an obvious mass or anatomical abnormality, pathology from the colorectum showed infiltration by leukemic cells consistent with myeloid sarcoma. The diarrhea improved with acute myeloid leukemia chemotherapy.

INTRAOPERATIVE FROZEN SECTION ANALYSIS OF ENDOMETRIOID OVARIAN BORDERLINE TUMOR: A DIFFICULT DIAGNOSIS

Abstract Introduction/Objective Borderline ovarian tumors (BOT) comprise approximately 15% of all primary ovarian neoplasms; of these endometroid borderline ovarian tumors (EBOT) are much rarer (2-3%). BOT is often potentially misdiagnosed as a malignant tumor based on its challenging histomorphological features and thus, treated aggressively. Herein, we present an unusual case of EBOT with adenofibromatous pattern in a 50-year-old gravida 3, para 2 female diagnosed on intraoperative frozen sections (IOFS). Methods/Case Report Patient with history of endometriosis presented with left lower quadrant abdominal pain. MRI revealed complex bilateral ovarian masses with solid and cystic components measuring 5 cm and 6.7 cm in right and left ovary, respectively. An ovarian malignancy was suspected. Patient underwent exploratory laparotomy, total abdominal hysterectomy with bilateral salpingo-opherectomy, and omentectomy. Grossly, bilateral ovaries (BO) showed intact capsule with solid and cystic components. On IOFS, the solid areas demonstrated endometrioid glands arranged in a lobular fashion with squamous morules. The cystic component demonstrated papillary projections with squamous differentiation. Cytology is mildly atypical at best. Based on these findings, a diagnosis of EBOT was made, necessitating staging. Differential diagnoses include atypical endometriosis, endometrioid adenofibroma (EAF) and endometrioid adenocarcinoma (EA). Lack of endometrial stroma surrounding the glands ruled out endometriosis. Presence of CC with papillary architecture ruled out EAF and lack of destructive stromal invasion with desmoplasia, confluence of glands and significant cytologic atypia ruled out EA. Final histopathological diagnosis of formalin-fixed paraffin-embedded specimen revealed EBOT, pT1bN0M0. Uterus and cervix revealed endometrial hyperplasia with atypia, adenomyosis, leiomyomas, and endocervical polyp. Results (if a Case Study enter NA) NA Conclusion The accurate diagnosis of BOT during IOFS is critical as it directs surgeons towards staging studies and in choosing conservative surgical treatment over aggressive treatment especially in cases of young women who desire future childbearing. As this is a rare entity, it serves the pathologist well to keep all relevant differential diagnoses in mind.

Unraveling the Clinical Spectrum: A Case Study of Classic and Aplasia-Related Paroxysmal Nocturnal Hemoglobinuria

Introduction: Paroxysmal nocturnal hemoglobinuria (PNH) is a rare nonmalignant clonal disorder of hematopoietic stem cells characterized by a phosphatidylinositol glycan protein A (PIGA) gene mutation. This mutation results in the deficiency of glycosylphosphatidylinositol (GPI)-anchored proteins, CD55 and CD59, on the cell surface, rendering red blood cells (RBC) susceptible to complement-mediated destruction. This leads to hemolytic anemia, thromboses, and bone marrow failure. Here we describe two cases of PNH presenting to a tertiary care center. Case 1 A 29-year-old male with a history of polysubstance use presented to the Emergency Department with a 2-day history of progressively worsening left lower quadrant abdominal pain. CT abdomen pelvis showed multiple renal infarcts and findings suggestive of pneumatosis intestinalis. A complete blood count (CBC) revealed pancytopenia with a leukocyte count (WBC) of 3 x 10 9/L, hemoglobin (Hb) of 94 g/L, and platelet count (Plt) of 48 x 10 9/L. Lactate dehydrogenase (LDH) was elevated (900 IU/L), haptoglobin level was low ( <8mg/dL), and direct antiglobulin test (DAT) was negative. Urine was positive for hemosiderin, and flow cytometry showed RBCs (6.7%), granulocytes (97.97%), and monocytes (89.02%) with PNH phenotype. Bone marrow biopsy (BMB) was negative for dysplasia and fibrosis with normal hematopoiesis but showed increased erythroid precursors. Enoxaparin was started for thromboses and levofloxacin for neutropenia. Treatment for PNH was initiated with a loading dose of ravulizumab and meningococcal vaccination. The patient was lost to follow-up after receiving the first maintenance dose. Case 2 An 81-year-old female with a medical history of hypertension and coronary artery disease was hospitalized for gradually worsening shortness of breath and fatigue ongoing for 2 months. She reported easy bruising but denied a history of obvious bleeding from any orifice. Physical exam was significant for petechial rash in her lower extremities. Labs revealed pancytopenia (WBC 1.44 x 10 9/L, Hb 68 g/L, Plt 8 x 10 9/L), low reticulocyte count, LDH of 276 IU/L, and negative DAT. BMB showed marked aplasia, and she became transfusion dependent. Subsequently, flow cytometry revealed PNH phenotype in 1.45% of RBCs, 54% granulocytes, and 54% monocytes. Eculizumab therapy was started for the diagnosis of PNH. However, her transfusion requirements did not decrease. She developed iron overload and showed positive conversion on DAT. Darbepoetin alfa and romiplostim were added. Her Hb stabilized at >70g/L in 3 years, following which she only required romiplostim to maintain Plt >20,000 ( Graph 1). After 5 years, she opted to discontinue all treatment. She is being followed up regularly and has since remained stable. Discussion The two cases above are reflective of how PNH can present in different ways, ranging from the classic triad of symptoms to those with subclinical findings associated with other underlying conditions, such as aplastic anemia or myelodysplastic syndrome. The introduction of complement inhibitors completely changed the natural history of PNH, as patients' median survival shifted from 15-20 years to align with age-matched controls. Indications for treatment include severe anemia, thrombosis, or PNH symptoms like dyspnea, fatigue, and painful paroxysms. Currently, eculizumab and ravulizumab are the only FDA-approved drugs for PNH treatment. Ravulizumab is non-inferior to eculizumab, with the added advantage of less frequent dosing (every 8 weeks versus 2 weeks). Regular monitoring for hemolysis is warranted with treatment. Many patients require long-term therapy, which continues to be a significant challenge, even with the spaced dosing of ravulizumab. Eculizumab protects from terminal complement-mediated damage preventing intravascular hemolysis. However, these cells are still deficient in CD55, making them vulnerable to opsonization by C3 and premature removal in the spleen. As a result, >50% of PNH patients receiving treatment show positive conversion on DAT, as seen in case 2. Heparin is preferred in acute thrombotic states. Most hematologists recommend anticoagulation till a few months after starting complement inhibition.

SAT675 GLP-1RA Therapy And Intussusception: A Case Report Of Bowel Telescoping In Anobese Patient After Successful Weight Loss On Therapy

Abstract Disclosure: S. Alqaisi: None. W.R. Doerfler: None. T. Latif: None. A. Bandi: None. Background: Glucagon-like peptide receptor agonists (GLP-1RA) are incretin-based drugs that are now a mainstay in managing type 2 diabetes and obesity, offering added cardiorenal benefits. GLP-1RAs slow gastric emptying and small bowel motility, leading to side effects like constipation, nausea, and diarrhea. Small bowel obstruction (SBO), though not well described in clinical trials, has been reported in observational studies. SBO due to intussusception is a rare condition in adults where one segment of the bowel telescopes into the adjacent segment, potentially causing intestinal ischemia. Although GLP-1RA therapy has not been previously linked to intussusception, we present a patient who developed intussusception while on GLP-1RA therapy for obesity. Case: A 54-year-old female with a history of prediabetes, generalized anxiety disorder, diverticulosis, and total hysterectomy with bilateral salpingo-oophorectomy who was referred for obesity class-I (BMI-33) management considered constitutional given the negative work-up. After an initial weight loss of 40 Ibs with diet and exercise, her success stalled. She was started on medical therapy, initially on orlistat which caused diarrhea, then switched briefly to phentermine-topiramate, that resulted in palpitations and increased anxiety. Hence, liraglutide was initiated, resulting in a further weight loss of 25 Ibs. Three months later, she admitted with left lower quadrant abdominal pain, nausea, vomiting, and diarrhea. Lab tests were unremarkable, and an abdominal CT scan showed an 8.9 cm segment of small bowel intussusception without obstruction. Her symptoms improved after a large episode of emesis and placement of a nasogastric tube. She underwent diagnostic laparoscopy followed by exploratory laparotomy. The entire small bowel length was examined, with no abnormalities found, indicating a transient intussusception. She was discharged on liraglutide. Later, she underwent a follow-up small bowel follow-through that showed normal small bowel features. Liraglutide therapy was discontinued, and she remains symptoms free. Discussion: This case highlights the importance of providers being aware of potential adverse effects, including the rare but serious complication of SBO in patients receiving GLP-1RA therapy. Significant weight and omental fat loss may have led to intussusception in our patient. Thinning of the mesentery and loss of visceral fat oppose less resistance to abdominal peristalsis, increasing the risk of intussusception. While the exact mechanism of GLP-1RA-induced SBO remains unclear, it is postulated that inhibition of intestinal motility may play a role, particularly in patients with pre-existing gastrointestinal neuropathy. Therefore, clinicians should monitor patients for signs of gastrointestinal distress or obstruction and investigate suspected cases promptly for timely management. Presentation: Saturday, June 17, 2023

THU386 Non-diabetic Ketoacidosis As A Rare Complication Of Colitis And Gastritis

Abstract Disclosure: J. Bosques-Lorenzo: None. J.J. Irizarry-Garcia: None. J. Baez-Torres: None. J. Colon-Castellano: None. Background: Starvation ketoacidosis is a rare cause of metabolic acidosis that is often under-recognized. To our knowledge, no cases of starvation ketoacidosis secondary to colitis and gastritis have been reported. Clinical Case: A 91 y/o male presented to the ER with nausea, vomiting, left lower quadrant abdominal pain, and anorexia that progressed for the previous two days. Physical examination was remarkable for a fragile man, acutely over chronically ill, with reduced skin turgor, dry oral mucosa, but a benign abdominal examination. Vitals signs upon arrival were stable. Basic laboratories showed hypoglycemia at 64 mg/dL (70 - 99 mg/dL), low CO2 17.7 mEq/dL (24 -32 mEq/dL), Na 137 mEq/dL (135 - 145 mEq/dL), Cl 94 mEq/dL (100- 110 mEq/dL). High anion gap metabolic acidosis was demonstrated (25 mEq/L). Renal function was preserved and within the patient's baseline, lactic acidosis was ruled out with normal levels in the laboratory, and CBC was negative for leukocytosis. Patient denied alcohol ingestion upon questioning. There were no suspected infectious foci. Abdomino-pelvic CT scan with oral contrast demonstrated colonic, rectal, and gastric inflammation. Case reevaluation and assessment of the data and history of present illness, led to B-hydroxybutyrate measurement. Surprisingly, ketones levels came back markedly elevated at confirming starvation ketoacidosis in the setting of colitis and gastritis. Patient was treated with aggressive intravenous fluids with normal saline for the first 24 hours, IV glucose to correct hypoglycemia, electrolytes were replaced as needed, and stomach antacids for symptomatic relief of abdominal discomfort. We slowly progressed diet as tolerated and electrolytes were carefully monitored for refeeding syndrome. Few days later the patient was discharged home with full resolution of symptoms. Conclusion: Metabolic acidosis secondary to ketoacidosis is mostly visualized to be exclusive for diabetic patients, leading to under-recognition of starvation ketoacidosis. This is the first case of starvation ketoacidosis secondary to colitis and gastritis. Understanding its association can lead to prompt recognition and treatment, especially in the non-diabetic population. Presentation: Thursday, June 15, 2023

A Man with Severe, Left Lower Quadrant Abdominal Pain.

An 84-year-old man presented to the emergency department with sudden, left lower quadrant cramping pain. Because critical hypotension was noted, point-of-care ultrasonography (POCUS) was performed immediately. The study revealed a pulsatile flow extravasating from the left common iliac artery into the left psoas muscle with hypoechoic para-aortic fluid collection. Common iliac artery rupture is rare and has nonspecific clinical presentations. A quick disposition can be made with a combination of clinical manifestations and POCUS results.

An unusual site for hydatid cyst on ovary misdiagnosed as an ovarian cyst: a case report.

The authors report a case of a 43-year-old woman with a primary hydatid cyst, the patient presented with left lower quadrant abdominal pain for 2 months. Ultrasound of the abdomen showed evidence of a multivesicular, fluid-containing cystic lesion in the left adnexa. The mass was excised and a hysterectomy with total left salpingo-oophorectomy was performed. Histopathology confirmed it to be a hydatid cyst. The clinical presentation of an ovarian hydatid cyst can differ, ranging from asymptomatic for years to dull pain if it compresses on the neighbouring organs or tissues, it may even cause a systemic immunological reaction if it ruptures. Cyst excision when possible is the best treatment, percutaneous sterilization techniques, and drug therapy may also be applied in certain cases.

Descending Colon Cancer with Hepatic Metastasis on Abdominal Ultrasound in Patients with Left Lower Abdominal Pain

Ultrasound is essential for differential diagnosis in patients with left lower quadrant (LLQ) abdominal pain. Causes of LLQ pain are variable such as diverticulitis, colitis, appendagitis, and rarely appendicitis (in situs inversus). Colon cancer also is an occasional cause. Ultrasound findings of colon cancer are irregular wall thickening with loss of wall stratification and luminal narrowing. We report a case of descending colon cancer with hepatic metastasis detected on abdominal ultrasound in a 78-year-old female patient with LLQ pain. Ultrasound findings showed irregular bowel wall thickening with loss of wall stratification, luminal narrowing at the descending colon, and multiple hyperechoic nodules with peripheral halo at S4, 7, and 8 of the liver.

Left-Sided Acute Appendicitis With Situs Inversus Totalis

Left-sided appendicitis is difficult to diagnose, but a delayed diagnosis may have a fatal outcome. We describe a patient case of acute appendicitis with situs inversus totalis and left lower quadrant abdominal pain. Unexpected faint heart sounds in their typical location and chest radiograph demonstrating dextrocardia prompted the suspicion of situs inversus totalis and left-sided appendicitis.

Symptomatic Uncomplicated Diverticular Disease (SUDD): Practical Guidance and Challenges for Clinical Management.

Symptomatic Uncomplicated Diverticular Disease (SUDD) is a syndrome within the diverticular disease spectrum, characterized by local abdominal pain with bowel movement changes but without systemic inflammation. This narrative review reports current knowledge, delivers practical guidance, and reveals challenges for the clinical management of SUDD. A broad and common consensus on the definition of SUDD is still needed. However, it is mainly considered a chronic condition that impairs quality of life (QoL) and is characterized by persistent left lower quadrant abdominal pain with bowel movement changes (eg, diarrhea) and low-grade inflammation (eg, elevated calprotectin) but without systemic inflammation. Age, genetic predisposition, obesity, physical inactivity, low-fiber diet, and smoking are considered risk factors. The pathogenesis of SUDD is not entirely clarified. It seems to result from an interaction between fecal microbiota alterations, neuro-immune enteric interactions, and muscular system dysfunction associated with a low-grade and local inflammatory state. At diagnosis, it is essential to assess baseline clinical and Quality of Life (QoL) scores to evaluate treatment efficacy and, ideally, to enroll patients in cohort studies, clinical trials, or registries. SUDD treatments aim to improve symptoms and QoL, prevent recurrence, and avoid disease progression and complications. An overall healthy lifestyle - physical activity and a high-fiber diet, with a focus on whole grains, fruits, and vegetables - is encouraged. Probiotics could effectively reduce symptoms in patients with SUDD, but their utility is missing adequate evidence. Using Rifaximin plus fiber and Mesalazine offers potential in controlling symptoms in patients with SUDD and might prevent acute diverticulitis. Surgery could be considered in patients with medical treatment failure and persistently impaired QoL. Still, studies with well-defined diagnostic criteria for SUDD that evaluate the safety, QoL, effectiveness, and cost-effectiveness of these interventions using standard scores and comparable outcomes are needed.

Bilateral Tubal Pregnancies Presenting 11 Days Apart: A Case Report.

Ectopic pregnancy is the most common cause of maternal mortality in the first trimester. Bilateral tubal pregnancy is the rarest subset with an estimated incidence of one in 725 to 1,580 ectopic pregnancies. Of the cases of bilateral tubal pregnancy reported in the literature, most were associated with the use of assisted reproductive techniques. Here we present the case of a patient, without a prior history of reproductive technology use, who underwent treatment for a tubal pregnancy and was subsequently found to have a second, contralateral tubal pregnancy 11 days later. A 35-year-old female gravida eight para two with a history of left tubal pregnancy and salpingectomy 11 days prior, presented to the emergency department (ED) with two days of left lower and upper quadrant abdominal pain. The patient's last menstrual period had been several months prior. A physical examination revealed left lower quadrant abdominal tenderness, rebound, guarding, and left adnexal tenderness. Her vital signs were unremarkable, and her laboratory studies revealed normal white blood cell and hemoglobin values. Her human chorionic gonadotropin had tripled from her last presentation 11 days prior. Transvaginal ultrasound showed a possible ectopic pregnancy adjacent to the right ovary. She promptly underwent a right salpingectomy. Pathology findings confirmed a tubal pregnancy, and the patient's postoperative course was uneventful. This case highlights the importance of maintaining a high index of suspicion for ectopic pregnancy in all biologically female patients of reproductive age who present to the ED with abdominal pain.

Ultrasound Diagnosis of Primary Epiploic Appendagitis: A Case Report

A rare differential diagnosis for severe abdominal pain is acute epiploic appendagitis. Its symptoms resemble those of acute diverticulitis, acute appendicitis, or omental infarction quite a bit. The primary imaging method used for diagnosis is computed tomography (CT). We are describing the case of a 27-year-old guy who underwent an abdominal ultrasonography after complaining of severe left lower quadrant abdominal pain. It identified an oval and non-compressible hyperechoic mass in the left iliac fossa. The mass was surrounded by a hypoechoic rim and there was no color Doppler signal. In the absence of CT, radiologists must be able to diagnose acute epiploic appendagitis on ultrasound in order to avoid unnecessary hospital admission, pricey laboratory tests, antibiotic treatment, and unnecessary surgery. In this instance, the patient was spared from ionization exposure from a potential CT scan and other invasive treatments including surgery with associated costs because of the reliable ultrasound diagnosis of epiploic appendagitis. After receiving conservative medical treatment, the patient was placed under surveillance and then discharged.

Exophytic interstitial ectopic pregnancy removal: novel use of Endoloop for uterine cavity preservation

Exophytic interstitial ectopic pregnancy removal: novel use of Endoloop for uterine cavity preservation

A Rare Case of Non-Gestational Ovarian Mixed Intermediate Trophoblastic Tumor Associated with a Mature Cystic Teratoma

Abstract Introduction/Objective Ovarian non-gestational trophoblastic tumors are rare with only a few documented cases. We report a case of a 22-year-old non-sexually active woman who presented to the emergency department with ongoing left lower quadrant abdominal pain. Workup showed elevated Beta-human chorionic gonadotropin levels (152 mIU/mL) and a left ovarian mass. This was initially thought to be an ectopic pregnancy, however patient was non- sexually active. Patient underwent a left oophorectomy and the specimen was sent to pathology. Methods/Case Report Microscopic examination of the ovary revealed a mature cystic teratoma with intimately associated foci of loosely cohesive pleomorphic atypical cells. The atypical cells also replaced some of the blood vessel walls and infiltrated the residual ovarian parenchyma. Mitoses were present at (2/10hpf). No necrosis or chorionic villi were identified. Immunohistochemical stains were performed, and the atypical cells were positive for GATA3, inhibin, and human placental lactogen. These cells also showed an elevated ki67 proliferative index (15%). All these findings supported a diagnosis of a placental site trophoblastic tumor. Focally, well-defined cystic structures composed of large epithelioid cells were also noted. These epithelioid cells were positive for GATA3, inhibin, and p63. These cells were negative for human placental lactogen and showed an elevated ki67 proliferative index (12%), findings consistent with an epithelioid trophoblastic tumor component. Ovarian intermediate trophoblastic tumors are rare and could be of gestational or non-gestational origin. To confirm a non-gestational origin, DNA genotyping was performed. Results showed identical genetic profiles in the teratoma, the intermediate trophoblastic tumor, and in the patient’s benign ovarian tissue. This finding confirmed the diagnosis of a non-gestational mixed intermediate trophoblastic tumor associated with a mature cystic teratoma. This tumor is exceedingly rare with only a few reported cases in literature. Results (if a Case Study enter NA) NA Conclusion The diagnosis of a non-gestational mixed intermediate trophoblastic tumor is exceedingly rare with only a few reported cases in literature. The combination of immunohistochemistry and dna genotyping confirmed our suspicion and yielded the correct diagnosis.

A Common Diagnosis Delayed by Three "Wrong Footing" Anchoring Errors - it is Difficult to Remember What You Have Forgotten.

If a patient has unexplained lower left abdominal pain, it is advisable to deploy a "searchlight" strategy.When a hydroureter was found to have no apparent source obstruction, a vertical tracing strategy should have been undertaken to detect its root cause.To avoid the wrong diagnosis through anchoring bias, pivot and cluster strategy - deploying differential diagnosis specific to the initial diagnosis (constipation in this case) - should be adopted at the start, considering the important differential diagnosis and thus preventing a missed diagnosis.

S2023 Endometrioma Presenting as a Sigmoid Colon Polyp

Introduction: Endometriosis refers to inflammation caused by active endometrium outside of the uterus. Colonic involvement can give rise to various complications, such as luminal narrowing, obstruction, and even perforation; all which can be avoided with endoscopic mucosal resection (EMR). Our case shows that endometrial implants in the colon can present similarly to colon cancer and should be considered as a potential etiology of findings on colonoscopy. Case Description/Methods: A 45-year-old female (G4P3) presented with a several month history of left lower quadrant abdominal pain, bloating and multiple episodes of blood per rectum. Past medical history was significant for endometriosis with hysterectomy, tubal ligation, and idiopathic thrombocytopenic purpura. She was referred for a rectosigmoid polyp concerning for malignancy. The mass found was a firm, rubbery, 15mm, exophytic sessile polyp positioned on the acute fold of the sigmoid colon. Using an underwater technique, piecemeal EMR was performed. Argon plasma coagulation (APC) ablation was performed on residual adjacent tissue and the resection bed. Histopathology showed endometriosis involving the muscularis propria and submucosa negative for hyperplastic polyp, adenoma or malignancy. Endometriosis stain was positive for CK7 and PAX-8 and negative for CK20 and CDX-2 confirming the diagnosis. Hormone therapy was initiated and showed significant improvement in symptoms (Figure). Discussion: Endometriosis can affect essentially any organ. Intestinal involvement usually presents with symptoms and gross appearance similar to many disorders including cancer or leiomyoma, such as in our case. Endometriosis usually involves serosa and subserosa. When there is deep invasion into the muscularis propria and submucosa, it can be mistaken for colon cancer, delaying and complicating diagnosis. The gold standard for diagnosing endometriosis is laparoscopy, but colonoscopy can provide direct visualization of lesions with the opportunity for EMR and confirmatory biopsy. As rectosigmoid endometriosis surgery is associated with high rates of complication when compared to other parts of the colon, EMR was preferred in our case. Hormone therapy can help prolong the recurrence interval between resection and recurrence, but has no effect on lesion size. A multidisciplinary approach to intestinal endometriomas with hormone therapy combined with EMR can lower recurrence, remove lesions completely, and help patients avoid endometrioma complications and high-risk surgical procedures.Figure 1.: a: Lesion development prior to EMR. b: Cap-assisted underwater technique piecemeal EMR performed using hot 20 mm and 10 mm snares. c: Lesion was completely removed, retrieved, and APC ablation was performed on residual tissue adjacent to the resection site, as well as resection bed.

S2794 An Unexpected Cause of Abdominal Pain in a Patient With Ulcerative Colitis

Introduction: Sickle cell crisis and Ulcerative Colitis (UC) can both present with abdominal pain, which can present a diagnostic challenge in patients with concomitant disease. Thorough work-up is required to appopriately achieve the diagnosis and guide treatment. Case Description/Methods: A 27 year old female with a history of UC presented to the ED with non-bloody diarrhea, diffuse abdominal pain, and right lower extremity pain. On exam, she was mildly hypotensive with decreased strength in bilateral lower extremities. CBC showed Hgb 7.6g/dL, and iron panel revealed: iron saturation 28%, elevated ferritin (580.5ng/mL), low haptoglobin ( < 30mg/dL), elevated reticulocyte count (7.47%), and reticulocyte index of 2.05. CT scan showed splenomegaly and diffuse bony infracts. Colonoscopy revealed Mayo 3 ulcerative pancolitis (FigureB and FigureC). Biopsy (FigureA) showed sickle cells in the capillaries and lamina propria with background features of chronic colitis. She was diagnosed with concomitant UC flare and sickle cell crisis. Her sickle cell crisis was managed with IV fluids, analgesics, and folic acid, and her UC was treated with IV solumedrol. She was discharged on a prednisone taper and initiated on infliximab infusions with significant improvement in her symptoms. Discussion: There is a rare predisposition of SCD to IBD, though the cause is not well elucidated [1]. In these patients, abdominal pain may be either due to SCD crisis or UC flare. Hence, elucidating the cause is important in guiding treatment. While acute pain due to vaso-occlusion often affects the extremities, it can also manifest as abdominal pain due to mesenteric vaso-occlusion. UC on the other hand, typically presents with left lower quadrant abdominal pain with associated diarrhea; however UC can also present with diffuse abdominal pain in the setting of pancolitis. Diarrhea and dehydration due to UC flares could presumably exacerbate SCD leading to more frequent crises. Dehydrated SCD patients, in the setting of travel, were more likely to be hospitalized for vaso-occlusive crises. Additional complications to consider in treating concurrent SCD and UC is avascular necrosis (AVN). AVN is an associated complication of SCD, as well as a side effect of long-term corticosteroid use. Due to the pro-thrombotic state associated with both diseases, prophylactic anticoagulation can also be considered in the setting of immobilization or hospitalization, and do not necessarily have to be stopped due to bloody diarrhea or anemia [3].Figure 1.: A: colonic biopsy demonstrating sickled red blood cells in the lamina propria and capillary. B and C depict Mayo 3 pancolitis.