Mild Epigastric Tenderness Research Articles

Unveiling the Unconventional: Exploring Atypical Manifestations of Scrub Typhus

Scrub typhus is a rickettsial illness caused by Orientia tsutsugamushi. It is a common cause of undifferentiated febrile illness, especially in the Indian subcontinent, usually with multiorgan involvement, though central nervous involvement is rare. Here, we demonstrate a case of a young female who presented with fever, headache, vomiting, and seizures. Her examination was remarkable for generalized blanchable macular rash, opsoclonus–myoclonus along with neck rigidity and mild epigastric tenderness. Contrast-enhanced magnetic resonance imaging brain was suggestive of leptomeningitis. She also had mild pancreatitis, transaminitis, thrombocytopenia, and transaminitis. Given the ongoing tropical fever burden in Northern India, further workup was done and enzyme-linked immunosorbent assay anti-scrub typhus immunoglobulin M came as positive. Doxycycline along with supportive treatment was started, and all signs and symptoms improved gradually.

A Critical Combination of Esophageal Rupture and Upside-down Stomach: A Case Report.

Spontaneous esophageal rupture, or Boerhaave syndrome, and upside-down stomach are rare pathologies associated with grave sequelae. Boerhaave syndrome can have a mortality rate as high as 44%. Upside-down stomach accounts for less than 5% of hiatal hernias and can lead to incarceration and volvulus. An 80-year-old woman presented to the emergency department with sudden onset, severe epigastric pain. Physical examination revealed normal vital signs with mild epigastric tenderness. Imaging obtained revealed a large hiatal hernia and findings concerning for esophageal perforation. The patient was started on 3.375 grams of intravenous piperacillin/tazobactam, and transfer to a tertiary care facility was initiated. After transfer, esophagography confirmed a perforation near the gastroesophageal junction and findings consistent with an upside-down stomach. The patient underwent successful repair of the esophageal perforation and gastropexy followed by intensive care unit admission and ultimately discharge. Boerhaave syndrome and upside-down stomach are two conditions with high associated morbidity and mortality requiring prompt intervention. Information obtained in the history and physical examination including acute onset of chest pain after vomiting, tachypnea, subcutaneous emphysema, and hypoxia can assist in the diagnosis of the described pathologies. These signs and symptoms can be subtle on examination but are important in raising clinical suspicion for an otherwise rare etiology for acute onset chest pain.

A surgical case of anti-coagulant ileus mimicking small-bowel tumors: a case report

BackgroundAnti-coagulant ileus, characterized by intramural hematoma due to excessive anti-coagulant therapy, presents a diagnostic challenge. Although previously considered uncommon, recently, reporting cases of anti-coagulant ileus have become more frequent. Herein, we report a rare surgical case of anti-coagulant ileus mimicking small-bowel tumors.Case presentationA 79-year-old man was admitted to our hospital for fatigue. He had been administered warfarin for 5 months for atrial fibrillation. On admission, the patient exhibited mild epigastric tenderness. Laboratory test results revealed anemia (hemoglobin, 8.4 g/dL); unmeasurably prolonged prothrombin time (PT) with international normalized ratio (INR) > 8; and elevated soluble interleukin 2 receptor (sIL-2R) levels (849 IU/mL; normal range, 122–496 IU/mL). Abdominal plain computed tomography (CT) showed a circumferentially thickened intestinal wall at one site in the jejunum and two in the ileum. After hospitalization, bowel obstruction did not improve with conservative treatment. Suspecting small-bowel tumors such as lymphoma, the patient subsequently underwent open surgery on day 3 after admission. No obvious tumor mass was observed intra-operatively. However, only thickened and hemorrhagic segments were identified at the suspected sites. We performed partial jejunal and ileal resections of 12 and 27 cm, respectively. Histopathology confirmed submucosal congestion, edema, and hemorrhage in each area without tumor components, leading to the final diagnosis of intramural hematoma. The postoperative course was uneventful, and he was discharged on postoperative day 9. No recurrence occurred during the 5-year follow-up period.ConclusionsWe encountered a surgical case of anti-coagulant ileus, which was difficult to differentiate from malignant lymphoma based on CT findings and high sIL-2R levels. The possibility of anti-coagulant ileus should always be considered in patients on long-term anticoagulation medication and bowel obstruction with high PT-INR values.

Left Portal Hypertension and Hypersplenism in a Child With Congenital Diaphragmatic Hernia: A Rare Case Report

Background: T Congenital diaphragmatic hernia (Bochdalek hernia), which occurs in 1/2,200 live births, is typically diagnosed in the prenatal or immediate postnatal period. Diaphragmatic hernia is rare in older children and adults and can be presented with acute respiratory failure, incarcerated hernia, acute pancreatitis, or rare conditions such as left portal hypertension and hypersplenism. Objective: The aim of this case report was to present 15-year-old male with vomiting and mild upper abdominal pain who had mild epigastric tenderness with no guard and an IV grade splenomegaly caused by Congenital Diaphragmatic Hernia. Case presentation: We report a case of left portal hypertension and hypersplenism in an adolescent with congenital diaphragmatic hernia. Typical clinical presentations include abdominal pain, respiratory symptoms, or intestinal obstruction in incarcerated diaphragmatic hernia. Additionally, some uncommon symptoms reported in literature include gastrointestinal bleeding as a result of portal hypertension, thrombocytopenia due to hypersplenism, and acute pancreatitis. Conclusion: The treatment has released the obstruction in the splenic vein and reduce returned collateral gastric blood flow. Splenectomy should be considered based on many factors, such as anatomic anomalies or the degree of hypersplenism and portal hypertension. This is a rare clinical entity with only a few cases that have been reported in the literature.

#6795 DISSEMINATED STRONGYLOIDES INFECTION IN A PATIENT WITH IGA NEPHROPATHY ON IMMUNOSUPPRESSIVE MEDICATIONS

Abstract Background and Aims Immunosuppressive medications such as high dose steroids and antimetabolites are frequently used in glomerulonephritis. However, use of these medications is usually associated with various adverse effects. Among the drawbacks of immunosuppressive therapy, the risk of reactivation of latent infections, including parasitic infestations, is to be considered. Method Case report. Results Our case is a 28 year old male patient who was diagnosed as a case of IgA nephropathy 7 months back with M1E1S1T1C0 lesions with a serum creatinine of 1.7 mg/dL and eGFR of 56 ml/min/1.73 m2. He was started on prednisolone (40mg daily) and mycophenolate mofetil (1000mg twice daily) for 1 month. He presented with us with diarrhea. He was treated with IV fluids and mycophenolate mofetil was stopped. After two weeks, he was readmitted with a 4-day history of fever, vomiting, and epigastric pain. On examination, he showed mild epigastric tenderness, normal vitals. The laboratory investigations on admission showed hemoglobin-15 g/dL, total leucocyte count-8600, eosinophilia with absolute eosinophil count 1900/ mm3, urea-92 mg/dL, creatinine-2 mg/dL. ECG showed sinus tachycardia, and HRCT chest revealed bilateral ground glass opacities and a calcified nodule in the left upper lobe. Liver function test was normal with normal amylase and calcium level. Blood culture was sterile. Ultrasound abdomen showed a bilateral raised Eco pattern in kidneys rest were normal. Upper GI endoscopy revealed diffuse edema, erythema, and superficial ulceration in duodenum and biopsy was taken. The duodenal biopsy showed features of strongyloidiasis stercoralis (Figure 1). Bronchoesophageal lavage was done which revealed strongyloidiasis stercoralis larvae. Meanwhile, the patient developed subacute small bowel obstruction with abdominal x ray showing multiple air fluid levels and CT scan showed features of small bowel obstruction with transition at mid-ileal level secondary to short segment thickening. Small bowel obstruction was relived with conservative mangement with ryles tube decompression and enemas. He was diagnosed with disseminated strongyloidiasis and treated with ivermectin for 14 days with full recovery Conclusion Our case signifies need of awareness among clinicians of the risk of disseminated strongyloidiasis as a complication of the treatment with immunosuppressive medications even in non-endemic areas.

Doormatobezoar: first case report of a bezoar formed by doormat ingestion

Bezoars are retained concretions of undigested foreign material that accumulate and coalesce within the gastrointestinal tract, most commonly in the stomach. A 12 years old male child presented to us with complaints of pain upper abdomen on and off for 2 months. He had a habit of biting and chewing doormat at home for several months. Physical examination revealed mild epigastric tenderness. Upper GI endoscopy revealed a mass of fibres in the stomach which was tightly organised and too large to safely remove endoscopically in toto. Hence patient was taken up for surgery and a mass of around 9×6 cm in size and oval in shape was removed from stomach. Postoperative recovery was uneventful. Doormatobezoars are rare cause of pain abdomen which can be treated safely and effectively surgically.

Man with episodic abdominal pain andjaundice.

A 51-year-old man without a past medical history presented to our emergency department with 2 months of intermittent epigastric pain radiating to the back, tan stools, fatigue, and weight loss. He denied current alcohol use. He appeared diffusely jaundiced. His abdomen was soft with mild epigastric tenderness and a negative Murphy sign. Serum analysis showed total bilirubin 13.7, aspartate transaminase 207, alanine transaminase 463, alkaline phosphatase 634, lipase > 4000, elevated carcinoembryonic antigen/carbohydrate antigen 19-9, and negative hepatitis panel. Imaging included point-of-care (POC) ultrasound (Figure 1, Video 1), computed tomography (CT; Figure 2), magnetic resonance imaging (MRI; Figure 3), and endoscopic retrograde cholangiopancreatograph (ERCP; Figure 4). Our patient had obstructive jaundice. POC ultrasound revealed a distended gallbladder with sludge without signs of acute cholecystitis. The dilated common bile duct >10 mm (normal < 6 mm) and dilated pancreatic duct >5 mm (normal < 3 mm) were consistent with the rare double duct sign. Dilatation without a clear etiology was confirmed on MRI and CT. ERCP revealed a duodenal ulcer with biopsy positive for invasive, poorly differentiated adenocarcinoma. Finally, a pancreaticoduodenectomy revealed a tumor of the pancreatic head. Etiologies of the double duct sign include neoplasms of the pancreatic head and ampulla of Vater and less commonly choledocholithiasis and chronic pancreatitis.1 Overall prevalence of associated malignancy varies from 58% to 100%.2 However, the presence of jaundice is strongly associated with malignancy whereas absence with benign conditions.3-5 Isodense culprit neoplasms are often not visualized on advanced imaging. As initial presentation of pancreatic cancer is insidious, the ominous presence of this sign should raise concerns for malignancy. The authors would like to thank Daniela Galan Alonso, MD, Department of Radiology, Jackson Memorial Hospital. Video.1 Point-of-care ultrasound of pancreas revealing double duct sign. Gallbladder (star), pancreatic duct (arrow), and common bile duct (circle). Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Isolated Superior Mesenteric Artery Dissection, A Rare Cause Of Abdominal Pain.

A 42-year-old previously healthy male presented with 5 days of spontaneous mid-epigastric intense abdominal pain and mild epigastric tenderness on palpation. CT angiography revealed a Sakamoto type 2 isolated superior mesenteric artery dissection (SMA) with a "cul-de-sac" shaped false lumen (B- C: large arrow), side branch perfusion from both lumens, andcompression of the true (A-D: small arrow) by the false lumen (A-D: large arrow). Dissection flap presented just distal to an aberrant right hepatic artery arising from the SMA (B.D: star). CT, clinical and analytic findings did not suggest visceral compromise and was successfully treated with bowel rest and anticoagulation. He is now on close clinical and imaging follow-up.

ODP165 Atypical DKA? Think Cannabis!

Abstract Diabetic ketoacidosis (DKA) can be life threatening if not recognized and treated promptly. DKA is characterized by hyperglycemia, acidosis, ketosis and elevated anion gap. The presence of these metabolic derangements is essential to make the diagnosis. The use of cannabis has been associated with atypical acid-base profile in DKA which may contribute to confusion in diagnosis and treatment. Case A 20-year-old man with type 1 diabetes since age 10 presented to the emergency department with 4 days of nausea, vomiting and elevated blood glucose (BG). Emesis occurred up to 6 times daily and started 2 days prior to hyperglycemia. He was unable to correct BG with rapid acting insulin. Moderate urine ketones were present. He denied symptoms of diarrhea, fever, sore throat, runny nose or cough and reported adherence to insulin regimen. Physical exam was remarkable for dry mucous membranes and mild epigastric tenderness. Lab evaluation showed BG of 268 (70-110mg/dL), sodium 133 (135-145 mmol/L), potassium 3.6 (3.5- 5.1 mmol/L), chloride 95 (98-107 mmol/L), bicarbonate 22 (22-32 mmol/L), creatinine 0.8 (0.6–1.2 mg/dL), Anion gap 16, beta-hydroxybutyrate 3.38 (&amp;lt;0.27 mmol/L). He had normal white blood cell count and infectious work up was unremarkable. The patient was started on continuous IV fluids and was managed with intermittent subcutaneous rapid acting insulin in addition to basal insulin. After anion gap closure he was transitioned to his home doses of insulin. Prior to discharge, the patient discretely asked about the effects of smoking marijuana on BG and subsequently disclosed he had increased his use of marijuana recently. Discussion Diabetic keto-alkalosis may present as a result of recurrent vomiting that leads to gastric acid loss. Cannabis use has been linked to an increased risk of diabetic keto-alkalosis. The underlying mechanism is hypothesized to be related to cannabis effects on the stomach causing delayed gastric emptying and leading to cyclic nausea and vomiting. One study conducted to investigate acid-base parameters seen in atypical DKA in Type 1 Diabetes referred to this as "Hyperglycemic Ketosis due to Cannabis Hyperemesis Syndrome" (HK-CHS) recommending obtaining urine drug screen in patients with atypical DKA 1 . Attention should be drawn to this phenomenon as cannabis use has grown with its legalization in many states. Individuals with T1D presenting with ketosis but normal or elevated pH and/or serum bicarbonate may confuse clinicians and delay proper diagnosis. When the patient does not disclose cannabis use voluntarily, taking a thorough social history is critical to making the correct diagnosis. Reference: 1. Akturk HK, Snell-Bergeon J, Kinney GL, Champakanath A, Monte A, Shah VN. Differentiating diabetic ketoacidosis and hyperglycemic ketosis due to cannabis hyperemesis syndrome in adults with type 1 diabetes. Diabetes Care 2021 December 8,: dc211730 Presentation: No date and time listed

THROMBOEMBOLISM AS THE INITIAL MANIFESTATION OF CHRONIC LYMPHOCYTIC LEUKEMIA

THROMBOEMBOLISM AS THE INITIAL MANIFESTATION OF CHRONIC LYMPHOCYTIC LEUKEMIA

S3488 Symptomatic Meckel’s Diverticulum in an Adult Presenting With Recurrent Gastrointestinal Bleeding

Introduction: Meckel’s diverticulum is a gastrointestinal congenital malformation that results due to persistence of the vitelline duct, and is commonly diagnosed in children before the age of two. Rarely, symptomatic Meckel’s diverticulum can present in adults, as in this case with recurrent gastrointestinal bleeding. Case Description/Methods: A 51-year-old male with a history of iron deficiency anemia presented to the hospital with hematochezia associated with mild epigastric tenderness. He had a similar presentation one year ago with unrevealing EGD, colonoscopy, and video capsule endoscopy. Three months ago, repeat colonoscopy was notable for a single nonbleeding diverticulum in the terminal ileum and outpatient double balloon endoscopy was recommended, however not yet done due to current hospitalization. He presented with tachycardia and hypotension as well as a hemoglobin 10.6g/dL (previously 11.4g/dL few weeks prior) and mildly elevated BUN. CT abdomen and pelvis was negative for any active bleeding. Repeat EGD and colonoscopy was unremarkable except for blood-tinged fluid interspersed in the colon but again the source of bleeding remained obscure. Given the history of a previous finding of a terminal ileum diverticulum and persistence of hematochezia, a Meckel’s scan was performed revealing abnormal uptake in the right mid to lower abdomen suspicious for Meckel’s diverticulum containing ectopic gastric mucosa. Patient was taken to the operation room; a large Meckel’s diverticulum was noted at approximately two feet proximal to the ileo-cecal valve along with hemorrhagic inflammatory changes within the local mesentery. Patient underwent partial small bowel resection and appendectomy with pathology revealing a Meckel’s diverticulum of the ileum with gastric heterotopia. Patient had an uncomplicated recovery postoperatively along with resolution of hematochezia. Discussion: A finding of Meckel’s diverticulum is common in the pediatric population; however, it is a rare diagnosis in adults. This case highlights the importance of considering Meckel’s diverticulum for instances of recurrent gastrointestinal bleeding, especially in patients who are still symptomatic despite an extensive workup. It is also important to notice that Meckel's diverticulum can be missed on video capsule study.

S3622 Idiopathic Culture-Negative Suppurative Gastritis With Gastric Abscess

Introduction: Suppurative gastritis is an uncommon infectious process involving the gastric wall from direct mucosal injury caused by a foreign object, reflux of proximal intestinal bacteria, and hematogenic or lymphatic spread from a distant infection. Intramural gastric abscess is rare with high mortality and morbidity if left untreated. Immediate management is required once there is clinical suspicion. Case Description/Methods: A 23-year-old female with unremarkable medical history presented to the emergency department with epigastric pain for 1-week. She endorsed chills, nausea, and non-bilious vomiting. There was no history of foreign body ingestion, prior endoscopy, proton pump inhibitor, tobacco, or recreational drug use. Patient reported drinking two bottles of wine a week over the month before her illness due to stress and constant use of non-steroidal anti-inflammatory drugs (NSAIDs) for relieving menstrual pain. On exam, she had mild epigastric tenderness. Laboratory work was significant for mild leukocytosis. Computed tomography revealed a lobulated mural thickening and submucosal edema involving distal gastric body & antrum, with a 4.3 cm rim-enhancing intramural collection suggestive of an abscess (a) The patient was started on empiric broad-spectrum antibiotics & Pantoprazole and intravenous fluids. Endoscopy showed a cratered ulcer in the antrum with a central sinus tract leading to the gastric wall. There was no pus exuding, and the abscess appeared to have drained spontaneously (b) Mucosal biopsies were negative for Helicobacter pylori. On endosonography, there was wall thickening of the distal stomach, measuring 20 x 35 mm, with a central hypoechoic sinus tract. The lesion originated from the deep mucosal layer (c) Fine needle biopsy revealed acute inflammation with pus in the gastric wall compatible with abscess. Cytology was negative for malignant cells. The patient was discharged on oral amoxicillin-clavulanate to complete ten days of therapy. Upon repeating endoscopy, two months later, the distal gastric ulcer healed completely, and the patient was doing very well (d). Discussion: Intramural gastric abscess is rare. Foreign body ingestion, systematic spread of infection, or prior endoscopic intervention have been described as etiologic factors. NSAIDs could be a potential contributing factor. Prompt recognition, endoscopic drainage, and antibiotic therapy are essential to improve the outcome.Figure 1.: EUS Finding of gastric mural abscess with a visualized sinus tract inside the thick antral wall.

S1871 A Case of Ketamine-Induced Cholangiopathy: A Novel Diagnosis Associated With Chronic Recreational Ketamine Use

Introduction: Ketamine, an analgesic commonly used for procedural sedation, has become a popular agent for recreational use among young adults. The diagnosis of ketamine-induced cholangiopathy is uncommon. We report a case of a young adult with clinical and radiological features consistent with cholangiopathy induced by chronic ketamine use. Case Description/Methods: A 19-year-old female with past medical history of peptic ulcer disease presented to emergency department (ED) with one year history of severe epigastric abdominal pain. On further questioning, patient reported chronic recreational ketamine use. Physical exam revealed mild epigastric and RUQ tenderness. Liver function test demonstrated elevated alkaline phosphatase of 174 U/L, AST of 237 U/L and ALT of 224 U/L. All other hematology and chemistry results were within normal limits. RUQ ultrasound showed minimally dilated common bile duct (CBD). An MRCP was obtained, showing mild-to-moderate dilatation of intra-/extra-hepatic bile ducts and dilated cystic duct (CD) without obvious intraductal calculi (Figure A). Endoscopic ultrasonography (EUS) was performed showing dilatation of CBD, minimal dilatation of common hepatic duct, and minimal dilatation of CD, once again without obvious calculi (Figure B). These imaging findings are compatible with ketamine-induced cholangiopathy. After being admitted for 6 days, the patient demonstrated significant improvement in her abdominal pain, with gradually improving liver test values. She was discharged with the recommendation to abstain from ketamine use and outpatient gastroenterology follow-up. Discussion: Chronic exposure to ketamine has been known to cause urologic injury, referred to as ketamine-induced ulcerative cystitis. In comparison to the urologic complications of chronic ketamine use, its effects on the biliary system have been less commonly reported. Existing reports have mostly come from regions of Asia where recreational ketamine use is more prevalent. The nonspecific gastrointestinal symptoms that are typically reported by patients with ketamine-induced cholangiopathy may make the diagnosis more challenging to recognize. Due to increasing recreational ketamine use among young adults in recent years, cases of ketamine-induced cholangiopathy are likely to rise. Therefore, a better understanding of the clinical and radiological features of this condition are needed to allow for prompt recognition of ketamine-induced cholangiopathy.Figure 1.: A. MRCP image showing mild-to-moderate dilatation of the intrahepatic and extrahepatic bile ducts and dilatation of the cystic duct. There are no visible stones or evidence of other etiology for the dilatation. B. EUS image displaying CBD dilatation measuring up to 10.6 mm in the head region, with smooth tapering to the ampulla where it measured 2.7 mm.

S3300 Acetaminophen Toxicity Amplified: Drug-Induced Liver Injury in a Malnourished Patient

Introduction: Acetaminophen toxicity is a leading cause of acute liver injury and failure in the U.S. Excess acetaminophen results in formation of N-acetyl-p-benzoquinoneimine (NAPQI) which causes irreversible oxidative hepatocyte injury and cell necrosis. Treatment with N-acetylcysteine (NAC) replenishes glutathione stores which inactivate NAPQI. In a healthy adult, acetaminophen doses less than 4 g per 24 hours are considered safe. Toxicity from therapeutic doses of acetaminophen, in the setting of malnourishment, has been rarely reported and is presented here. Case Description/Methods: A 37-year-old female with a history of gastroparesis and chronic malnutrition was admitted for elevated liver enzymes on routine blood work. She reported symptoms of fatigue, nausea, and poor oral intake from suspected gastroparesis. She also admitted to taking 1300 mg of acetaminophen intermittently during the past week for myalgias. Exam revealed normal mentation without evidence of hepatic encephalopathy (HE), cachexia with a BMI of 15.2, and mild epigastric and left upper quadrant tenderness. Laboratory data (36 hours after last ingestion of acetaminophen) revealed an ALT of 1180 u/L, AST of 1950 u/L, ALP of 121 u/L, total bilirubin of 2.7 mg/dL, direct bilirubin of 2.5 mg/dL and INR of 1.6. Her acetaminophen level was 15.8 mcg/mL. A liver ultrasound was unremarkable. NAC was subsequently administered as per protocol 21 hour infusion. She was ruled out for other etiologies of acute liver injury. She never developed HE and her liver enzymes, along with INR, normalized at discharge. Discussion: This case highlights the lower threshold for toxicity of acetaminophen in a malnourished patient. In previous case reports, acetaminophen doses less than 2 g per 24 hours are listed as being safe in a nutritionally deficient patient. Our case questions this assertion given our patient ingested 65% of this amount. Evidence in the relatively limited pool of literature suggests that malnourished patients generally have low stores of glutathione, thereby limiting the metabolic clearance of acetaminophen ingested even at normal dosages, amplifying total acetaminophen levels, and leading to increased NAPQI. Prospective study is limited to rat models and single case reports. Fortunately, our patient was promptly treated with NAC and did not progress to liver failure. This case highlights the narrow therapeutic window of acetaminophen in malnourished patients, one that warrants close observation by clinicians.

S3689 Unforeseen Postoperative Complication in a Bariatric Patient: The Rare Case of a Large Phytobezoar Causing Gastric Outlet Obstruction

Introduction: Bariatric surgery has become increasingly popular in the treatment of obesity to achieve sustainable weight loss. Despite its numerous benefits, complications can arise due to postoperative gastric hypoacidity and motility disorders. Phytobezoars is an infrequent complication of bariatric surgery that arise from impacted aggregates of indigestible fruit and vegetables. Rarely, bezoars can cause gastric outlet obstruction and/or perforation. The following case highlights the presentation, diagnosis and treatment of phytobezoars and the importance of diet compliance in bariatric patients. Case Description/Methods: A 60-year-old woman with hyperlipidemia was admitted due to progressive epigastric fullness and postprandial emesis of 2 weeks’ duration. Moreover, nausea was constant associated with abdominal bloating and 7-pound weight loss. Pepcid did not alleviate symptoms. She denied fever, chills, chest pain, shortness of breath, diarrhea, constipation, hematochezia nor hematemesis. Her past surgical history was pertinent for sleeve gastrectomy in 2017. She denied toxic habits. Labs were unremarkable except for isolated thrombocytopenia. Physical exam was pertinent for mild epigastric tenderness; no abdominal rigidity nor guarding present. Despite abdominopelvic CT revealing a gastric fundus dilation, an upper GI series was the study that diagnosed a large lobular filling defect compatible with a 7.2 cm phytobezoar.1 Upon questioning, the patient reported that she arrived from a cruise vacation before onset of symptoms. She recalled consuming large amounts of vegetables, nuts and fruits. Initial intervention consisted of papain meat tenderizer to help dissolve bezoar. Nevertheless, symptoms persisted due to oral medication intolerance. Upper endoscopy was performed and phytobezoar was removed with Roth Net retriever. After procedure, patient was able to progressively tolerate diet and was discharge home with resolution of symptoms. Avoidance of excessive high fiber diet was recommended to prevent future bezoar formations (Figure 1). Discussion: The incidence of large phytobezoars has been reported as low as 0.3% in the general population, and therefore, its identification is a diagnostic challenge. Even though most of the patients remain asymptomatic, large bezoars can cause gastric outlet obstruction that could end in perforation if not treated promptly. This case emphasizes the importance of considering phytobezoars as a cause of GI symptoms and the importance of diet education in bariatric patients.Figure 1.: 1. Upper GI series X-ray showing a 7.2 cm phytobezoar causing a large lobular filling defect in the stomach fundus.

S3421 HIV/AIDS, and MAC vs COVID Diarrhea

Introduction: During the COVID pandemic, it was difficult to differentiate COVID diarrhea vs other causes, especially in the HIV/AIDS population. HIV infected patients are at high risk for GI infections. Biopsy of the small intestine identifies etiologies which help to differentiate infection, inflammatory, and neoplastic GI disease. Case Description/Methods: A 39-year-old male presented with two months of epigastric abdominal pain, severe diarrhea, and dehydration during the COVID pandemic in 2020. Past medical history of AIDS wasting syndrome. The patient was severely hypotensive. Exam was notable for mild epigastric tenderness,and hepatomegaly. Complete blood count (CBC) revealed a Hemoglobin (Hg) of 4.3 g. COVID 19 was positive. Gastrointestinal panel PCR was negative. CD4 count 1, HIV RNA viral load 48,700. MRI of the abdomen and pelvis showed diffuse bowel wall thickening in the small intestines. On hospital day 2, Esophagogastroduodenoscopy (EGD) and Colonoscopy were performed for anemia and diarrhea, which revealed abnormal variegated mucosa in the duodenum. Colonoscopy showed a normal mucosal appearance. The pathology report of the duodenum revealed macrophages in the lamina propria, which stained positive for Acid Fast Bacilli. Duodenal biopsy showed markedly expanded lamina propria with numerous histiocytes having finely granular chromatin pattern (Panel 1 and 2). The patient was diagnosed with Mycobacterium avium-intracellulare enteritis. Discussion: This 39-year-old male presented with chronic diarrhea without fever or respiratory symptoms. The most pertinent question for the health care team was whether COVID 19 caused the diarrhea.. Endoscopy with biopsy of the small intestine was essential for an accurate diagnosis. MAC infection in HIV has been dramatically declining since the widespread use of antiretroviral therapy and prophylaxis against MAC infection compared to the 1990s (from 65.3/1000 in 1992 to 2/1000 in 2015) (1). It is important to differentiate MAC from other diseases with a macrophage infiltration or inclusions: including Whipple’s, histoplasmosis, and macroglobulinemia. Patients with MAC enteritis present with fever, and watery diarrhea with diffuse small bowel malabsorption which mimics Whipple’s disease. However, the key to differentiate these two entities is doing a duodenal biopsy showing foamy macrophages with PAS-positive acid-fast bacilli (2).Figure 1.: Histology finding.

Hematemesis From Varices in a 14-year-old Without Hepatobiliary Disease: A "Wandering" Diagnosis.

Hematemesis From Varices in a 14-year-old Without Hepatobiliary Disease: A "Wandering" Diagnosis.

Man With Epigastric Pain

An 84-year-old man presented to the emergency department with a 1-day history of dull epigastric pain, decreased appetite, and frequent hiccups. He had a remote perforated gastric ulcer and had, therefore, undergone subtotal gastrectomy with Billroth II anastomosis. His blood pressure was 150/91 mm Hg and pulse rate was 86 beats/min. A physical examination was noteworthy only for mild epigastric tenderness. His WBC count was 6,760/μL, creatine level was 1.4 mg/dL, lipase level was 1,866 U/L, and total bilirubin level was 0.68 mg/dL.

S3557 Esophageal Xanthoma: A Case Report

Introduction: Xanthoma is a non-neoplastic lesion resulting from the accumulation of foamy histiocytes. Xanthomas in the gastrointestinal tract are asymptomatic and often discovered incidentally during gastrointestinal endoscopy. Esophageal xanthoma is a very rare condition, but understanding the endoscopic and pathologic features of these lesions are key to their management and differentiating from other diseases. Case Description/Methods: A 43-year-old male presented with epigastric abdominal discomfort. He complained of epigastric discomfort not related to food intake, and metallic taste in the mouth. He did not have any nausea, vomiting, diarrhea, constipation, melena, or bright red blood per rectum. An abdominal ultrasound performed at the outpatient setting was unremarkable. The abdominal exam was mostly benign except for mild epigastric tenderness. He subsequently underwent esophagogastroduodenoscopy (EGD) which showed normal stomach and duodenum. However, during EGD an incidental finding of a single 2 mm small plaque in the lower third of the esophagus was found and biopsied. The pathology report revealed numerous foamy histiocytes in the lamina propria, consistent with esophageal xanthoma (Figure 1). Discussion: Gastrointestinal xanthoma is a rare condition, reported in 0.23% of the patient who underwent EGD in one study[1]. The most common site of gastrointestinal xanthoma is the stomach. Esophageal xanthoma, however, is very rare. Esophageal xanthomas are usually asymptomatic and were often detected incidentally during upper endoscopy. Although xanthomas in other body parts are associated with various conditions including metabolic syndrome and dyslipidemia, there is no significant correlation between GI xanthoma and metabolic disorders [2]. Esophageal xanthoma is a benign condition, however, it is clinically significant due to its resemblance to other more common esophageal lesions such as esophageal carcinoma, lysosomal storage disease, lymphomas, or infections such as Whipple disease, tuberculosis, or AIDS. Characteristic endoscopic appearances for esophageal xanthoma are yellowish, flat to granular spots or verruciform lesions, usually solitary and measuring between 2 to 20 mm. Biopsy with pathology review is the gold standard for diagnosis. The foam cells are strongly immunopositive for CD68 and in all lesions, CD34-positive intrapapillary capillaries surrounded the aggregated foam cells.Figure 1.: Histology of esophageal xanthoma

Transient Empty Portal Vein With Gastric Emphysema

An 88-year-old man who underwent gastrostomy was admitted for aspiration pneumonia. The patient used glucocorticoid and immunosuppressants for rheumatoid arthritis and interstitial lung disease. Two days after the gastrostomy tube replacement, the patient experienced abdominal pain and vomiting. His vital signs were stable, and only mild epigastric tenderness was noted. Blood tests revealed a white blood cell count of 9700 /μL, elevated C-reactive protein of 3.85 mg/dL, aspartate aminotransferase of 40 U/L, and alanine aminotransferase levels of 28 U/L.