Mucosal Nodularity Research Articles

S1748 Primary Follicular Lymphoma of the Colon: A Rare Case in a Rare Place

INTRODUCTION: Primary lymphomas of the colon are rare, accounting for < 1% of all GI malignances. Studies describing the disease suggest that it most commonly involves the cecum and presents symptomatically in patients with abdominal pain and weight loss. However, given the rarity of the cancer, literature on the clinical and pathologic features of the disease are still evolving. Here, we present a case of primary follicular lymphoma affecting the sigmoid colon with a description of the corresponding colonoscopy and histologic findings. CASE DESCRIPTION/METHODS: The patient is a 71-year old female referred from her PCP for iron deficiency anemia with a hemoglobin of 11.3 g/dL and positive fecal immunochemical testing (FIT). Her symptoms included intermittent episodes of constipation for several weeks. She denied changes in stool caliber including bloody or tarry appearing stools, B-symptoms such as weight loss or night sweats, or family history of colorectal malignancy. Physical exam was unremarkable. Subsequent colonoscopy revealed an 8mm sessile polyp and 10mm semi-pedunculated polyp with a localized area of nodular mucosa in the sigmoid colon. Polyp and mucosal biopsies demonstrated atypical lymphoid infiltrate with abnormal follicular proliferation positive for CD-20, BCL-2 and BCL-6, consistent with low-grade, stage IE, follicular lymphoma. At 1-month follow-up with oncology, the patient remained asymptomatic after polypectomy and chose conservative management with active surveillance. DISCUSSION: Primary lymphoma of the colon is rare, accounting for less than 0.2% of all GI malignancies. There is limited data on the clinical and pathologic features of the disease however, current studies indicate a female predominance, chief presenting symptoms of abdominal pain and weight-loss, and largely cecum involvement. Here, we present a rare case of follicular lymphoma in the sigmoid colon of a female presenting with constipation and iron deficiency anemia. Colonoscopic features included a sessile and semi-pedunculated polyp with nodular mucosa and histology showing an atypical lymphoid infiltrate positive for CD-20, BCL-2, and BCL-6. This case provides insight both into the varying clinical and pathologic characteristics of a relatively rare disease and the importance of lymphoma as part of the differential in this patient population.Figure 1.: Colonoscopy demonstrating a 10-mm Semi-pedunculated Polyp of the sigmoid.Figure 2.: Nodular Hyperplasia of the sigmoid colon.Figure 3.: Biopsy specimen with the round follicles characteristic of follicular lymphoma seen on histology (arrows).

S3588 Chronic Lymphocytic Gastritis

INTRODUCTION: Lymphocytic gastritis (LG) is an uncommon cause of chronic gastritis, accounting for only 5% of cases. The pathology has no clear etiology, however, it is frequently associated with Celiac disease, found in approximately 40% of the patients. H. pylori infection, Crohn’s disease, HIV infection and lymphoma have also been associated in patients with LG. CASE DESCRIPTION/METHODS: A 37-year-old woman with no relevant past medical history who presented to the GI clinic for evaluation of iron deficiency anemia, change in bowel habits, chronic tenesmus and dyspepsia. Menstrual history was unremarkable and anemia did not improved with oral iron supplementation. Laboratory studies showed microcytic normochromic anemia, with an RDW of 15%. Iron profile was consistent with iron deficiency (serum iron of 25 µg/dL and ferritin of 14 ng/mL). Further work up included thyroid studies, vitamin B12 level and testing for celiac disease, which all resulted negative. Subsequent endoscopy and colonoscopy evaluation were unremarkable for macroscopic abnormalities, however, gastric biopsies revealed increased intraepithelial lymphocytosis suggesting a diagnosis of lymphocytic gastritis confirmed via CD3 stain. Colonic biopsies revealed chronic inflammation of lamina propia with intraepithelial lymphocytosis and positive CD3 stain. The patient was started on esomeprazole for lymphocytic gastritis and budesonide for lymphocytic colitis with improvement of symptoms. DISCUSSION: LG is commonly present in middle aged adults, affecting both male and females equally. Initial symptoms are usually non-specific and vary from dyspepsia, nausea, vomiting, diarrhea, anorexia and weight loss. Up to 20% of the cases are labeled as idiopathic, but commonly associated conditions thought to contribute to LG development include autoimmune diseases, infection or environmental influences. Upper endoscopy findings can show nodules, erosions, large gastric folds, or no abnormalities. Diagnosis is achieved by means of histopathological findings, with >25 lymphocytes per 100 epithelial cells. The treatment consists of symptomatic relief, with PPIs or with H. pylori eradication; however, some patients exhibit spontaneous remission. We present this case of refractory iron deficit anemia due LG in a rare location outside the colon resulting in malabsorption.Figure A.: H&E stain of biopsy from nodular gastric mucosa demonstrating increased intraepithelial lymphocytes and expanded lamina propria. Figure B: CD3 stain demonstrated predominant CD3 positive T cells with CD8 co-expression.

S1981 Beyond SCC: Basaloid Squamous Cell Carcinoma of the Esophagus

INTRODUCTION: Basaloid squamous cell carcinoma (BSCC) is an aggressive and poorly differentiated variant of squamous cell carcinoma that has both basaloid and squamous components. Its first description suggests that the tumor originates from totipotential cells in the basal layer of squamous epithelium. CASE DESCRIPTION/METHODS: A 57-year old African American female with a history of chronic GERD and stroke was referred for 3 months of dysphagia to solids, a weight loss of 30 lbs, and abnormal barium swallow. She denied alcohol use and smoking. Barium swallow from the referring facility showed segmental narrowing and a long irregular distal esophageal stricture. Upper endoscopy revealed a circumferential ulcerated mass at 25 cm up to 32 cm from the incisors, preventing passage of the adult gastroscope. This was exchanged for a pediatric gastroscope. A patch of nodular mucosa with ulceration was seen at 23 cm from the incisors. Pathology showed moderately to poorly differentiated basaloid squamous cell carcinoma. DISCUSSION: BSCC is predominantly seen in the upper aerodigestive tract (nasopharynx, tongue, larynx, trachea), where it can be associated with human papillomavirus (HPV). Esophageal BSCC is very rare, accounting for only 0.068-4.0% of esophageal carcinomas, and its associated with HPV is less certain. Patients with esophageal BSCC are older, have higher proliferative activity, and higher apoptotic indices when compared to typical squamous cell cancer of the esophagus. Like our case, patients with esophageal BSCC often present with dysphagia and weight loss. On endoscopy, deeply invasive, large bulky ulcerated fungating masses are seen. Histologically, BSCC consists of small basaloid cells with oval to round nuclei, pale chromatin, and scant basophilic cytoplasm. The cells are arranged in solid or cribriform lobules with comedo-necrosis. On immunohistochemistry stains, there is poor reactivity for cytokeratin 13 and 14, antibodies that are typical of squamous cell epithelia. Widespread metastases are usually present upon diagnosis. However, if curative resection is possible, the prognosis of patients with esophageal BSCC is similar to that of patients with typical SCC.Figure 1.: Proximal end of the esophageal tumor.Figure 2.: Distal end of the esophageal tumor.

Eosinophilic gastroenteritis as a cause of non-Helicobacter pylori, non-gastrotoxic drug ulcers in children

BackgroundWhile Helicobacter pylori (H. pylori) ulcers has declined recently, H. pylori-negative and/or gastrotoxic drug-negative peptic ulcers (HNGN-PU) has increased. This study aimed to analyze the etiology of peptic ulcers in children and the differences in clinical, laboratory, endoscopic, and histopathologic findings of peptic ulcers according to etiology, including eosinophilic gastroenteritis (EoGE).MethodsIn total, 255 children (157 boys and 98 girls) with peptic ulcers were recruited. The subjects were categorized into 5 groups according to the etiology of the ulcer: 1) H. pylori infection (n = 51); 2) gastrotoxic drugs (n = 18); 3) idiopathic (n = 144); 4) systemic disease (n = 23); 5) EoGE (n = 19). Clinical data were reviewed and analyzed retrospectively.ResultsAge at diagnosis, ulcer recurrence, atopic dermatitis history, white blood cell count, blood eosinophil count, platelet count, serum albumin level, iron level, erythrocyte sedimentation rate, and C-reactive protein level differed significantly among the 5 groups (all p < 0.05). Regarding endoscopic findings, multiple ulcers and gastric mucosal nodularity differed among the 5 groups (all p < 0.05). When comparing the EoGE ulcer group with the others, EoGE group revealed older ages (p = 0.022), higher rates of ulcer recurrence (p = 0.018), atopic dermatitis history (p = 0.001), and both blood and tissue eosinophilia (both p = 0.001).ConclusionsEoGE ulcers constituted 10.2% of HNGN-PU in pediatric patients. In children with HNGN-PU, peripheral eosinophilia, ulcer recurrence, and atopic dermatitis history might imply EoGE, necessitating thorough investigation of tissue eosinophils during endoscopic biopsy.Trial registrationA total of 255 children was retrospectively registered between between July 2003 and April 2017.

Complete resolution of diffuse inflammatory tracheal stenosis in a dog

A four-year-old female entire Weimaraner, recently diagnosed with epilepsy, was referred with a three-week history of coughing and lethargy. The dog had been diagnosed with aspiration pneumonia on thoracic radiographs,...

Clinical and Magnifying Narrow-Band Imaging Endoscopic Finding–Olmesartan-Associated Collagenous Gastroduodenitis

AbstractCollagenous gastroduodenitis is a rare and may be associated with olmesartan, an angiotensin–II receptor antagonist used for management of hypertension. It is characterized by marked subepithelial collagen deposition with mucosal inflammatory infiltrate. The characteristic endoscopic finding of collagenous gastritis is nodular mucosa and other findings include erythema friability, erosions, ulcers and atrophy. Olmesartan-associated collagenous gastroduodenitis without colonic involvement is exceptionally rare with only one case reported in literature to date. The association may be difficult to recognize because of its clinical and histologic similarity to the clinical entity collagenous gastroduodenitis. We present a case of Olmesartan-associated collagenous gastroduodenitis, which was observed on magnifying narrow-band imaging endoscopic findings.

Tu1510 LYMPHOCYTIC GASTRITIS AND ASSOCIATION WITH ATOPIC SYMPTOMS: A CASE SERIES

Lymphocytic gastritis is rare, characterized by >25 intraepithelial lymphocytes per 100 epithelial cells, specifically CD8+ T-cells. Prevalence has been reported as <0.3%. Little is known about the pathophysiology, however up to 80% may be found with Helicobacter pylori infections or celiac disease. Endoscopically, the gastric mucosa is classically described as nodular with hypertrophied rugae, with or without erosions and plaques. Lymphocytic gastritis is a histologic diagnosis and when encountered, clinical management is ill-defined. We sought to identify clinical characteristics of this disease. Patients with histological diagnosis of lymphocytic gastritis were identified from January 2007 to August 2019 at our tertiary-care, medical center. Each patient’s chart was reviewed. Demographic information, medical history and outcomes, medications, endoscopic findings, and pathologic results were recorded. Serologic tests for human immunodeficiency virus (HIV) were reviewed. Serologic or duodenal biopsies were used to screen for celiac disease. Twenty-six patients were identified with lymphocytic gastritis. Fifty percent were male and age ranged from 2 years to 77 years, averaging 49 years at time of upper endoscopy. Atopy (e.g. asthma, allergies, or eczema) was noted in 46% of patients. Five (19%) patients had history of autoimmune disorders. The most common indications for upper endoscopy included abdominal pain (30%) and anemia (23%). Fifteen percent of the patients had concomitant Helicobacter pylori infections based on gastric biopsies. Low proportions of patients were tested for celiac disease (50%) and HIV (26.9%); none were positive. Endoscopically, 75% had erythema and erosions and only 20% demonstrated the classically described nodular mucosa. Histologically, lymphocytic gastritis was commonly seen with chronic inflammation (65.4%). Among the 11 patients with duodenal biopsies, 36.4% had increased lymphocytes in the duodenum. Nearly half of the patients in our case series were noted to have atopy. Although lymphocytes are not typically associated with atopic illnesses, there are several studies elucidating the roles of CD4+ and CD8+ T cells in relation to eosinophils and mast cells in atopic dermatitis and asthma. Current management revolves around symptom control, however, further studies are needed to evaluate the implications of this pathological finding.Demographic information, clinical history, endoscopic findings, and pathologic results of patients diagnosed with lymphocytic gastritis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Helicobacter pylori Prevalence and Impact: A Histology-Based Report About Children from an Endemic Country.

BackgroundHelicobacter pylori is spreading worldwide with a high prevalence rate in the developing countries. Our primary goal was to measure the histology-based prevalence of Helicobacter pylori infection in children and to quantify its impact on the gastric inflammation and anemia. Our secondary goal was to study possible predictors for the presence of Helicobacter pylori in this cohort.MethodsA retrospective chart review was performed for children who underwent Esophago-gastro-duodenoscopy at Jordan university hospital in Jordan from 2008 to 2016. Data collected included epidemiological data, indication for endoscopy, endoscopic findings, and laboratory data. The gastric biopsies were re-examined by a pathologist to check for the presence of Helicobacter pylori, the presence of gastritis, and to grade gastritis according to the updated Sydney criteria.ResultsA total of 98 children (53 girls–54%) underwent Esophago-gastro-duodenoscopy. The average age was 11.7 years ± 4.7 years. Of them, 53 patients (29 boys–55%) had Helicobacter pylori identified in the gastric biopsy. The histology-based prevalence rate of Helicobacter pylori was 54%. The most common indication for endoscopy was abdominal pain (53%) followed by vomiting (18%). Nodular gastric mucosa was present in 43% of the Helicobacter pylori-positive group, and in only 11% of the Helicobacter pylori-negative group (P-value <0.0.5). Moderate to severe chronic gastritis was seen in 59% of the biopsies of Helicobacter pylori-positive group, compared to 31% in the Helicobacter pylori-negative group (p value <0.05). Presence of anemia was not different between the two groups (p value > 0.05). Presence of endoscopic nodularity, active gastritis by histology, and moderate to severe gastritis by histology were positive predicators for the presence of Helicobacter pylori. (p value <0.05).ConclusionHelicobacter pylori infection in this study cohort of Jordanian children is common, with a histology-based prevalence rate of 54%. Nodularity of the stomach is the most common positive endoscopic feature, and its presence predicts the presence of Helicobacter pylori. Moderate to severe active gastritis is associated with Helicobacter pylori. The presence of Helicobacter pylori does not affect anemia status in this cohort of Jordanian children.

Gastrointestinal Mucosal Lymphoid Hyperplasia: Mutation in PIK3CD Gene.

A 4-year-old boy presented with difficulty defecating, hematochezia, and large rectal prolapse. Upper endoscopy and colonoscopy showed polypoid lesions throughout the colon and nodular mucosa of the esophagus, stomach, and duodenum (Fig. 1). Histology demonstrated mucosal florid lymphoid hyperplasia (Fig. 2). Workup revealed elevated inflammatory markers (erythrocyte sedimentation rate, C-reactive protein (ESR, CRP)), elevated fecal calprotectin, and positive QuantiFERON. Despite negative computed tomography (CT) chest, with negative for tuberculosis (TB) on his gastrointestinal biopsies, he was treated for latent TB with isoniazid. He had negative workup for lymphoma. Immunologic workup revealed decreased CD4 T-cells, CD21-positive cells, and increase in CD1-negative cells. Genetic testing revealed a heterozygous pathogenic mutation in phosphatidylinositol 3-kinase, catalytic, delta PIK3CD. This mutation is associated with activated phosphoinositide 3-kinase δ syndrome resulting in combined immunodeficiency disorder that can present with lymphoid hyperplasia of gastrointestinal and respiratory mucosal surfaces, recurrent infections, immunodeficiency, and/or malignancy (1). Patients with activated phosphoinositide 3-kinase δ syndrome may benefit from mammalian target of rapamycin (mTOR) inhibitors such as sirolimus or other immunosuppressants (2). Our patient was treated with budesonide and hydroxychloroquine as a bridge therapy to sirolimus while he was being treated for latent TB. Although his repeat endoscopy did not show major improvement, he had excellent clinical response, so he was maintained on the current regimen.FIGURE 1: A, Colon: lymphoid hyperplasia presenting as polypoid lesions. B, Duodenum: lymphoid hyperplasia presenting as nodular lesions.FIGURE 2: Lymphoid hyperplasia of the colonic biopsy. B, Lymphoid hyperplasia of the duodenum biopsy.

1926 Gastrointestinal Bleeding in a Patient With Latent Tuberculosis and Remote T-Cell Lymphoma

INTRODUCTION: Immunosuppressed patients such as those with malignancies are susceptible to reactivation of tuberculosis (TB), which can affect the gut. CMV should also be considered as a cause of colitis in these patients. CASE DESCRIPTION/METHODS: A 68-year-old man with a history of T-cell lymphoma of the kidney and nasal cavity and latent TB presented with weight loss and cough. He was cachectic and had diffuse rhonchi in the lung bases. CT of the chest showed areas of cavitation. Multiple sputum cultures positive for acid-fast bacilli (AFB) and a positive mycobacterium tuberculosis (MTB) PCR confirmed active TB infection. The patient developed repeated episodes of melena with a hemoglobin level of 5.0 g/dL, MCV of 71.5 fL, iron of 4.5 ug/dL, transferrin saturation of 1%. Colonoscopy revealed extensive diverticulosis in the sigmoid colon and evidence of a prior cecectomy with ulceration of the ileocolonic anastomosis. Biopsies showed dense mature lymphocytic infiltrate and granulation tissue with no evidence of T-cell lymphoma. A CT revealed a 4 cm segment of terminal ileum with mild wall thickening, mucosal hyperenhancement and thickened folds of a distal loop of jejunum. Stool AFB culture and MTB PCR were both positive, indicating a probable diagnosis of TB enteritis. A push enteroscopy showed a 60 mm infiltrative lesion with ulcerated bases and three smaller lesions of similar appearance on the anterior wall of the stomach along with jejunal ulceration. Ulcer biopsies revealed large cells with inclusions consistent with CMV enteritis. Stains for AFB were also positive. Biopsies of the stomach lesions revealed an ulcerative oxyntic mucosa with dense atypical lymphoid infiltrate. Markers were consistent with a diagnosis of Burkitt’s Lymphoma (BL). The patient was treated with TB therapy, ganciclovir, and R-CHOP. DISCUSSION: Immunosuppression due to this patient’s BL likely led to dissemination and reactivation of latent TB and susceptibility to infection with CMV. The stomach and bowel are the most common sites of extranodal involvement in BL. The incidence of TB in malignancy is highest in non-Hodgkin’s lymphoma like BL. Bowel involvement in TB is seen in less than 5% of cases in the United States. Common endoscopic findings include ileal or ileocecal disease, non-confluent involvement of the colon, and nodular mucosa with areas of ulceration. The diagnosis can be made by biopsy showing caseating granulomas, a positive TB culture or PCR result, or by clinical suspicion with improvement following treatment.

2656 A Rare Case of Gastrointestinal and Hepatic Extra-Pulmonary Involvement of Sarcoidosis Mimicking Crohn’s Disease

INTRODUCTION: Sarcoidosis is a systemic disease characterized by noncaseating granulomas. While pulmonary and lymphatic involvement is common, gastrointestinal involvement is rare. We report a case of diffuse gastrointestinal and hepatic involvement of sarcoidosis initially mimicking Crohn’s disease. CASE DESCRIPTION/METHODS: A 62 year-old man with history of chronic thrombocytopenia and sarcoidosis, presented for further evaluation of suspected Crohn’s disease after undergoing high-risk surveillance colonoscopy. The colonoscopy was significant for congested mucosa in the terminal ileum and colon as well as multiple colonic erosions (Figure 1). Pathology showed chronic active colitis with crypt abscesses in the left colon and poorly formed granulomas without dysplasia in the right colon suggestive of Crohn’s disease. The patient reported no gastrointestinal or systemic complaints and stated good control of his underlying sarcoidosis. An esophagogastroduodenoscopy (EGD) was then completed and showed moderately-congested mucosa with many non-bleeding gastric body, antral and superficial duodenal ulcers positive for Helicobacter pylori. Despite normal liver chemistries, given the presence of indirect signs of portal hypertension (splenomegaly, thrombocytopenia), a transjugular liver biopsy was pursued which was significant for portal hypertension as well as moderate chronic portal hepatitis with cirrhosis, non-necrotizing granulomas consistent with sarcoid involvement, and no histologic features of PBC (Figure 2). Labs, including hepatitis B and C serologies, ANA, and anti-mitochondrial antibody, were grossly unremarkable. After establishing an elevated portal pressure gradient, a repeat EGD was done approximately six-months later which was significant for grade I esophageal varices, erythematous and nodular mucosa in the gastric antrum and erythematous duodenopathy; biopsies were negative for H. Pylori. The patient was then referred back to pulmonology for further assessment of his pulmonary disease prior to consideration of treatments for his progressed liver disease. DISCUSSION: Typically presenting with pulmonary involvement, gastrointestinal involvement of sarcoidosis, particularly of the small bowel, is a very rare extra-pulmonary manifestation of sarcoidosis. Hepatic involvement with progression to cirrhosis is uncommon. Above, we present a very interesting case with both diffuse gastrointestinal and hepatic sarcoidosis subsequently noted to have progressive liver disease with portal hypertension.

2009 Bleeding Intestinal Lymphangiectasia Diagnosed and Treated by Using Double Balloon Enteroscopy in a 41-Year-Old Female: Case Report and Review of Literature

INTRODUCTION: Intestinal lymphangiectasia (IL) is a rare disease characterized by dilated lymphatic vessels in the intestinal wall and small bowel mesentery, which induce loss of protein and lymphocytes into the bowel lumen. Gastrointestinal bleeding (GIB) rarely has been described as the only symptom of IL. We describe a case of obscure GIB in a young female caused by lymphangiectasia localized to the distal jejunum by antegrade double balloon enteroscopy. CASE DESCRIPTION/METHODS: A 41-year-old African American female who initially presented to her PCP with chronic fatigue and intermittent episodes of melena. The patient was subsequently placed on iron supplementation and referred to gastroenterology for further work up. Physical examination finding were largely unremarkable. On laboratory tests, her hemoglobin declined to 5.8 g/dL (from a baseline of 10 g/dL). Initial Esophagogastroduodenoscopy (EGD) showed 2 cm hiatal hernia but was otherwise unremarkable. A subsequent colonoscopy showed mild internal hemorrhoids and a 3 mm solitary ulcer in the distal rectum but no other obvious sources of GI bleeding. Magnetic resonance enterography (MRE) was unremarkable. Next, a video capsule endoscopy was done which showed a site of active bleeding from the mid-small bowel and was associated with nodular mucosa and prominent lacteals. A subsequent double balloon enteroscopy (DBE) showed an oozing fold in the distal jejunum with white speckled appearance consistent with a bleeding lymphangiectasia. A total of seven clips were placed on the lesion and during application of clips, a white milky substance was noted coming from the lesion suggesting the diagnosis of lymphangiectasia. DISCUSSION: IL is most commonly found in the small bowel, making its diagnosis difficult by EGD or colonoscopy. DBE and video capsule endoscopy (VCE) are the two most important diagnostic modalities available to evaluate the entire small intestine.The noninvasive nature of VCE and its capability to visualize the entire small bowel has made it a first-line tool in many centers. However, DBE is preferred over video capsule endoscopy because of higher sensitivity from better endoscopic visualization and ability to perform biopsies for pathologic diagnosis. In this report, we present an extremely rare case of primary intestinal lymphangiectasia in causing obscure GIB and successful intervention using DBE. We believe this is the second case to report small bowel bleeding from jejunal lymphangiectasia, which was successfully treated using DBE.

1507 A Rare Case of Intestinal Endometriosis Mimicking Acute Appendicitis and Sigmoid Malignancy in a Five Year Time Span

INTRODUCTION: Endometriosis is characterized by implantation of endometrial epithelium outside the uterus. The prevalence is about 10-15% in women of reproductive age. The most common extra-pelvic site is the GI tract, affecting 4–37% of women with endometriosis. The sigmoid colon and rectum are the most common sites followed by the ileum, appendix and cecum. CASE DESCRIPTION/METHODS: Here we present a very rare case of severe intestinal endometriosis involving multiple GI sites including the terminal ileum, appendix and recto-sigmoid colon in the past 5 years. 4.5 years ago, the then 27 year old otherwise healthy female presented with worsening RLQ pain. She had leukocytosis of 15K WBC with CT scan showing a dilated and thickened distal appendix consistent with appendicitis. She underwent laparoscopic appendectomy without complications. Pathology reported endometriosis (Figure 1). After appendectomy, she continued to have diffuse abdominal pain with nausea and constipation. As part of GI workup, she underwent EGD and colonoscopy about 3 years ago with findings of two recto-sigmoid strictures with biopsies showing endometriosis. The patient was then lost followup until she was readmitted with multiple GI complaints including nausea/vomiting, abdominal pain, with alternating diarrhea and constipation. It appears that she had been treated for IBS and also received hormonal treatment for endometriosis in the past two years. On admission, she had leukocytosis of 16K and a CT scan showing a 3 cm focal apple-core lesion in the distal sigmoid colon. Colonoscopy showed a very severe stricture at the distal sigmoid colon with nodular mucosa in the proximal rectum. Pathology was negative for malignancy or endometriosis. She then underwent laproscopy with findings of 2 strictures in the recto-sigmoid colon together with another stricture 5 cm proximal to the IC valve in the distal ileum. Partial resection of the recto-sigmoid colon together with a right hemicolectomy was performed. Pathology of both TI and recto-sigmoid colon showed endometriosis (Figure 2). During the one-month post-op followup, she reported resolution of constipation. DISCUSSION: Our patient represents a rare case of symptomatic multi-focal gastrointestinal endometriosis with mucosal involvement at different times mimicking appendicitis and sigmoid malignancy. Endometriosis should be considered in the differential diagnosis in any young woman with lower GI symptoms.

2760 A Case of Collagenous Gastritis: A Rare Entity

INTRODUCTION: Collagenous gastritis (CG) is a rare histopathologic entity that involves marked subepithelial collagen deposition in the gastric mucosa. Endoscopic findings can be diverse such as mucosal erythema, nodularity and ulceration. The presentation is very diverse such as abdominal pain, weight loss, gastrointestinal bleeding and dyspepsia. Its treatment remains unclear. CASE DESCRIPTION/METHODS: 71-year-old with long history of dyspepsia was referred to our institution due to a 6-month history of epigastric discomfort, profound weight loss (50 lb) and early satiety. Symptoms were mildly improved with sucralfate and smaller and more frequent meals. Tissue transglutaminase antibody was negative. Endoscopy at other institution suggested collagenous gastritis but biopsies were not conclusive. Endoscopic ultrasound at our institution was done for further characterization of the stomach layers and revealed a tubular J-shape stomach deformity with diffuse atrophic mucosa in the gastric body. Localized submucosal wall thickening was visualized endosonographically in the entire body of the stomach which measure up to 5 mm in thickness in the gastric wall. Random gastric biopsies could not confirm CG diagnosis. Persistent symptoms led to further work up including MRI enterography and gastric emptying study, all negative. Eight months later, “well type” biopsies were taken from the gastric body and antrum. Pathology report revealed antral glands atrophy with pyloric hyperplasia, prominent smooth muscle hyperplasia in the lamina propia, along with gastric corpus and antrum with thickened subepithelial collagen layer on hematoxylin and eosin, confirmed on trichrome stain. These features were consistent with a diagnosis of collagenous gastritis. Although limited evidence on the treatment of this disease, patient was started on budesonide therapy (9 mg/day). Future endoscopic surveillance and clinical follow up is planned to assess symptomatic improvement. DISCUSSION: Collagenous gastritis is a rare entity as only 60 cases have been reported in the literature. We need more awareness of this disease for early recognition and reduction of unnecessary work up. Clinical presentation is very diverse and endoscopic findings can be very subtle. High clinical suspicion is necessary to allow proper biopsy techniques. The well technique permits deep tissue sampling by taking multiple samples from the same site and has been advocated for use in subepithelial lesions, avoiding the need for full thickness biopsy or surgery.

2146 Combined Novel Endoscopic Techniques in Esophageal Carcinoma Management

INTRODUCTION: A variety of techniques are currently being investigated to provide optimal resection of submucosal tumors by endoscopy. Specifically, peroral endoscopic myotomy (POEM) is a form of natural orifice transluminal endoscopic procedure which was originally established as a minimally invasive technique to treat achalasia and esophageal motility disorders. Due to its success in treatment of esophageal motility disorders, certain Centers of Excellence for advanced endoscopy have expanded the use of POEM in combination with other advanced endoscopic techniques for treating esophageal cancers. In this case, we present a 69-year-old male with squamous cell cancer (SCC) in the lower third of the esophagus who was successfully treated using combined endoscopic submucosal dissection (ESD), submucosal tunneling, and POEM techniques. CASE DESCRIPTION/METHODS: A 69-year-old male with a medical history of 50-pack-year tobacco abuse, chronic alcohol use, and chronic pancreatitis was initially evaluated with EGD and EUS for anorexia, weight loss, and pancreatic cysts. Initial EGD required biopsies of nodular esophageal mucosa revealing underlying squamous cell carcinoma in situ. Repeat endoscopy 2 months later revealed a large tumor circumferentially involving 80% of the lumen in the lower esophagus. Subsequently, the patient received therapeutic intervention combining ESD and POEM techniques for tumor resection, prognostication, and symptom relief. Lesion borders were marked, and a circumferential incision was made around the lesion lifting it from the muscularis propria allowing for successfully mass excision. The submucosal dissection combined with circumferential tunneling technique allowed for complete resection of the tumor. The patient reported post-procedure symptomatic relief and was able to resume oral intake. DISCUSSION: POEM is a combination of the pre-existing endoscopic myotomy procedures in conjunction with endoscopic submucosal tunneling techniques. Although POEM is labor intensive, its application gives precision by granting access to the neoplasms without affecting deeper esophageal layers. This promising advance in gastrointestinal procedures compared to esophagectomy has shown in reported studies to offer a lower morbidity rate while providing similar cancer-free survival. Our case demonstrates successful treatment using POEM and adjunct endoscopic therapies in submucosal tunneling and submucosal tunneling endoscopic resection (STER) in the treatment of large circumferential esophageal cancer.

2736 A Rare Case of Gastric Sarcoidosis

INTRODUCTION: Gastrointestinal involvement in sarcoidosis is quite rare, in which it either presents as systemic disease or as an isolated case. It can mimic other disease processes, including malignancy, gastritis, and peptic ulcer disease. We present a 28-year-old female who had weight loss, epigastric pain, and early satiety found to have symptomatic gastric sarcoidosis that rapidly improved with steroid treatment. CASE DESCRIPTION/METHODS: A 28-year-old with no past medical history presented to the emergency department with complains of epigastric pain, weight loss, and early satiety. She had onset of pain in epigastrium described “like ringing out a washrag”, better with eating and marked early satiety. She was found to have an iron level of 11 with period less heavy than years ago. Vitals showed Wt 142 lb, BP 118/66, Pulse 85, and O2 sat 98% on room air. Physical exam was significant for only epigastric tenderness and bilateral edema. Labs showed hemoglobin 8.9, MCV 57, iron level 11, Na 138, Cl 108, and CO2 20. EGD showed body and antrum with markedly thickened, pale appearing, firm/friable folds. Colonoscopy showed no abnormalities. Gastric fold biopsies showed noncaseating epithelioid granulomatous infiltrate suggestive of sarcoidosis. AFB and GMS fungal stains showed no microorganisms and H. Pylori was negative. The patient was initially started on prednisone 40 mg daily tapering dose and had near immediate resolution of symptoms with increase in weight. DISCUSSION: Sarcoidosis is a systemic disease characterized by pathognomonic formation of noncaseating granulomas with rare gastrointestinal involvement. Infection, malignant, and inflammatory causes must be ruled out as part of the broad differential before making diagnosis of sarcoidosis. Patients typically have symptoms of early satiety, nausea, and weight loss. Gross findings on endoscopy typically include mucosal nodularity, thickened and enlarged irregular folds, and deformity of the antrum. For recurrence of symptoms, surveillance endoscopy is warranted to examine extent of disease. As in our patient, there is excellent response to glucocorticoid treatment and patients should be monitored clinically with tapering doses.

1650 A Case of Rectal Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma Presenting as Telangiectasia: A Case Report

INTRODUCTION: The World Health Organization classification of lymphoid neoplasms consists of several marginal zone lymphoma subtypes, the most common of which is extranodal marginal zone lymphoma of mucosa associated lymphoid tissue (MALT lymphoma). Extranodal marginal zone lymphomas can stem from a number of epithelial tissues, including the lungs, thyroid, skin, and GI tract. Of all tissues with possible extranodal lymphoma involvement, the GI tract is the most common. However of these GI sites, colorectal lymphoma is rare, accounting for approximately 3 percent of the GI lymphomas and only 0.3 percent of all large intestinal malignancies. Symptoms including abdominal pain, occult bleeding, bowel obstruction and diarrhea are possible findings in patients with colorectal lymphoma. Findings on colonoscopy can include mucosal nodularity, ulceration and or even a mass. CASE DESCRIPTION/METHODS: This is a 68-year-old male with a past medical history of hemorrhoids who initially presented to clinic with complaints of hematochezia for 15 days. Patient denied any associated symptoms including fever, chills, nausea or vomiting. Physical exam revealed bright red blood per rectum. A colonoscopy was scheduled, during which the patient was found to have inflamed proximal rectal mucosa of which a biopsy was taken and sent for pathology report. Biopsy revealed diffuse infiltration of the mucosa by small lymphoid cells focally involving the epithelium which were positive for b-cell immunoperoxidase markers. These findings were consistent with malignant lymphoma (B-cell phenotype) of the extranodal marginal zone mucosa associated type. Following postoperative recovery, the patient opted for conservative management with repeat colonoscopy scheduled 6 months later. DISCUSSION: Extranodal marginal zone lymphomas can arise from numerous tissues. While these neoplasms often remain localized to the tissue from which the originate, diagnosis is critical because not only does recurrence frequently occur locally, but they also have the potential to transform into aggressive B cell lymphoma variants with eventual systemic spread. Although MALT lymphoma of the GI tract can present in different forms such as nodularity, ulceration or mass, this is a case of MALToma presenting in the form of telangiectasia. In this patient, correctly taking a biopsy of a telangiectatic region of mucosa resulted in diagnosis of a rare yet treatable pathology.

1646 Primary Colorectal Diffuse Large B-Cell Lymphoma: A Rare Presentation of a Rare Colonic Neoplasm

INTRODUCTION: Diffuse Large B Cell Lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma accounting for 25% of cases. Of those, only one third are found to have a primary extranodal source. While this is known to arise from the stomach, a colorectal primary site is exceedingly unique. We present the case of primary colonic DLBCL diagnosed in a patient admitted for hematochezia. CASE DESCRIPTION/METHODS: An 85-year-old female with coronary artery disease on aspirin and diverticulosis presented to the emergency room with acute hematochezia and left lower quadrant (LLQ) abdominal pain. She was hemodynamically stable with reproducible LLQ tenderness and rectal exam confirming bright red blood. Labs were pertinent for leukocytosis and hemoglobin of 12.1 g/dL down from a baseline of 14.4 g/dL. Contrasted abdominal CT revealed a 4.1 cm soft tissue mass in the ascending colon with extravasation of contrast consistent with active bleeding. Due to concern for a malignant bleeding etiology, interventional radiology performed CT angiography, but were unable to identify an active arterial source. The patient continued with hematochezia and was taken for urgent colonoscopy. Within the ascending colon, a 5cm non-obstructing, fibrous mass with central ulceration was identified and biopsied. Colorectal surgery was consulted; due to concern for recurrent bleeding a right hemicolectomy was performed the following day. Final pathologic diagnosis revealed primary colonic DLBCL with local lymph node involvement. PET/CT showed complete resection of disease and, through multidisciplinary shared decision making, further treatment or surveillance was not pursued. At follow up the patient is doing well without recurrent symptoms. DISCUSSION: Primary colorectal DLBCL accounts for less than 0.3% of all cancers involving the large intestine. While data is limited, the majority of patients are male between the 5th and 7th decades of life. Symptoms are nonspecific with few cases discovered due to overt bleeding. Endoscopic appearance is variable including mucosal nodularity, ulceration or a mass with or without ulceration, which can mimic adenocarcinoma. Due to the abundance of lymphoid tissue, most lesions involve the cecum and ileocecal valve. Diagnosis of primary colonic DLBCL can include local lymph node involvement, but distant nodal disease must be excluded. The mainstay of treatment is surgical resection with adjuvant chemotherapy, however, due to patient age and preference a conservative strategy was pursued.

3213 Giant Gastric Heterotopia (GH) in the Duodenal Bulb (DB): A Possible Cause of Gastric Outlet Obstruction (GOO)

INTRODUCTION: The presence of gastric mucosa within the DB usually is an incidental finding during endoscopy and is seen in up to 8.9% of cases. While GH usually produces no symptoms, our patient presented with symptoms of GOO, which we attributed to the large size of the GH lesion, occupying &gt;50% of the DB. This case of DH merits attention due to its uncommon appearance and presentation. CASE DESCRIPTION/METHODS: A 47-year-old woman with a history of insulin-dependent diabetes mellitus presented with abdominal pain, nausea, and post-prandial emesis for 1 year. Physical exam was normal, without a sucussion splash or post-prandial abdominal distention. Hematologic testing showed a Hb 9.8 mg/Dl. Other labs, including basic metabolic panel and liver biochemical tests, were normal. Abdominal CT without IV contrast was non-diagnostic. EGD identified a single polyp in the DB measuring 1.5 cm × 2 cm (Figure 1). Additionally, there was a more distal, irregular, cratered mass in the duodenum that was surrounded by a “carpet” of mucosal nodularity consistent with the appearance of Brunner's gland hyperplasia (BGH) (Figure 2). Both areas were biopsied. The pathology of the polyp showed gastric heterotopia (Figure 3) and the cratered mass showed peptic duodenitis. DISCUSSION: GH is seen throughout the adult GI tract but most commonly in the duodenum, with an incidence of 0.5% to 8.9%. 1 In most cases, GH causes no symptoms and is undiagnosed. When symptomatic, GH may cause abdominal pain from mucosal irritation secondary to the release of hydrochloric acid from parietal cells. Rarely, as in our patient, obstructive symptoms may be present. 2 For symptomatic patients, proton pump inhibitors (PPIs) are the cornerstone of treatment as they help to decrease acid secretion and, therefore, mucosal irritation. After EGD, our patient was started on a PPI and rapidly had symptomatic improvement. We suspect that her abdominal pain resolved due to decreased acidity within the DB, and that obstructive symptoms improved secondary to decreased inflammation within the DB. We present this case as a rare example of GOO caused by GH.

1584 A Rare Case of Follicular Lymphoma of Sigmoid Colon

INTRODUCTION: Follicular lymphoma is defined as a neoplasm of follicle B cells and is characterized immunohistochemically by a positive reaction to B-cell markers and Bcl-2. Follicular lymphomas of the colon are very rare. Within GI Lymphomas, colorectal lymphomas are very uncommon and account for only 3% of GI lymphomas and 0.3% of large intestinal malignancies. We describe an unusual presentation of extra-nodal follicular lymphoma within the sigmoid colon. CASE DESCRIPTION/METHODS: A 59-year-old Caucasian female with history of hypertension was referred by her primary care physician for an average risk screening colonoscopy. Prior to referral for screening colonoscopy, the patient was being screened for colon cancer with annual occult stool testing which had been negative. She underwent a colonoscopy which showed a sessile polyp in the hepatic flexure and two polypoid lesions in the sigmoid colon (Figure 1). The patient was referred for endoscopic mucosal resection of the polyps. A snare mucosal resection was performed for the hepatic flexure polyp (12 mm in size). The 2 sessile polyps in the sigmoid colon (8-12 mm in size) were also resected with a hot snare. Pathology from the sigmoid colon polyp was consistent with Grade IIIA Follicular Lymphoma and immunohistochemistry was positive for CD20, CD10, BCL6 and BCL2 (Figure 2). The polyp in the hepatic flexure was noted to be a benign sessile serrated polyp. Patient was referred to Oncology for further management. A bone marrow biopsy and PET/CT did not show any evidence of disease involvement elsewhere. DISCUSSION: Primary NHLs of the GI tract are rare, accounting for only 1 to 4 percent of malignancies arising in the stomach, small intestine, or colon. Colonoscopy with biopsy is the principal diagnostic modality. Colonoscopic findings of follicular lymphomas include mucosal ulcerations, diffuse mucosal nodularity or polypoid mass like lesions. However, due to its rarity, an optimal diagnostic work up and treatment plan has not been well established. Making a correct diagnosis of the disease based on findings of biopsied samples can be challenging and multiple biopsies or endoscopic mucosal resection may be required in addition to appropriate consultation with pathologists.