Superficial Ulceration Research Articles

An Unusual Cause of Acute Gastroenteritis, Ascites, and Eosinophilia in a 29-Year-Old Woman

An Unusual Cause of Acute Gastroenteritis, Ascites, and Eosinophilia in a 29-Year-Old Woman

Abstract 15867: A Swimming Heart: A Unique Complication of Gastropericardial Fistula

Background: Gastropericardial fistula is a rare clinical entity associated with gastroesophageal operations. Case: 63-year-old female with medical history of hypertension, GERD, and hiatal hernia status post Nissen fundoplication presented to the ER with one week of chest pain and dyspnea. Six months prior to presentation, she was found with ischemic colitis, candida esophagitis and slipped Nissen. In the ER, she was febrile and hypoxic. Chest x-ray showed a large hydropneumopericardium with air-fluid level. CT chest showed pneumomediastinum. Upon arrival to our facility, an echocardiogram showed normal EF 65% and a large complex pericardial effusion with presence of gas, liquid, and organized material without evidence of tamponade. Repeat CT abdomen showed a thin-walled collection of gas and fluid projecting from the area of the Nissen through the diaphragmatic hiatus in contact with the pericardium suspicious for a gastropericardial fistula. She went to the OR for pericardial window with drainage of 700 cc of purulent fluid and findings of chronic-appearing granulation of the pericardium. Intraoperative endoscopy noted a perforation near the GE junction that was stented with a 155 x 23 mm covered esophageal stent. Cultures grew Candida and gramnegative bacilli. She then underwent staged right thoracotomy with repair of fistula with intercostal muscle flap. Postoperative course was complicated with posterior wall hemorrhage requiring embolization of the left eight intercostal artery. The esophageal stent was removed three months post insertion due to distal migration causing superficial ulceration and esophagitis. Patient has since recovered gradually without further complications. Discussion: Gastropericardial fistula is associated with high morbidity and mortality. The treatment is surgical with early pericardial drainage usually by pericardial window and de-functioning esophagostomy or gastrostomy plus repair of the defect.

An Esophageal Cooling Device During Radiofrequency Ablation for Atrial Fibrillation-A Comparison Between Reactive and Proactive Esophageal Cooling.

Esophageal thermal injury is one of the most feared risks of ablation of the posterior left atrium despite the various devices used to monitor esophageal temperature or deviate the esophagus. Reactive cooling, in which cold water is manually instilled into the esophagus via an orogastric tube in response to rises in luminal esophageal temperature (LET), has been used by operators, but the availability of a dedicated esophageal cooling device offers the ability to provide proactive esophageal cooling without having to react to individual temperature rises in the esophagus. The objective of this study was to evaluate the feasibility of using a commercially available esophageal cooling device to provide esophageal protection during left atrial catheter ablation, then to compare this approach to standard LET monitoring with reactive cooling via manual cold-water instillation. In this study, we randomized 6 patients undergoing catheter ablation for atrial fibrillation. Three patients received the standard of care for our site (use of a single-sensor temperature probe, with adjunct ice-water instillation for any temperature increases of >1°C). Three patients underwent standard ablation after placement of the esophageal cooling device at a circulating water temperature of 4°C, without the use of any esophageal temperature monitoring. All patients underwent transesophageal echocardiography and esophagogastroduodenoscopy on the day prior to the ablation, followed by a second esophagogastroduodenoscopy the day after. The 6 patients in this study were enrolled between March and August 2018. In the 3 control patients, 1 had no evidence of esophageal mucosal damage, 1 had diffuse sloughing of the esophageal mucosa and multiple ulcerations, and 1 had a superficial ulcer with a large clot. Both patients with lesions were classified as 2a cases using the Zargar grading scheme for caustic injury. In the 3 patients treated with the cooling device, 1 had no evidence of esophageal mucosal damage, 1 had esophageal erythema (Zargar grade 1), and 1 had a solitary Zargar grade 2a lesion. At 3 months of follow-up, 1 patient in each group had recurrence of atrial fibrillation. Although a number of subsequent studies have confirmed the reduction of esophageal injury with the use of proactive esophageal cooling, this study is the only one to date to compare reactive cooling (via manual cold-water instillation) and proactive cooling (via a dedicated esophageal cooling device). Moreover, this is the first study to support the feasibility of using a dedicated cooling device for this purpose and provides the basis for further investigation.

Filiform polyposis presenting with rapid growth and severe anemia case report

Giant inflammatory polyposis (GIP) is a rare manifestation of inflammatory bowel disease (IBD), and it is described as a worm-like projection of 1.5cm or more in diameter with unclear pathogenesis. GIP may be related to the severity of IBD. GIP presents with a wide range of symptoms, including crampy abdominal pain, anemia, and intestinal obstruction. The histopathology of GIP is a polyp lined by normal colonic mucosa with superficial ulceration that may show mild crypt distortion. Our case reports a patient with ulcerative colitis diagnosed via colonoscopy and histopathology 10months before presenting with severe anemia due to lower gastrointestinal bleeding. Colonoscopy showed GIP obstructing the descending and sigmoid colon, and total colectomy showed the entire colon full of worm-like polyps up to 14cm the longest polyp. Giant inflammatory polyposis which is seen in 17% of UC with active colitis, as seen in our patient, the histopathology component was acute in addition to chronic, which formed within 6months. According to the data in the literature, the average duration reported for formation since diagnosis with UC is approximately 3 to 276months. With a length up to 16cm, the sigmoid colon is the most common site. Surgical intervention is indicated for filiform polyposis (FP) if it is complicated, such as bleeding or obstruction, which is reported in a few cases. However, there are no clear guidelines for surgical intervention for complicated FP, but the safest method is to tailor the management according to the guidelines for each underlying disease.

Mitomycin c can minimize corporal scarring following explantation of an infected penile implant

Delayed replantation following extrusion of an infected penile implant is hindered by the corporal scarring that issues. This renders the procedure difficult and with a higher rate of complications. In addition to the anti-tumour anti-biotic properties of Mitomycin C, it is known to be a potent anti-fibrotic agent with multiple applications in surgery such as esophageal atresia and bladder neck strictures. This work aims to evaluate the efficacy and safety of Mitomycin instillation upon removal of infected implants in preventing or minimizing corporal scarring Twelve patients with infected penile implants were included in the study. Upon extraction of the infected implant, corporal bodies were irrigated with antibiotics and antiseptics. This was followed by instillation of Mitomycin C, 10 mg in 250 cc saline, 125 cc into each cavernous space. Caution was observed to prevent contact with corporotomy and skin edges. The latter were freshened and closed. Re-implantation was performed 10-12 weeks subsequently. Four patients received an inflatable 3-piece implant and eight received a malleable. The cavernous cavity was found preserved, though tunica albuginea was thickened in all cases. Corporal dilatation was without resistance, using blunt Hegars. Ten patients received the same size of implant in length and girth. Two cases received a shorter implant (1 cm in one patient and 1.5 in the other). No re-infection, extrusion or urethral injuries were encountered. Two patients exhibited superficial skin ulcerations that resolved with topical care over 6-8 months. Mitomycin C instillation upon explantation of an infected penile prosthesis minimizes corporal scarring. Patients should be warned as to the possibility of postoperative skin ulceration. We believe this can be prevented by implantation of a narrower girth if the tunica albuginea is evidently thickened. None

A Clinical Study on the Surgical Management of Third Eyelid Gland Prolapse in Dogs

Background: The current study was undertaken to evaluate the clinical efficacy of two different surgical methods for management of third eyelid gland prolapse in dogs. Methods: The study was conducted on 14 eyes of 11 dogs presented with third eyelid gland prolapse for surgical treatment. Two groups dogs were subjected to clinical and ophthalmic examination based on the surgical technique used i.e., Group I (n=8) in which modified Morgan’s pocket technique, Group II (n=6) in which modified orbital rim anchorage technique was used. Among the breeds brachycephalic dogs (54.54%, n=6) followed by mesocephalic dogs (45.45%, n=5). The modified Morgan’s pocket technique was adopted in 8 eyes of 7 dogs (1 bilateral, 6 unilateral) and the modified orbital rim anchorage technique was performed in 6 eyes of 4 dogs (2 bilateral, 2 unilateral). In Group I, the mean pre-operative Schirmer tear test value was 16.87±0.72 mm/min and in Group II, it was 17.33±0.67 mm/min, both values increased on 30th Post-operative day. Statistical analysis revealed that there was no significant difference between the two groups (p greater than 0.05), but there were significant differences within each group (p less than 0.05). The fluorescein dye test was repeated on 1st,7th,14th, 30th days post-operatively and found positive in the left eye of one dog with the reduced bilateral cherry eye on 7th post-operative day in group I. Third eyelid mobility was normal post-operatively in all the cases of group I. Whereas in group II, it is restricted in all the cases. Three cases regained normal contour by the 10th post-operative day whereas 5 cases by the 14th postoperative day in group I. In group II, 3 cases regained normal contour by 12th post-operative day and 3 cases regained by 14th post-operative day. One case in the group I tested positive for superficial corneal ulcer on the 7th post-operative day. One dog in group I had a recurrence after 45 days of repositioning. One dog in group II with reduced bilateral cherry eye had a recurrence in the left eye 30 days after surgery. Result: Present study, Modified Morgan’s pocket technique was considered superior over the modified orbital rim anchorage technique in view of technical feasibility and unrestricted third eyelid mobility.

The efficacy and safety of secondary focused ultrasound therapy for recurrence of non-neoplastic epithelial disorders of the vulva

Objective To investigate the efficacy, safety, and influencing factors of secondary focused ultrasound (FU) therapy for recurrence of non-neoplastic epithelial disorders of the vulva (NNEDV). Methods Patients with NNEDV who have relapsed after initial FU treatment were included in this study. They were treated with secondary FU therapy between July 2015 and July 2021. Outcome measures included the degree of symptom severity and operative complications. We further analyzed the relationships between age, course, time between relapse and initial treatment, menopause status, lesion size, pathological types, severity of symptoms, and curative rate. Results There were 98 patients enrolled in this study, with a mean age of 47.4 ± 11.4 years. All patients successfully underwent secondary FU therapy. Blisters developed among 16 (16.3%) patients, of whom 6 (6.1%) developed superficial skin ulcers. A curative response was observed among 46 (46.9%) patients, while an effective response was observed among 44 (44.9%) patients. Only 8 (8.2%) patients showed no improvement. The total response rate was 91.8%. A total of 12 (12.2%) cases recurred among all effective cases. Patients with a recurrence of NNEDV after more than 1.5 years following their first FU therapy demonstrated a higher response rate than those with a recurrence after less than 1.5 years. Conclusions A second FU therapy remains effective for patients with recurrent NNEDV with no obvious side effects. The response rate, however, is higher for patients who experience recurrence of NNDEDV after more than 1.5 years.

S2899 A Rare Case of Small Cell Lung Cancer in the Posterior Mediastinum Diagnosed With Endoscopic Ultrasound-Guided Fine Needle Biopsy

Introduction: Lung cancer is the leading cause of cancer mortality worldwide, accounting for 2 million diagnoses and 1.8 million deaths in 2020.1 10-15% of all lung cancers are small cell lung cancer (SCLC), an aggressive form that grows more rapidly and metastasizes more easily than NSCLC. Thus, in patients with suspected lung cancer, a tissue diagnosis is crucial. Here, we present a unique case of a man with a posterior mediastinal mass for whom obtaining a tissue diagnosis presented a diagnostic challenge. Case Description/Methods: A 49 y/o M, with a 30 pack-year smoking history, presented with worsening left-sided chest pain and a 10-pound unintentional weight loss over 2 months. Vital signs and physical exam were unremarkable. Labs demonstrated a mild anemia (Hb 11-12, MCV 82) and elevated inflammatory markers (ESR 54, CRP 70.9). CT scan demonstrated a 12.0x10.7x8.4 cm hypodense soft tissue density mass in the left posterior mediastinum, extending from the level of T1 to T7 vertebral bodies. The mass displaced the trachea, esophagus, and adjacent vessels. Several enlarged mediastinal lymph nodes were seen, the largest measuring up to 1.5 cm. However, there was no lymphadenopathy seen elsewhere and no convincing evidence of metastatic disease in the abdomen or pelvis. CT surgery recommended a CT-guided biopsy with IR vs. endoscopic bronchial US-guided biopsy. IR was unable to find a safe access point to go in for the biopsy as there was no window, as the lung was seen overlying the mass. The patient was discharged, and he returned the next week for outpatient EUS-FNB, which demonstrated a 72x39 mm mediastinal mass (Fig 1A). EUS-FNB was performed and EUS-guided transesophageal biopsies were performed. He was also found to have erosive gastritis, healing superficial sub-cm gastric ulcers, and multiple healing superficial duodenal ulcers. Pathology results demonstrated SCLC (Fig 1B-E) and H. pylori. He was treated with standard quadruple therapy, referred to his PCP to confirm eradication in 6 weeks, and referred to Oncology. For stage III-b SCLC treatment, he completed external beam RT and chemotherapy. Repeat PETCT demonstrated a decrease in the residual mass to 5.5x3.5x5.8 cm. Discussion: For patients presenting with a posterior mediastinal mass, for whom IR may not be able to perform a biopsy, obtaining a tissue diagnosis may be a diagnostic challenge. EUS-FNB provides a useful tool to assess the mediastinum and can provide timely diagnosis and staging of patients with rare forms of lung cancer.Figure 1.: A) A posterior mediastinal mass vs. esophageal mass measuring 72.1 mm by 39.2 mm was identified status-post EUS with FNB x 6. This mass appeared to arise from the muscularis propria of the esophagus; however, an extrinsic mediastinal mass could not be definitively ruled out due to the severe compressive effects of the mass on the esophagus. Mediastinal mass, needle biopsy: -Minute fragments of malignant neoplasm with necrosis. -Tumor cells are positive for AE1/3, CAM5.2, Chromogranin, Synaptophysin, CD56 and negative for p40, CD3, CD20, and CD45. Ki-67 demonstrats about 60% positivity. Combined with morphological features, this immunoprofile supports the diagnosis of small cell carcinoma. B) Hematoxylin and eosin (H&E) stain. C) CAM5.2. D) CD56. E) Chromogranin.

S2930 Calciphylaxis Due to Alcoholic Liver Disease

Introduction: Advanced liver disease often has multiorgan involvement, including dermatological findings. These range from spider angiomas to palmar erythema. Here we present a case of calciphylaxis as a manifestation of decompensated alcoholic liver disease. Case Description/Methods: A 38 year-old female with decompensated alcoholic cirrhosis (portal vein thrombosis, ascites, hepatic encephalopathy, and hepatic hydrothorax) reported to the emergency room complaining of new right thigh wounds. Her vital signs were unremarkable and her exam demonstrated ascites and bilateral lower extremity edema with right medial thigh erythema, induration, and superficial ulceration (Figure 1). Labs showed sodium 125 mEq/L, Creatinine 0.95 mg/dL, WBC 16.2 x109, and total bilirubin 1.6 mg/dL. CT of her thigh demonstrated bilateral, symmetric subcutaneous induration consistent with anasarca and possible superimposed cellulitis. She was admitted and treated with IV antibiotics. As the lesions became duskier and more painful dermatology was consulted who initially were concerned for a vasculopathic process versus calciphylaxis. The patient was placed on empiric treatment for calciphylaxis with sodium thiosulfate. Skin biopsies were performed and showed non-uremic calciphylaxis (Figure 2). The patient then developed an AKI thought to be from hepato-renal syndrome and was trialed on albumin, midodrine, and octreotide with no improvement in renal function. She then developed acidosis, eventually requiring a bicarb drip, and her wounds continued to progress (Figure 1). When she started becoming repeatedly hypotensive her family transitioned her to comfort care and she was discharged to hospice. Discussion: Calciphylaxis is a rare disease that was first described in 1961 by Selye et al and is largely thought to be related to uremia. Here we describe a case of calciphylaxis in a patient with alcoholic liver disease and initial normal renal function. Our review of the literature found fewer than 11 case reports of calciphylaxis associated with liver disease. The mechanism in these cases appears to be poorly understood though is believed to be connected to protein C and protein S deficiency. As in those with advanced renal disease, calciphylaxis has a poor prognosis with high mortality often reported as greater than 50% even despite treatment. Thus it is important that clinicians recognize its association with alcoholic liver disease to aid in diagnosis and ensure prompt initiation of treatment.Figure 1.: A: Right medial thigh wound B: High power of calcium deposits and thrombus (arrow) within the subcutaneous fat C: corresponding von kossa stain (arrowhead).

S3440 Malignant Melanoma of Unknown Primary Presenting With Small Intestinal Masses

Introduction: GI melanomas are extremely rare and require thorough investigation. Most GI melanomas are metastatic from an oculocutaneous lesion, however, and if not found, are termed melanoma of unknown primary (MUP.) MUP represents only 2% of all melanomas yet it is a major cause of mortality. Common areas of metastasis involve the lymph nodes, small intestines, and subcutaneous sites. We present a case of MUP that developed large abdominal masses within 7 months. Case Description/Methods: A 68 year old male presented with 1 week of LLQ abdominal pain and constipation. He had undergone a normal colonoscopy 1 year prior. He had normal vitals and labs excluding hemoglobin of 9.5 g/dL, compared to a baseline of 15.2 g/dL. CT scan of the abdomen and pelvis showed: a multi-lobulated heterogeneously enhancing mass centered in the LLQ involving the small bowel measuring 6.8 x 5.6 x 6.5 cm, as well as a 3.5 x 9.0 x 4.1 cm metastatic hilar lymph node encompassing the duodenal bulb. Of note, these findings were not visualized on imaging 7 months prior. Tumor markers were normal. EGD showed an extrinsic mass compressing the duodenal bulb with a superficial ulcer. Colonoscopy was normal. Percutaneous biopsy of the porta hepatis lymph node was done showing evidence of malignant melanoma. The patient had an extensive skin evaluation yielding no skin/ocular findings consistent with melanoma, making a diagnosis of MUP. (Figure) Discussion: GI MUP has rarely been reported in the literature. Diagnosis is typically definitive in the absence of primary cutaneous, ocular, or mucosal melanoma. Melanoma first found in the GI tract requires a thorough investigation to determine the primary lesion. After a GI melanoma is diagnosed, a detailed physical exam of the lymph nodes. nasopharynx, eyes, anus, and skin must be performed. If no primary lesion is discovered, a PET scan should be done to determine if the GI melanoma is primary, metastatic, or of unknown origin.Figure 1.: (A) Axial view of contrast-enhanced CT showing a partially cystic heterogeneous mass in the hilar region encompassing the duodenal bulb measuring 3.5x 9.0x 4.1 cm (Red Arrow). (B) Coronal view showing RUQ mass causing duodenal bulb compression(Red Arrow), as well as partially visualizing LLQ mass (Yellow Arrow.) (C) Sagittal view of multi-lobulated heterogeneously enhancing mass centered in the LLQ involving the small bowel measuring 6.8 x 5.6 x 6.5 cm (Yellow Arrow.)

S2754 New-Onset Inflammatory Bowel Disease After Ixekizumab Initiation for Psoriatic Arthritis

Introduction: Monoclonal antibodies have become common practice for treatment of psoriatic arthritis (PsA), inflammatory bowel disease (IBD), and many autoimmune diseases. IL-17 inhibitors (IL-17i), such as Ixekizumab (IXE), are suspected to paradoxically exacerbate subclinical IBD or induce new-onset IBD in psoriatic arthritis patients. Case Description/Methods: A 50-year-old male presented with worsening upper abdominal pain, intermittent fevers, and diarrhea for 3-weeks. Patient began IXE 2-months prior for PsA. One-week before admission, computed tomography (CT) showed changes consistent with proximal and transverse colitis, autoimmune panel found ASCA IgG 27.7. Colonoscopy 3-years prior for hemorrhoidal banding showed diverticulosis in the sigmoid colon. On arrival, patient was hypotensive with labs: fecal calprotectin 3424 mcg/g, ESR 40 mm/hr, CRP 227 mg/L, and C. difficile negative. IXE was held and colonoscopy revealed severe rectal proctitis, sparing of sigmoid and distal descending colon, with inflamed ulcerations in the transverse colon preventing advancement of the scope, leading to initial diagnosis of indeterminate IBD (A,B). While on IV methylprednisolone 20 mg every 8 hours for 1-week, symptoms persisted with repeat labs: fecal calprotectin 725 mcg/g, ESR 11 mm/hr, CRP 1.72 mg/L. Repeat colonoscopy showed improved inflammation in a continuous circumferential pattern from transverse colon to the cecum, with sparing of the rectum and descending colon (C). Days later, he improved and was discharged with outpatient follow-up on oral prednisone 40 mg. One-month later, patient worsened with fecal calprotectin 2990 mcg/g. After another month, colonoscopy revealed pancolitis from rectum to cecum (D), with biopsies, diagnosis of ulcerative colitis was confirmed. Patient was initiated on Adalimumab shortly after and is now feeling significantly better as he tapers off his steroid regimen. (Figure) Discussion: IL-17i's ability to affect cell dysregulation and gut dysbiosis can explain the suspected risk of IBD in PsA. Recent literature has found rare cases and low incidence rates of new-onset IBD when treating diseases like PsA with IL-17i (2.4 per 1000 patient-years). Despite the rarity, there are practical recommendations prior to initiating IL-17i: discuss adverse risks, screen IBD history, obtain fecal calprotectin, and if > 250 mcg/g with further testing confirming inflammation (colonoscopy, CT), IL-17i are contraindicated and alternative immunosuppressive agents are recommended.Figure 1.: (A) Colonoscope view of transverse colon; inflammation characterized by congestion, erythema, and friability in a continuous and circumferential pattern from descending colon to the transverse colon, graded as Mayo Score 3 (severe, with spontaneous bleeding, ulcerations) preventing colonoscope from advancing past the transverse colon. (B) Rectal biopsy found severe chronic active proctitis, crypt abscesses, and mucosal erosions/ulceration; negative for dysplasia or granulomas. (C) Repeat colonoscope view of transverse colon; colitis with altered vascularity, congestion and pseudopolyps in a continuous circumferential pattern from transverse colon to the cecum. (D) Final colonoscope view of transverse colon; mild to severe pancolitis from rectum to cecum, with superficial ulcerations and friability of mucosa, Mayo Score 3.

S3581 Common Variable Immunodeficiency and Gastric Carcinogenesis: Two Illustrative Cases

Introduction: Common variable immunodeficiency (CVID) is linked to an increased risk for gastric cancer which seems to be associated with achlorhydria, H. pylori infection, decreased production of gastric IgA, and autoimmune phenomena. We present two patients illustrating progression of gastric pathology in CVID through dysplasia to cancer. Case Description/Methods: A 42-year-old woman with CVID presented with dyspepsia, diarrhea and a 75 lb weight loss. Small intestinal bacterial overgrowth was diagnosed and treated. EGD revealed a superficial ulcer at the incisura. Pathological examination demonstrated chronic active gastritis with H. pylori and intestinal metaplasia (IM) without dysplasia. Triple therapy was unsuccessful; repeat EGD 1 year later demonstrated 3 superficial ulcers at the incisura and antrum; biopsies revealed chronic active gastritis with H. pylori and IM without dysplasia. Second-line therapy failed. 3 years later, EGD showed a non-bleeding cratered ulcer with a nodular edge on the greater curvature in the antrum. Biopsies demonstrated an invasive tubular adenocarcinoma arising in a background of IM with low and high grade dysplasia and no evidence of H. pylori. Partial gastrectomy with Roux-en-Y gastrojejunostomy and modified D2 lymphadenectomy was performed. Pathologic examination confirmed a T1aN0M0 moderately differentiated adenocarcinoma. A 64-year-old woman with CVID, celiac disease, pernicious anemia and a CTLA4 gene mutation presented in 2019 for surveillance following removal of a gastric adenoma by EMR 2 months earlier. From 2018-2022, EGDs with gastric mapping were performed every 6 months and revealed progression from low to focal high grade dysplasia. In 2019, surveillance biopsies showed foci of low and high grade dysplasia in the antrum. EMR of a sessile polyp and ESD of 2 sessile polyps were performed followed by EMR of a sessile antral polyp and EMR of diffusely nodular mucosa at the incisura 5 months later. Biopsies have been consistently negative for H. pylori. Discussion: These cases illustrate progression to cancer in CVID and exemplify two risk factors: Helicobacter pylori and achlorhydria. Both progressed from low to high grade dysplasia and, in one, to invasive cancer within 4 years. Guidance on surveillance for IM in the non-CVID population varies in terms of frequency and intervals; with the risk of progression to cancer in CVID increased 10-47-fold, there is an urgent need for guidelines on surveillance.

S3693 When Should I Follow Up? A Case-Based Discussion of Endoscopic Surveillance in Diffuse Gastric Polyposis

Introduction: Diffuse gastric polyposis is a rarely seen pathology without well defined surveillance guidelines. One study has shown that 2.1% of patients with gastric polyposis were later found to have malignancy.(1) This raises the question: how often should we perform surveillance endoscopy in such a rare but serious disease? Case Description/Methods: A 54-year-old male with past medical history of GERD was referred from primary care clinic for evaluation of chronic epigastric abdominal pain for one year. Patient’s vitals on examination were stable and physical examination unremarkable. Upper endoscopy performed showed numerous (>50) large, pedunculated polyps with superficial ulceration (ranging in size from 3 mm to 2 cm) noted throughout the stomach. Multiple biopsies showed gastric hyperplastic polyps, negative for metaplasia or dysplasia. Patient was asymptomatic on PPI and was offered prophylactic gastrectomy, however, patient refused and chose to follow-up with surveillance endoscopy. Endoscopy was initially repeated monthly, followed by every 3-months, followed by every 6-months with unchanged findings showing numerous (>50) biopsy proven gastric hyperplastic polyps. The patient has been under our care for nine years and is currently being followed up with yearly surveillance endoscopy while continuing to remain asymptomatic (Figure 1). Discussion: Guidelines do not exist to guide our management of this patient. We began with frequent endoscopies with biopsy and gradually decreased the frequency over the last nine years with good results. We chose to present this case because we would like to raise awareness amongst gastroenterologists about the lack of guidelines and to use this case as an example for future cases. We are advocating for physicians or larger healthcare systems to create a database to monitor these patients or create a retrospective study to determine the timeline for potential malignancy of these gastric polyps. With this data an endoscopic surveillance guideline can be created so that we can prevent the disaster of discovering gastric malignancy late in its course.Figure 1.: Upper endoscopy revealing multiple gastric hyperplastic polyps.

S2172 A Unique Case of Disseminated Histoplasmosis Presenting as Colonic Ulcers

Introduction: Histoplasmosis is the most common endemic mycosis in the United States with a disseminated form usually only seen in immunocompromised patients. While localized infections are usually self-limiting and often asymptomatic, some patients present with extra-pulmonary disseminated disease. Although case reports have described colonic and ileal involvement, gastrointestinal manifestations are uncommon. Here we report isolated colonic involvement of disseminated histoplasmosis in an asymptomatic patient. Case Description/Methods: A 62-year-old male with a history of end stage renal disease secondary to IgA nephropathy status post living donor renal transplant on chronic immunosuppressive therapy presented for a routine screening colonoscopy. The patient denied gastrointestinal and pulmonary symptoms to include: cough, shortness of breath, fever, abdominal pain, diarrhea and gastrointestinal bleeding. He grew up in the state of Mississippi and currently resides in Texas working in landscaping. Within the cecum, there were 2 discrete areas of abnormal appearing tissue (Figure A). A 10mm irregular, superficial ulcer with no high-risk stigmata for bleeding was also noted within the distal transverse colon (Figure B). Cold forceps biopsies were obtained at both sites. Surgical pathology with Grocott’s methenamine silver stain demonstrated abundant intra-histiocytic and extracellular organisms morphologically compatible with histoplasmosis. Given a potential for fungal morphological mimicry, the patient was serologically tested for histoplasmosis, coccidioides, and blastomyces. Ultimately, PCR from the tissue sample taken during the biopsy tested positive for Histoplasma capsulatum. The patient was started on itraconazole for 12 months duration which he tolerated without side effects and remained asymptomatic on follow up. Discussion: This case demonstrates an unusual presentation of disseminated histoplasmosis with asymptomatic colonic involvement including the variable endoscopic appearance of this fungal infection. With a mortality rate as high as 31% in the immunocompromised population gastroenterologists need to remain cognizant when encountering colonic ulcerations or abnormal mucosa in high risk patients. In addition, this case highlights the importance of tissue sampling to secure the diagnosis along with the efficacy of itraconazole in treating this potentially deadly infection.Figure 1.: A. Discrete area of anomalous tissue in the cecum B. Area of ulceration along the distal transverse colon.

S2021 Dilemma of a Rectal Mass

Introduction: Mucosal prolapsing polyps of the colon are uncommon findings during colonoscopy that are often misdiagnosed as malignant lesions that many times lead to unnecessary endoscopic and surgical resection. At times rectal prolapse/ mucosal prolapse syndrome can present as rectal submucosal mass similar to one another. Herein we present a case of a 63-year-old male with rectal prolapse that mimicked Submucosal rectal mass. Case Description/Methods: A 63-year-old male with prior medical history of hypertension, hyperlipidemia, obesity, treated Heliobacter pylori, hemorrhoids presented to the gastroenterology clinic due to 3-month history of dizziness, abdominal pain and bright red blood per rectum. Initial vitals were stable except for tachycardia. Physical examination was unremarkable except for external rectal hemorrhoids that were appreciated. Labs were also unremarkable on admission except for Normocytic anemia. Patient was planned and taken for colonoscopy which had poor bowel preparation, revealed large rectal mass, 2 small polyps in ascending and transverse colon which were resected. Patient was planned for flexible sigmoidoscopy and lower endoscopic ultrasound evaluation of rectal mass which revealed a hypoechoic, submucosal lesion measuring 14mm by 7mm. Patient underwent endoscopic submucosal resection of the rectal mass and removal of lesion. Post op he had rectal pain along with hypotension, which led patient to be admitted for overnight observation. On follow up patient complained of recurrent dizziness and BRBPR, sigmoidoscopy was planned and revealed superficial mucosal ulceration which was treated with bipolar cautery. Pathology of the rectal mass revealed largely denuded benign appearing congested polyp with granulation tissue and cautery artifacts. Patient’s symptoms improved on subsequent follow ups (Figure). Discussion: Mucosal prolapse presents as a common underlying mechanism rectal prolapse, inflammatory polyps, solitary rectal ulcer syndrome that were previously proposed to be grouped under the umbrella term “mucosal prolapse syndrome”. Mucosal prolapse can manifest as ulcerated, flat erythematous, or polypoid lesions. At times they can even mimic adenocarcinomas, adenomas both endoscopically and histologically. Most of the time rectal prolapses polyps have been seen in patients with mucosal prolapse syndrome. Thus, it is vital to differentiate and diagnose rectal prolapse versus true rectal mass in order to exclude malignancies. This will help guide management and surveillance strategy.Figure 1.: Nodules from Colonoscopy.

S2366 Rare Case of 27-Year-Old With Esophageal Cancer

Introduction: Amongst esophageal cancers, neuroendocrine tumors represent 0.5 to 2.0% of cancers with a median age occurrence of 69 years old.1 Our case represents a 27-year-old patient with neuroendocrine esophageal cancer. Case Description/Methods: 27 year old female with history of obesity presented to clinic for acid reflux with globus sensation and stated symptoms are worse after eating. The patient started on famotidine 20mg daily with no improvement, patient developed dysphagia to solids daily. Esophagogastroduodenoscopy (EGD) demonstrated a 4cm mass at distal esophagus bridging the gastroesophageal junction with a 2cm cratered ulceration at the distal end of the mass. Computed tomography of the abdomen showed abdominal adenopathy and 11cm metastatic lesion at the liver as seen in Figure 1. Pathology was chromogranin A positive representing a neuroendocrine tumor. Patient started on carboplatin and VP-16. Currently, the patient continuing to receive chemotherapy and will receive PET scan within the next month. Discussion: As neuroendocrine tumors of the esophagus compromise a small portion of esophageal cancers with a female to male ratio of 1 to 3.7 emphasizing the importance of our case report.1 Clinical manifestations include weight loss, anemia, and dysphagia. Endoscopic biopsy will confirm biopsy. Visualization on biopsy provides guidance on staging; early esophageal cancer presents as superficial plaques, nodules or ulcerations. Advanced lesions will appear as strictures, ulcerated masses, circumferential mass, or a large ulceration. Regardless of visualization on endoscopy, diagnosis is confirmed by biopsy. Biopsy confirms with an endocrine marker, example chromogranin A, synaptophysin, and CD 56. Staging then assists in guiding treatment. Endoscopic ultrasound is one of the most accurate techniques to assess with locoregional staging. Most common sites of metastasis are liver, lungs, bones and adrenal glands. There is controversy regarding the use of diagnostic laparoscopy but procedure generally reserved for patients who have potentially resectable tumor, T3 or T4 staging, Siewert II or III adenocarcinomas of the esophageal gastroduodenal junction, or when there is a suspicion for an intraperitoneal metastatic disease that cannot be confirmed otherwise.Figure 1.: 1: large heterogeneous lesion within the right hepatic lobe, measuring 10.5 x 11.5 cm which appears to demonstrate central necrosis.REFERENCE 1. Egashira A, Morita M, Kumagai R, et al. Neuroendocrine carcinoma of the esophagus: Clinicopathological and immunohistochemical features of 14 cases. PLoS One 2017;12(3):e0173501.

S2425 A Case Report of Volatile Ingestion-Induced Acute Esophageal Necrosis

Introduction: Acute esophageal necrosis (AEN), also known as black esophagus or acute necrotizing esophagitis, is a rare syndrome with diffuse circumferential black discoloration often of distal third esophageal mucosa due to relative hypovascularity and termination at the gastro-esophageal junction. It usually presents with upper GI hemorrhage. Despite controversial pathogenesis, there is strong consideration for a 2-hit hypothesis where an initial low-flow vascular state predisposes the mucosa to a severe topical injury. Chemical injury by gastric contents, toxin ingestion, severe infectious diseases, diabetic ketoacidosis and shock are associated with AEN. Advanced age, male gender and comorbidities like diabetes mellitus (DM), hypertension, cardiovascular disease, chronic kidney disease, malnutrition, chronic alcohol abuse, post-irradiation are predisposing risk factors for AEN. We present a patient with a favorable outcome of a generally rare, life-threatening condition due to early recognition and treatment. Case Description/Methods: A 74-year-old male presented to the hospital with shock and 3-day history of hematemesis. He had history of coronary artery disease, Type II Diabetes Mellitus, chronic obstructive pulmonary disease, esophageal adenocarcinoma post chemotherapy and radiation complicated by erosive esophagitis and alcoholism. Labs were significant for acute kidney injury (AKI), high anion gap metabolic acidosis (HAGMA), osmolar gap of 59 mOsm/kg and hemoglobin drop from 14 to 9 g/dL. Volatile panel not sent; drug-screen benign, infectious work-up negative. CT abdomen had distended stomach; thus, NG tube placed for decompression, yielding 700cc of coffee ground emesis. Upper endoscopy performed 2-days later showed Los Angeles Grade D esophagitis with entire esophagus with black appearance, gastric body erosions and superficial clean-based duodenal ulcers. Patient was continued on PPI twice daily for 8 weeks with planned repeat EGD (Figure). Discussion: This patient likely had volatile ingestion chemical injury given shock, hematemesis, AKI with HAGMA and osmolar gap. Despite AEN’s rarity with prevalence of 0.2 percent in autopsy states, given overall 32 percent mortality rate and 6 percent mortality rate directly attributed to complications of AEN, early recognition and prompt medical management is imperative for favorable outcomes. Treatment focuses on supportive therapy: namely resuscitation, PPIs, sucralfate, keeping the patient NPO and avoiding nasogastric tube to avoid esophageal perforation.Figure 1.: Proximal Acute Esophageal Necrosis.

S3216 When to Start Anticoagulation? A Case of Portal Vein Thrombosis in a Post-Partum Cirrhosis Patient With Variceal Bleeding

Introduction: While portal vein thrombosis (PVT) is a relatively rare disease in the general population, the prevalence of PVT in cirrhosis increases in parallel with the severity of cirrhosis. The pathogenesis of PVT in cirrhosis is thought to be multifactorial resulting mainly from alterations in the different components of Virchow’s triad. Case Description/Methods: Here we report a case of a 36-year-old woman with history of alcoholic cirrhosis who presented 2 weeks status post c-section complaining of acute onset abdominal pain, bloating, and nausea with two episodes of hematemesis. Her initial vital signs were unremarkable and hemoglobin was 7.4 gm/dL. Her model for end-stage liver disease (MELD) score was 16. She underwent upper endoscopy (EGD) with successful banding of 3 columns of large varices which showed stigmata of recent bleeding. Patient also underwent diagnostic and therapeutic paracentesis which did not show signs of spontaneous bacterial peritonitis (SBP). However, she did have history of wound dehiscence of her cesarean incision with persistent leakage of serous fluid despite prior negative pressure wound therapy. Therefore, CT abdomen/pelvis was obtained which demonstrated nonocclusive thrombus in the main portal vein extending into both the right and left branches. Due to finding of PVT, MRI was also obtained which showed no evidence of malignancy. As her hemoglobin remained stable ( >7 gm/dL) during hospitalization, she was started on therapeutic low molecular weight heparin (LMWH). Unfortunately, patient was re-admitted five days later for hematemesis and drop in her hemoglobin to 5.6 gm/dL. She received blood products, and repeat EGD showed cratered and superficial esophageal ulcers at the site of prior variceal treatment. Ultimately LMWH was held and resumed after hemoglobin stabilized. Discussion: This case demonstrates the conundrum of if/when to treat PVT in patients with cirrhosis. Current guidelines recommend anticoagulation as the mainstay of PVT treatment. However, this is can be complicated by other sequelae of decompensated cirrhosis such as variceal bleeding. Consequences of non-treatment include further increase in resistance to portal blood thus worsening portal hypertension. In this case, patient’s post-partum status also favors anticoagulation as other society guidelines have recommended anticoagulation with LMWH for postpartum patients with vascular disease of the liver. Therefore, individualized treatment algorithms should be developed and used to guide management.

S2399 When All You See Is Black: A Case of Acute Esophageal Necrosis

Introduction: Acute esophageal necrosis (AEN), sometimes called “black esophagus” given its endoscopic appearance, is a rare condition with an incidence of around 0.01% of all patients undergoing EGD. The pathophysiology of AEN is hypothesized to be multifactorial involving hemodynamic compromise, backflow of stomach acid, any state where esophageal mucosal repair mechanisms are diminished, or thromboembolic phenomena. The primary associated symptoms are hematemesis, melena, and shock. AEN is a life-threatening condition with a mortality rate of approximately 32%. Case Description/Methods: A 73-year-old male with a medical history of NASH cirrhosis, hypertension, coronary artery disease, abdominal aortic aneurysm, and diabetes mellitus type 2 presented from home with hematemesis. He was discharged 24 hours before presentation after spending 5 days in the hospital for hepatic encephalopathy. On physical examination he was afebrile, normotensive with a slight tachycardia. Hemoglobin and hematocrit were 11g/dL and 31%, respectively. He was started on an octreotide drip, given IV Protonix 80 mg, and 1 gram of Ceftriaxone. EGD later that day revealed black material coating the esophagus unable to be washed away, portal hypertensive gastropathy, a large amount of altered blood mixed with food in the stomach, duodenitis, and superficial duodenal ulcers. A repeat EGD 24 hours later revealed ulceration of the mid and distal esophagus consistent with acute esophageal necrosis. A CTA aorta was negative for stenosis or thromboembolic phenomena. He remained hemodynamically stable, did not develop esophageal pain, and was started on a Sucralfate slurry. He was able to progress his diet quickly. Six days after admission his labs normalized and was discharged home (Figure). Discussion: Our patient had multiple factors likely leading to the development of AEN due to his numerous comorbidities. It is important to monitor for complications of AEN, including perforation and microbial superinfection during the initial recovery period, and stenosis or strictures as a late sequala. Due to the patient’s prompt triage and intervention with appropriate therapy, a good outcome was achieved. This case highlights the importance of quickly triaging patients and intervening appropriately to combat the high mortality rate of AEN.Figure 1.: 1: Endoscopic appearance of the esophagus on day of presentation (A) showing black necrotic appearance of esophagus and 24 hours later on repeat examination (B) demonstrating ulcerated esophageal mucosa.

S3419 Ileocolitis Associated With the Checkpoint Inhibitor Palbociclib (PAL)

Introduction: Cancer treatments are continuously being updated to optimize survival. Newer checkpoint inhibitors (CDK4/6 inhibitors) have demonstrated promising responses in ER-positive breast cancers. We report a rare side effect of ileocolitis with Palbociclib (PAL) treatment. Case Description/Methods: A 30-year-old female with biopsy confirmed stage IV ER+, PR+, HER2− ductal breast carcinoma with metastasis to liver and bone presented with abdominal pain, diarrhea, and hematochezia 2 months into therapy with letrozole and PAL. Subsequent colonoscopy 4 months after onset of symptoms showed diffuse colitis with congestion, erythema, and shallow ulceration scattered through the whole colon, and several superficial aphthous ulcerations in the ileum. Stool for C. difficile by PCR was negative and biopsies revealed nonspecific ileitis and colitis. There was concern for IBD vs drug induced enteritis/colitis. PAL was held and the patient was started on prednisone taper with resolution of symptoms after 1 month. Given concern for disease progression, PAL was restarted 1 month later with return of symptoms and hospital admission. Laboratory studies showed WBC 1.84 TH/uL, Hgb 7.6 g/dL, plt 24 TH/uL, LDH 4211 U/L, ALT 450 U/L, AST 221 U/L, alk phos 223 U/L, total bilirubin 1.3 mg/dL, ESR 49 mm/hr and CRP 45 mg/L. Infection was excluded via stool studies including C. difficile PCR and blood culture. Colonoscopy was performed and showed erythema, friability, congestion, erosions, and ulceration in the TI compatible with ileitis (Figure) as well as patchy erythema, edema, erosions, and ulcers throughout the colon with skip lesions and sparing of the rectum. Biopsies were reported as normal TI and colon. PAL was discontinued indefinitely and the patient had complete resolution of symptoms within weeks. Discussion: CDK4/6 inhibitors are new first-line treatment for metastatic HR-positive breast cancer. There are no prior reports of PAL induced enterocolitis without concomitant radiation. In our patient, symptoms could not be easily distinguished from infectious colitis or IBD clinically. Ileal and colonic biopsies showed nonspecific ileitis and colitis or were reported as normal. As CDK4/6 inhibitors become used more as the first-line treatment of metastatic HR-positive breast cancer, additional evidence of GI related toxicities may emerge. Checkpoint inhibitor induced ileitis/colitis should be considered in a patient with new onset hematochezia and diarrhea after initiation of these agents.Figure 1.: Erythema, friability, congestion, erosions, and ulceration in the terminal ileum.