Abstracts S1161

2035_B  Figure 2. Images of the polypectomy. (a) : A detachable snare was used for the prevention of bleeding during polypectomy (B) The polyp was removed without complica-
tion (c) The resected specimen of duodenal polyp

2035_C  Figure 3. Microscopic findings. Traditional serrated adenoma; (a): exophytic, tubulovillous or villous polypoid lesion; (b): deep clefts, indentations and slit-like
spaces, leading to broad luminal fronds that protrude into the gland lumen or from surface of a papillary frond often in a broad flat-topped, mushroom-like or jigsaw puzzle-
like appearance; (c): striking granular eosinophilic cytoplasm, luminal serrations, presence of elongated, penicillate nuclei with evenly dispersed coarse chromatin and small
inconspicuous nucleoli

duodenum are very rare and asymptomatic in previously reported cases. However, we experienced a case of
duodenal serrated adenoma with bleeding which was diagnosed and treated endoscopically. An 80-years-
old-female visited the emergency department due to hematochezia. The laboratory result showed that
hemoglobin was 4.2g/dl and iron deficiency anemia. For evaluation of gastrointestinal bleeding, the patient
underwent esophagogastroduodenoscopy(EGD) and colonoscopy. The result of EGD was atrophic change
and intestinal metaplasia. The colonoscopy showed hyperplastic polyps at ascending colon. Abdominal
computer tomography(CT) showed a 1.8cm lobular enhancing nodule at duodenojejunal junction. After
she underwent capsule endoscopy, we found a pedunculated polyp at distal duodenum. For further evalua-
tion, we used a colonoscopy to approach the duodenojejunal junction because upper endoscopy could not
reach the polyp. A 2.5cm sized lobulating pedunculated polyp was found at 4thportion of duodenum and
there was fresh blood near the polyp.(Fig. 1) We considered the polyp as the cause of anemia and bleed-
ing, we recommended her to resect the polyp. We planned to use a detachable snare during polypetomy
for the prevention of bleeding and successfully removed the polyp without any adverse event.(Fig. 2) The
final pathology result was a traditional serrated adenoma.(Fig. 3) After polypectomy, the patient did not
show any bleeding sign. The serrated adenomas are precursors of colorectal cancer and serrated pathway is
related with 15% of all colorectal cancer. The prevalence of serrated adenomas of small intestine is very rare
and their clinical features are insufficiently known. Based on previous report, traditional serrated adenoma
of upper digestive tract showed aggressive behavior with high malignant potential and should be resected
for the prevention of cancer progression. Serrated lesions of duodenum are usually found in the bulb and
2nd portion. Our case showed a relatively large size and location in the distal part of duodenum that could
not be reached by upper endoscopy. A Delay in detection might cause size increasing and bleeding. To our
knowledge, this is the first case of duodenal traditional serrated adenoma which caused overt bleeding.
2036
Pernicious Anemia: Early Detection of the Historical “Great Pretender"
Huy A. Le, MS41, Tejas V. Joshi, MD2, Corey Saraceni, MD2, Lee Engel, MD, PhD3. 1. UMHS-St. Kitts,
New York, NY; 2. LSU Health New Orleans School of Medicine, New Orleans, LA; 3. LSU Health Sciences
Center, New Orleans, LA
Pernicious anemia (PA) is the late manifestation of autoimmune metaplastic atrophic gastritis
(AMAG) characterized by the presence of anti-intrinsic factor with eventual decreased absorption
of cyanocobalamin. Various clinical manifestations from subtle anemia to serious neurological symp-
toms gives PA notoriety as a “great pretender”. We present a case of an asymptomatic patient who was
found to have severe gastritis with anemia leading to further evaluations revealing a chronic autoim-
mune disorder.
A 52-year-old female with history of HTN, abnormal uterine bleeding, DM2 and anemia presented with
abnormal labs. Colonoscopy completed 6 years ago for iron deficiency anemia found no etiology. Labs
revealed Hb 6.0g/dl, Hct 17.5%, Plt 140,000/uL, MCV 114, RDW 27.2%, Iron 108µg/dL, ferritin 338ng/
ml. Iron Saturation 32%, transferrin 258mg/dL, TIBC 335µg/dL, vitamin B12 <50pg/mL, Folate 22.8ng/
mL, vitamin D 25-OH 13ng/mL. Fecal occult blood test was negative.EGD was performed to screen for
(PA) and gastric malignancies which revealed frank blood in the gastric fundus, friable gastric mucosa,
and erythematous mucosa in the pylorus. Pathology was consistent with autoimmune gastritis. Intrinsic
factor antibody assay was positive. She was started on Cyanocobalamin injections, and continued on
lifelong B12 supplementation.
PA accounts for 20-50% of all cobalamin deficiencies in adults, and it is a complex disorder associated
with hematological, gastric, immunological and neurological alterations. It has a prevalence 0.1% in
the general population and is diagnosed in up to 15-25% of patients with AMAG. Disease progression
includes symptoms ranging from fatigue and weakness, to atrophic glossitis, to more severe peripheral
neuropa thies and subacute combined degeneration. Increase in MCV and hypersegmented neutro-
phils are usually the initial laboratory findings. This case illustrates the need to have early detection and
timely treatment of PA induced vitamin B12 deficiency. Vitamin D displays immunomodulatory proper-
ties may be a risk factor. One case-control study revealed levels of vitamin D in autoimmune gastritis
patients were significantly lower than in the general population. Evaluation by EGD and histopathology
of AMAG is necessary due to its precancerous nature. Gastric carcinoid tumors have been observed
in 4-9% of patients with AMAG and PA so continued surveillance should always remain a part of the
patient’s plan of care.

© 2016 by the American College of Gastroenterology The American Journal of GASTROENTEROLOGY

S1162 Abstracts

Introduction: This is a rare case of hyperinfection syndrome secondary to Strongyloidesstercoralis infec-

tion presenting with GI bleeding.
Presentation: This is the case of a 90-year-old female, who immigrated from Laos 30 years prior, with a
history of atrial fibrillation on pradaxa, uncontrolled asthma of 20 years, requiring intermittent steroids,
who used to work on a farm, and presents with GI bleeding. She had several days of nausea, malaise,
and an episode of bloody emesis. In the ED, she had melena mixed with red blood and a Hb of 9.9 g/
dL, hypotension, received pradaxa-bind, and underwent prompt EGD and flexible sigmoidoscopy. The
findings were severely inflammed and friable mucosa of the duodenum, gastric antrum and esophagus
with patchy erythema of the sigmoid colon (see images). Subsequently, two out of two sets of blood
cultures were positive for E. coli. The pathology revealed a high parasitic load of Strongyloides stercora-
lis. She was started on ceftriaxone and ivermectin, did not improve, and went to hospice. Discussion:
Strongyloides stercoralis is a threadworm endemic to tropical areas. Risk factors include working with soil
contaminated by human feces. Acute strongyloidiasis involves filariform larva that enter the skin causing
local reactions, ascend the tracheobronchial tree causing tracheal irritation and cough, and descend the
GI tract causing multiple GI manifestations. Patients with chronic strongyloidiasis can remain asymp-
tomatic up to 75 years. Hyperinfection syndrome refers to an accelerated reproduction of larvae in a
colonized host due to alteration of the immune system. It can be complicated by bloodstream infections
due to GI mucosal inflammation and hematogenous spread. This patient presented with gastrointestinal
bleeding, which is rare. The patient’s diagnosis of asthma may have been a manifestation of chronic
strongyloidiasis. Subsequent treatment with steroids may have led to hyperinfection syndrome. Retro-
spectively, it was found that this patient had a positive Strongyloides IgG antibody. While not specific, a
positive serologic test in a patient whose history correlates with stronglyloides infection may warrant
empiric treatment. Screening has been suggested for individuals with risk factors who are likely to be
placed on immunosuppressive therapies. We propose routine screening for individuals with risk factors
2036_A  Figure 1. Upper GI Bleed who will require immunosuppression in order to reduce the risk of developing hyperinfection syndrome.

2036_B  Figure 2. Gastritis

2037_A  Figure 1. Friable mucosa of the 2nd part of the duodenum. Underlying
biopsy showed duodenal mucosa with villous blunting, increased active chronic inflam-
mation and reactive epithelial changes.

2036_C  Figure 3. Friable Gastric Mucosa

2037
Fatal Strongyloides stercoralis Hyperinfection in a Patient With Gastrointestinal Bleeding and
Asthma: A Case to Screen for Asymptomatic Carriers
2037_B  Figure 2. Patchy erythema of the sigmoid colon seen on flexible sigmoidos-
copy. Underlying biopsy showed colonic mucosa with moderate active colitis and reac-
Atchayaa Gunasekharan1, Daniel Greenwald, MD2, Caroline Loeser, MD, FACG3. 1. Saba University
School of Medicine, Ottawa, ON, Canada; 2. Yale New Haven Health System, Bridgeport Hospital,
tive epithelial hyperplasia. Focal parasites were identified suggestive of Strongyloides
Bridgeport, CT; 3. Yale University School of Medicine, Bridgeport, CT stercoralis morphology.

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