Abstracts S1115

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[2114] Figure 2. Push enteroscopy showing (a) multiple diverticula in jejunum with (b) blood
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clots present.

S2115

Hemobilia Secondary to Spontaneous Cystic Artery – Gallbladder Fistula - A Unique

Gastrointestinal Anomaly
Abhishek D. Polavarapu, MD1, Sudeep Acharya, MD1, Indraneil Mukherjee, MD2, Gloria Lan, MD1.
1 2
Staten Island University Hospital, Staten Island, NY; Staten Island University Hospital, New York,
NY.

INTRODUCTION: Hemobilia is rare and is approximately 6 % of all the causes of acute gastro-
intestinal bleeding. The most common etiology is iatrogenic (surgical intervention), inflammatory
process such as cholecystitis or traumatic which results in an abnormal connection between the
vascular system and biliary tract. Spontaneous cystic artery (CA) to gallbladder fistula is an extremely [2115] Figure 2. Angiogram image showing abrupt cut off of cystic artery.
rare condition and we report on such unique case that was managed with coil embolization.
CASE DESCRIPTION/METHODS: A 62-year-old female presented with fresh blood per rec-
tum(BPR) and abdominal pain. Initially the patient remained hemodynamically stable with hemo-
globin of 9.5 and elevated liver enzymes with alkaline phosphatase of 313, aspartate aminotransferase
of 92, alanine aminotransferase of 65 and total bilirubin of 3.2. Computed tomographic (CT) scan of
abdomen demonstrated porcelain gall bladder. Ultrasound of the abdomen showed mild hepato-
megaly with 2.5 cm gall stone, negative Murphy’s sign and common bile duct of 4 mm in size. She
was planned for colonoscopy next day but later developed an episode of massive BPR after which her
hemoglobin dropped with tachycardia. She was resuscitated and was taken for emergent upper
endoscopy (UE). It showed a blood clot in the second portion of the duodenum with blood dripping
from above, there was a high suspicion for haemobilia. Then UE was exchanged with side viewer
duodenoscope and blood was noted to be dripping from the ampulla. Intervention radiology was
consulted and patient underwent hepatic angiogram it confirmed the CA fistula with gallbladder.
Subsequently CA coil embolization was done to control the bleeding vessel. An elective cholecys-
tectomy was planned for finding of porcelain gall bladder which may represent underlying
malignancy.
DISCUSSION: Identification of vascular-biliary fistula can pose a diagnostic challenge and it should
be suspected in acute gastrointestinal bleeding patients with acute elevated liver enzymes. In these
cases an additional effort is to be made to examine the ampulla for hemobilia during UE. Once

[2115] Figure 3. CT angiogram image showing cystic artery bleeding into gallbladder.

hemobilia noted prompt angiogram has to be performed to identify the bleeding vessel and consider
embolization. The mechanism of this spontaneous CA and biliary tract fistula is not known. How-
ever, it can be suggested that the inflammatory process following the stone formation in biliary tract
and mechanical pressure of the stone may have resulted in adhesion formation with the anatomical
structures in proximity, promoting fistula formation.

S2116

Novel Presentation of Rectal Granular Cell Tumor Leading to Severe Hemorrhoidal Bleeding
With Pathological Diagnosis Identified Only After Hemorrhoidectomy: Case Report and
Literature Review
Ismail Hader, MD1, Mitual B. Amin, MD2, Laith Jamil, MD1.
1 2
William Beaumont Hospital, Royal Oak, MI; William Beaumont Hospital, Royak Oak, MI.

[2115] Figure 1. Axial section of CT Abdomen showing Porcelean Gallbladder.
INTRODUCTION: Granular cell tumors (GCTs) are rare benign tumors that rarely involve the
gastrointestinal (GI) tract, and extremely rarely involve the rectum. Rectal involvement typically
presents as an incidental finding on colonoscopy. A novel case is presented of a 67-year-old female
who presented with severe acute rectal bleeding out of proportion of hemorrhoidal bleeding due to
GCT with erosions on top of the hemorrhoid.
CASE DESCRIPTION/METHODS: 67-year-old female, presented with spontaneous painless rectal
bleeding. This bleeding was different from her usual hemorrhoidal bleeding by being much more

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Copyright © 2020 by The American College of Gastroenterology. Unauthorized reproduction of this article is prohibited.
 S1116 Abstracts
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[2116] Figure 1. H&E stained image of tissue from different part of the resected tissue showing
hemorrhoids which are distended thin walled venous spaces filled with blood.
voluminous. The patient denied recent change in stool caliber or consistency, straining, mucous per
rectum, anal discomfort, weight loss, weakness, or dizziness. Physical exam revealed BMI 31.2 kg/
sq.m. and stable vital signs. The abdomen was soft, non-tender, and non-distended, without hep-
atosplenomegaly. Anorectal examination revealed large, edematous, and tender external hemor-
rhoids, and edematous grade III–IV prolapsed internal hemorrhoids. Hemoglobin was 11.3 g/dL,
platelets 251 bil/L. Remainder of physical examination and blood tests were within normal limits.
Patient failed therapy with high fiber diet, sitz baths, and topical hemorrhoidal cream, then un-
derwent hemorrhoidectomy. Postoperative pathology revealed a 4-mm-wide GCT on top of a
hemorrhoid with areas of erosions. Symptoms resolved after surgery.
DISCUSSION: GCT is a mesenchymal soft tissue neoplasm arising from Schwann cells. It is usually
a benign tumor, but 1%–2% of cases are malignant. It is more common in females, and most
common in 10–50-year-olds. GCTs usually occur in head and neck, mainly in skin, subcutaneous
tissue, and oral cavity, but rarely in the GI tract. Esophagus is the most common location in the GI
tract, followed by duodenum, anus, and stomach, with rectum and colon as the rarest locations. GCTs
usually present as a solitary mass; multiple GCTs are uncommon. Resection is generally curative.
There are few case reports of rectal GCTs discovered incidentally during routine screening colono-
scopy. The presentation of GCT triggering hemorrhoidal bleeding is novel. To our knowledge, this is
the first reported case of rectal GCT immediately on top of hemorrhoids presenting as “hemor-
rhoidal” bleeding. GCTs Although typically benign, failure to recognize and resect GCTs early might
rarely lead to malignant transformation.
[2116] Figure 2. Low power view of H&E stained section showing one of the resected polypoid
fragments of rectal mucosa lined by squamous mucosa, containing a cellular proliferation (area
between asterisks) in the submucosal location. Left inset shows a high power view of these tumor
cells which contain abundant eosinophilic granular cytoplasm and low grade nuclear features.
Right inset shows a high power view demonstrating positivity for S-100 (both cytoplasmic and
nuclear positivity) in these tumor cells.
The American Journal of GASTROENTEROLOGY
Copyright © 2020 by The American College of Gastroenterology. Unauthorized reproduction of this article is prohibited.
S2117
The GIST of It: A Rare Presentation of Neurofibromatosis Type I
Mohammad U. Azam, MD1, Amit Hudgi, MBBS1, Muaaz Masood, MD2,
Hafiz Muhammad Sharjeel Arshad, MD1, Isaac E. Perry, DO1, John Erikson L. Yap, MD3.
1 2
Medical College of Georgia, Augusta, GA; Augusta University Medical Center, Augusta, GA;
3
Medical College of Georgia at Augusta University, Augusta, GA.
INTRODUCTION: Neurofibromatosis Type 1 (NF1) is an autosomal-dominant disease with an
incidence of 1 in 2500–3000 individuals. NF1 confers up to a four-fold increase in overall malignancy
risk compared to the general population, and patients are 34 times more likely to develop gastro-
intestinal stromal tumors (GIST). GIST are rare mesenchymal tumors involving the gastrointestinal
tract (GI) and their increased incidence has been associated with the history of NF-1. We present a
case of a patient with NF-1 associated with an unusual presentation of GIST.
CASE DESCRIPTION/METHODS: 42 years old female with past medical history of NF-1 initially
presented to the ED for maroon-colored stools for 2 days. She endorsed infrequent use of ibuprofen
with last use being 3 months ago. Initial physical exam was significant for mild hypotension
responding to fluid resuscitation, and rectal exam negative for blood. The hemoglobin in the ER was
7.9 g/dL (baseline 11.3 g/dL) with an elevation of BUN: Creatinine ratio (24 mg/dL, 0.65 mg/dL). An
EGD was performed which demonstrated mild duodenitis. An ileocolonoscopy was performed and
blood clots were in the entire colon including the terminal ileum. No source of active bleeding in the
colon seen after extensive suctioning done. The patient underwent a video capsule endoscopy (VCE)
and an abdominal CT with contrast. VCE demonstrated a endophytic mass with active bleeding. CT
revealed numerous exophytic and endophytic masses with the largest mass at the anterior wall of the
ileum measuring 2.4 cm 3 2.2 cm, which was noted to have a brisk active arterial bleeding. Surgery
was consulted and she underwent emergent exploratory laparotomy with surgical resection of the
ileal segment containing the actively bleeding mass. Histopathologic staining was positive for receptor
tyrosine kinase (C-KIT) and DOG-1, consistent with GIST. Patient was initiated on imatinib therapy
and has remained symptom free.
DISCUSSION: Our novel case describes life-threatening GI bleeding from GIST in a patient with
NF-1. GISTs are 34 times more common in patients with NF-1. In NF-1 patients presenting with GI
bleeding, Small bowel GISTs should be considered as a differential and clinicians must have a low
threshold for obtaining abdominal imaging by CT, VCE or nuclear imaging in case endoscopy does
[2117] Figure 1. CT Abdomen with IV contrast : A lobulated endophytic avidly enhancing mass
is identified in the Ileum, which measures approximately 2.4 3 2.2 cm. This lesion demonstrates
brisk active arterial bleeding into the intestinal lumen.
[2117] Figure 2. CT abdomen with IV contrast: There is a round partially exophytic avidly
enhancing mass measuring approximately 1.6 3 1.5 cm in the 4th portion of the duodenum,
favored to represent a GIST. This lesion is without evidence of active bleeding on the current
exam.
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