Lumen-apposing metal stents (LAMSs) have been widely used for drainage of peripancreatic collections. A 71-year-old woman with a history of necrotizing pancreatitis who underwent LAMS placement 3 months ago for symptomatic pancreatic fluid collection presented with hematochezia and hemodynamic instability. Computed tomographic angiography of the abdomen showed concerns for stent erosion into the splenic artery. Esophagogastroduodenoscopy revealed a large pulsating nonbleeding vessel within the LAMS. She underwent a mesenteric angiogram, which showed splenic artery pseudoaneurysm, and coil embolization was performed. Gastrointestinal bleeding secondary to pseudoaneurysm should be considered in patients with recent LAMS placement who present with signs of gastrointestinal bleeding.

Introduction: Sarcina ventriculi is an anaerobic, gram-positive coccus that grows in acidic environments including the stomach. Case reports have implicated its role in causing gastric ulcers, emphysematous gastritis, and gastric perforation. There has been only one case report in the literature on S. ventriculi causing gastric mass lesion to our knowledge. Here we report a rare case of S. ventriculi infection causing a pyloric mass leading to gastric outlet obstruction (GOO). Case Description/Methods: A 65-year-old male with a past medical history of Barrett's esophagus and tobacco use presented to the emergency department with progressive worsening of abdominal pain, nausea, and vomiting. Esophagogastroduodenoscopy (EGD) performed locally showed a small pyloric channel ulcer with traversable pyloric narrowing. Gastric biopsies showed no significant pathology and were negative for H. pylori. Abdominal computed tomography showed circumferential nodular wall thickening of the pylorus and a dilated, fluid-filled stomach consistent with GOO (Figure 1A). No pneumatosis or perforation of the stomach was noted. EGD was repeated one month later at our institution due to worsening symptoms and revealed near complete obstruction of the pyloric channel by a protruding friable pyloric mass (Figure 1B). Biopsies of the mass revealed S.ventriculi organisms in the background of reactive gastropathy, with no evidence of malignancy (Figure 1C, D). A nasojejunal feeding tube was placed and the patient was treated with ciprofloxacin and metronidazole for 7 days along with pantoprazole twice daily. Repeat EGD performed two weeks later showed near complete resolution of the mass lesion. Discussion: S. ventriculi infections are associated with delayed gastric emptying. It is unclear if the infection is a result of the poor gastric emptying or the cause of it. In our case the patient presented with an obstructing pyloric mass due to reactive gastropathy in the setting of S. ventriculi infection, and repeat EGD after treatment with antibiotics and a proton pump inhibitor showed near complete healing of the mass and ulcer but persistent poor gastric emptying in the absence of obstruction. We report this case to expand on the paucity of literature regarding S. ventriculi gastrointestinal infections and to raise awareness of it presenting as a gastric mass lesion.[3661] Figure 1. A: Abdominal CT axial section showed circumferential nodular wall thickening of the pylorus (yellow arrows) and distended fluid-filled stomach. B: EGD showed circumferential, protruding, friable mass at the pylorus causing near obstruction of the pyloric channel. C: Low-power view (503) of the pyloric mass revealed polypoid reactive gastropathy with S. ventriculi organisms present on the mucosal surface. D: High-power view (3003) of the green frame area in (C) demonstrating S. ventriculi organisms with characteristic thick cell walls and arrangement in tetrads.

Introduction: Rituximab (RTX) is a common therapy for several autoimmune and lymphoproliferative diseases, including hematologic malignancies. Development of autoimmune enterocolitis secondary to RTX is a rare but known adverse effect. The exact mechanism of pathogenesis is not completely understood. Case Description/Methods: A 60-year-old woman with history of non-Hodgkin lymphoma in complete remission, on maintenance RTX therapy for 2.5 years, was referred to gastroenterology for 3 months of early satiety, abdominal pain, vomiting, constipation, and diarrhea. Symptoms occurred daily and were accompanied by 12 pounds of unintentional weight loss over this period. She had no preceding gastrointestinal disease. Colonoscopy revealed abnormal thickening of the ileocecal valve and linear ulceration in the terminal ileum (TI) that could not be traversed with the colonoscope. Colonoscopy was repeated 1 month later along with MRE, both redemonstrating inflammation of the TI. She was diagnosed with Crohn's disease based on endoscopic and radiographic findings, elevated fecal calprotectin, and symptoms. She was induced on budesonide therapy with good response, then transitioned to vedolizumab, with improvement in symptoms. Due to her atypical age of presentation, development of Crohn's disease was associated with her chronic RTX exposure. Discussion: There have been few documented cases of RTX induced Crohn's disease, with most involving elderly patients on maintenance RTX therapy. Although not completely understood, it is suggested that the CD201 lymphocytes, which are reduced by RTX, must play a role in the pro and anti-inflammatory equilibrium within the gastrointestinal mucosa. The depletion of B regulatory cells which secrete antiinflammatory interleukin-10 is likely of particular importance in promoting a pro-inflammatory state. This case highlights a rare adverse effect of RTX in a patient who otherwise did not have any clear risk factors for developing inflammatory bowel disease. It is important to be aware of the possibility of Crohn's disease in a patient presenting with classical symptoms such as diarrhea, abdominal pain, and weight loss when on RTX therapy.

We present a case of a 77-year-old Amish man who developed a contained, ruptured mycotic thoracic aortic aneurysm caused by salmonella bacteremia likely from consumption of unpasteurized milk. He was successfully treated with an aortic arch replacement and long-term antibiotics. CASE PRESENTATION:Our patient is a previously healthy 77-year-old Amish man who originally presented to Emergency Department (ED) with acute onset severe chest pain, intermittent rigors and myalgias. His initial work up was not suggestive of an acute bacterial process. There was high suspicion for acute coronary syndrome (ACS) due to his age and location of his pain, but ECG and cardiac enzymes did not show evidence of ischemia. Cardiology was consulted in the ED, who recommended that he stay overnight to undergo a stress test. The following day after a negative dobutamine stress echo, he developed encephalopathy, ataxia, and urinary incontinence, and was admitted to the hospital for further evaluation. He was found to have significant drop in hemoglobin and thus underwent CT imaging to evaluate for internal source of bleeding. Imaging revealed a contained, ruptured thoracic aortic aneurysm. It was also discovered that his admission blood cultures grew enterobacter species, which raised suspicion for mycotic aneurysm. Cardiac and Vascular surgery teams presented a harrowing clinical predicament: high risk of aortic rupture with delayed repair but also high risk of mortality with endovascular repair with bacteremia. The blood culture species was subsequently identified as Salmonella, making the consensus opinion of a mycotic aortic arch very likely. After shared decision making the plan was made to proceed with aortic arch replacement as endovascular options were felt to be suboptimal both in terms of anatomy and cure rate. The surgery team successfully debrided the infected aortic arch tissue and placed a Dacron graft. The patient had a relatively short and uneventful postoperative course. He was maintaining his saturations on room air and ambulating without difficulty by post-operative day two, and ultimately discharged home seven days after surgery.DISCUSSION: Infectious aortitis can present itself as localized thickening of the aortic wall to more serious complications such as aortic aneurysms with impending risk of rupture. If untreated, the complications are lethal. While salmonella infection and aortitis is a common association, the presentation is quite rare. In our patient, consumption of unpasteurized milk led to salmonella infection which ultimately resulted in bacterial seeding of a prior intimal injury or atherosclerotic plaque.CONCLUSIONS: Clinicians should maintain a high degree of suspicion of aortic aneurysm in patients with persistent chest pain despite negative ACS work-up. If mycotic aneurysm is suspected, therapy involves both antibiotics and surgery.