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7:00Pm Presenterss at Posters from 5:30Pm – 6:30Pm ENDOSCOPY/QI/EDUCATION 1 ESOPHAGEAL SQUAMOUS PAPILLOMA (WART) in TWO PEDIATRIC PATIENTS: an UNUSUAL LESION

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7:00Pm Presenterss at Posters from 5:30Pm – 6:30Pm ENDOSCOPY/QI/EDUCATION 1 ESOPHAGEAL SQUAMOUS PAPILLOMA (WART) in TWO PEDIATRIC PATIENTS: an UNUSUAL LESION Thursday, October 8, 2015 POSTER SESSION I Exhibit Hall 5:00pm – 7:00pm Presenterss at posters from 5:30pm – 6:30pm ENDOSCOPY/QI/EDUCATION 1 ESOPHAGEAL SQUAMOUS PAPILLOMA (WART) IN TWO PEDIATRIC PATIENTS: AN UNUSUAL LESION. A.R. Shahein, Pediatrics, K. Hovnanian Children's Hospital , Tinton Falls, New Jersey, UNITED STATES|T. Matulewicz, A. Soroush, Pathology, Jersey Shore Unversity Medical Center, Neptune City, New Jersey, UNITED STATES|. Case Summary: Esophageal squamous papilloma (ESP) is a rare benign lesion observed in pediatric and adult patients. Few case reports showed an association with gastroesophageal reflux disease (GERD) or human papilloma virus infection. The natural course of esophageal papilloma is not well described and according to current evidence, most patients are asymptomatic. We report two cases of ESP in adolescent patients. Case #1 is a 14 year-old female with history of long standing constipation, who was being evaluated for new onset diffuse abdominal pain, nausea, heartburn and loss of appetite. Patient had suboptimal response to proton pump inhibitors and interim weight loss, which prompted endoscopic evaluation. Upper endoscopy showed friable esophageal mucosa, 4 x 2 mm polypoid lesion in mid esophagus, gastric hyperemia and small hiatal hernia. Lesion was successfully removed with cold biopsy forceps. Histopathological examination of the lesion showed squamous cell hyperplasia suggesting a benign papilloma with negative in-situ hybridization testing for low and high-risk human papilloma virus in esophageal tissue. Distal and upper esophageal mucosa demonstrated basal cell hyperplasia suggesting acid reflux. Stomach biopsies visualized mild chronic inflammatory cell infiltration in the antrum with negative staining for H. Pylori. Case #2 is a 14 year-old male with history of multiple food allergy, GERD and indeterminate colitis managed with oral proton pump inhibitors (PPI) and Mesalamine. Patient was being evaluated for persistent acid reflux symptoms and new onset diffuse abdominal pain. Upper endoscopy exposed esophageal nodularity, furrowing and mild trachealization. A small 3 x 4 mm polypoid lesion was visualized in upper esophagus and successfully removed with cold biopsy forceps. Histopathological examination confirmed typical appearance of squamous papilloma with no eosinophil infiltration. Gastric mucosal microscopic appearance was suggestive of erosive gastritis with negative staining for H. Pylori. Conclusion: Squamous cell papilloma is defined as a small benign growth involving squamous cells found in the epidermis, the respiratory and digestive tract mucosa. Our patients who were found to have ESP suffered from GERD with failure of the oral proton pump inhibitor therapy to resolve their reflux related symptoms. Previous clinical reports described similar association, yet further studies including larger number of patients are required to better characterize this possible relationship. In contrast to laryngeal papillomatosis, the contribution of Human papilloma virus in solitary esophageal squamous papilloma is unclear. Endoscopists will do well being aware of this rare entity and should thoroughly assess the entire esophagus. 6 OCCULT MAGNET INGESTION PRESENTING AS MULTIPLE GASTROINTESTINAL FISTULAE IN AN OTHERWISE HEALTHY CHILD. A. Grover, V.L. Fox, M. Mobassaleh, Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, UNITED STATES|D. Jarrett, Radiology, Boston Children's Hospital, Boston, Massachusetts, UNITED STATES|T. Jaksic, Surgery, Boston Children's Hospital, Boston, Massachusetts, UNITED STATES|. A fistula is an abnormal communication between two epithelial lined surfaces; enteric fistulas are often the result of surgical intervention, trauma or other inflammatory injury. We present an unusual case of a 4-year-old girl with multiple enteric fistulae in the absence of prior surgery or clinical evidence of active inflammatory disease. CASE DESCRIPTION: A four year old previously healthy female presented for evaluation of intermittent abdominal pain, emesis and diarrhea of 4 month’s duration. At the onset, her symptoms consisted of severe abdominal pain and fever for 2 days. She also had multiple bouts of non-bloody, non-bilious, non-feculent emesis and watery stools for the course of 4 days. Thereafter, her symptoms resolved, but would return every 2 weeks and last for one day. In the interval periods, she was asymptomatic, tolerated a full diet and passed formed stool daily. Review of systems was unremarkable. The family history was negative for inflammatory bowel disease (IBD). PHYSICAL EXAM was normal. LABORATORY examination included normal thyroid function studies, celiac serology, hematological, and biochemical profiles. Her erythrocyte sedimentation rate and C-reactive protein level were mildly elevated. Plain abdominal radiography revealed a moderate stool burden. Given the chronicity of her symptoms and elevated inflammatory markers, endoscopy was performed to investigate possible IBD. Colonoscopy revealed 2 prominent, separate fistulae at the level of the transverse colon. The surrounding mucosa appeared normal. Traversing one fistula led to normal appearing small bowel. The second, smaller fistula could not be passed with the colonoscope. The remainder of the colon and the terminal ileum appeared normal. Biopsies confirmed normal tissue from the colon, terminal ileum, and small-bowel (obtained via the fistula). Esophagogastroduodenoscopy revealed a fistula from the body of the stomach to small bowel. The surrounding mucosa again appeared normal. Barium contrast studies of the upper GI tract, small bowel and colon revealed multiple enteroenteric fistulae. Upon further questioning, it was determined that the patient’s father owned multiple “Bucky Ball” neodymium magnets, and the patient had been found playing with these prior to the onset of her symptoms. Laparotomy confirmed the presence of a gastro-colonic, jejuno-colonic, and gastro-jejunal fistula, requiring limited small bowel resection. No inflammation was found in the resected bowel. The patient’s symptoms resolved completely after surgery. DISCUSSION: This case illustrates both the significant morbidity associated with accidental magnet ingestion and the potential for using such devices to create stable enteroenteric anastomoses. The application of high-power magnets to achieve desired gastrointestinal anastomoses is an active area of endoscopic and surgical research. 7 MASQUERADING MECKEL'S? GASTROINTESTINAL PECOMA CAUSING HEMATOCHEZIA IN 9 YEAR-OLD FEMALE. A. Srivastava, J. Thorn, Y. Zeng, B. Braunhut, A. Har, University of Arizona, Tucson, Arizona, UNITED STATES|. Background: Perivascular endothelial cell neoplasms (PEComas) are rare mesenchymal tumors that occur in variety of anatomic locations including abdominopelvic and retroperitoneal sites, visceral organs and soft tissues of extremities, skin and bones. Coined in 1996, PEComas are smooth muscle and melanocytic marker positive (smooth muscle actin, HMB45, Melan-A, MiTF) and are part of a family of tumors which include angiomyolipomas, lymphangioleiomyomatosis, clear cell “sugar” tumor of the lung, extrapulmonary clear cell “sugar” tumor, and clear cell myomelanocytic tumor. Most recent reviews estimate pediatric PEComa cases involving the GI tract to be under 20. Due to their relative rarity, no formal system currently exists regarding classification, associated prognostic factors, and treatment. Case: A 9 year old previously healthy female presented with 2 episodes of hematochezia. Her hemoglobin decreased from 12.7 (g/dL) to 9.5 in the first 35 hours then down to 6.9 in the following 24 hours. Presentation of massive painless rectal bleeding with currant jelly stools appeared classic for Meckel’s diverticulum and patient was taken to the OR without Meckel’s scan. Surgical evaluation did not note the presence of a diverticulum; appendix was removed per parents request. Patient hemoglobin continued downtrending post-operation and tagged red blood cell scan was performed, revealing physiologic distribution of tracer and no abnormal radiotracer pooling consistent with no active gastrointestinal bleeding. Decision was made for an esophagogastroduodenoscopy and colonoscopy; colonoscopy revealed a 2.5 cm multilobulated polyp at the hepatic flexure. Location of the polyp was tattooed endoscopically and later removed surgically. Histopathology was consistent with PEComa with no features of malignancy, confirmed from several independent histopathology labs. Although patient’s PEComa showed no features of malignancy the margins were not clear; a repeat colonoscopy was performed 6 months post-resection did not reveal recurrence of the lesion and her hemoglobin has since been stable. Conclusion: Although rare in presentation, diagnosis of gastrointestinal PEComa should be entertained in cases of hematochezia without an obvious source of bleeding. Patients with a negative Meckel’s scan or seemingly atypical presentation of a Meckel’s diverticulum may warrant additional workup. 10 SUCCESSFUL ENDOSCOPIC REMOVAL OF 12CM TOOTHBRUSH FROM DUODENUM. A. Lakhole, C. Lin, T. Grikscheit, Y. ZHENG, Pediatric gastroenterology, Children's Hospital Los Angeles, Los Angeles, California, UNITED STATES|. 16 year old female with medical history of bulimia and illicit drug use presented with abdominal discomfort and intermittent epigastric pain. 5 days prior to the presentation, the patient incidentally swallowed a toothbrush handle without
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