bluuebunny/crossref_metadata_2025 huggingface dataset:
1166 Female Authorship of Major Gastroenterology Society Guidelines and Technical Reviews
Authors: Bushyhead Daniel W. , Strate Lisa L.
Published: October 2019

INTRODUCTION:

Authorship in gastroenterology society guidelines and technical reviews may aid academic advancement. Challenges facing women in academic gastroenterology have gained recent attention, and there may be a disparity in authorship of these documents. The purpose of this study was to analyze the proportion of female authors of major gastroenterology society guidelines and technical reviews in comparison to males.

METHODS:

American Association for the Study of Liver Disease (AASLD), American College of Gastroenterology (ACG), and American Gastroenterological Association (AGA) guidelines and technical reviews were identified from online materials. Documents were included from 2007 to 2018. The sex of each author, and the total number of guideline authors were abstracted. The number of female authors was compared to the total number of authors. We also examined the proportion of guidelines and technical reviews with female first authors. The time period was broken into three equal periods: 2007-2010, 2011-2014 and 2015-2018. Data were analyzed with descriptive statistics using Excel (Version 16.23). The Cochrane-Armitage trend test was used to compare the proportion of female authors between time periods.

RESULTS:

Eighty-three guidelines and technical reviews from 2007 to 2018 were identified. A total of 425 authors were identified after combining author totals of each guideline and technical review while excluding duplicates. Eighty-eight (21%) of authors were women. The total percentage of guideline and technical review authors who were women varied according to each society and over time but remained persistently below that of men (see Figure 1). The proportion of female authors of AASLD guidelines increased from 21% in 2007-2010 to 34% in 2015-2018 (P = 0.042). Female authorship was stable across time for ACG guidelines (20%, 16%, 18%; P = 0.713). For AGA guideline and technical reviews, female authorship declined from 24% in 2011-2014 to 13% in 2015-2018 (P = 0.045). The majority of first authors of guidelines and technical reviews for each society were male (see Figure 2).

CONCLUSION:

There were significant disparities in female authorship of guidelines and technical reviews by the AASLD, ACG and AGA. There was a statistically significant increase in female authorship over the past ten years only for AASLD guidelines. Addressing disparities in guideline and technical review authorship may promote academic advancement for female gastroenterologists.
1173 Patients Taking Proton Pump Inhibitors Are More Likely to Respond to Endoscopic Dilation of Benign Duodenal Stenosis, Regardless of the Etiology
Authors: Chittajallu Vibhu , Simons-Linares Roberto , Bhatt Amit , Stevens Tyler , Vargo John , Chahal Prabhleen
Published: October 2019

INTRODUCTION:

Benign duodenal stenosis (BDS) is usually managed by endoscopic balloon dilation (EBD), but there is very limited literature on this practice outcomes. We sought to investigate the etiological spectrum, response to EBD and predictors for successful EBD.

METHODS:

We performed a cohort study of a prospectively maintained database of benign duodenal stenosis at a tertiary referral center between 2013 and 2018. Pyloric stenosis patients were excluded. All patients that underwent EBD were analyzed. Dilation was performed using through the scope balloons. Technical and clinical success of initial and repeat EBD were compared among the BDS etiologies, location within the duodenum, and number of stenotic tracts. Logistic regression models were performed using SAS software.

RESULTS:

A total of 276 patients were analyzed, of whom 87 patients underwent EBD for BDS. Most common etiology was peptic ulcer disease (PUD) 42 (45%) (Table 1). Upon initial EBD, technical success was 96.5% and clinical success was 74.4%. Upon repeat EBD, technical success was 98.1% and clinical success was 78.7%. When comparing PUD vs. All others, initial clinical success was 77.8% vs. 71.4% (P = 0.52), and on repeat EBD clinical success was 72.0% vs. 86.4% (P = 0.23). When comparing Crohn’s disease vs. All others, initial EBD clinical success was 72.2% vs. 75.0% (P = 0.81), and repeat EBD clinical success was 91.7% vs. 74.3% (P = 0.20). When comparing location of the stenosis in the 1st portion of the duodenum vs. distal duodenum, initial EBD clinical success was 70.0% vs. 82.1% (P = 0.24), and repeat EBD clinical success was 75.0% vs. 78.7% (P = 0.36). When comparing single vs. multiple strictures, initial EBD clinical success was 73.0% vs. 100.0% (P = 0.57), and repeat EBD clinical success was 77.3% vs. 100.0% (P = 0.99) (Table 2). 15 patients underwent planned/prophylactic EBD, but this did not impact the outcomes. Males were more likely to have distal duodenum stenosis when compared to females (63.6% vs. 36.4%, P = 0.007). African American had a lower likelihood of clinical success (aOR 0.083, P = 0.004), and usage of PPI increased likelihood of clinical success (aOR 3.65, P = 0.04) (Table 3).

CONCLUSION:

EBD has very high technical and clinical success rates in BDS. Males tend to have more distal duodenal involvement; African Americans ethnicity are less likely to respond to EBD and importantly, PPI usage was an independent predictor for EBD clinical success regardless of etiology.
1179 Characterization of the Bacterial Makeup and Quantitative Distribution in Patients With Suspected Small Intestine Bacterial Overgrowth (SIBO): A Meta-Analysis
Authors: Jones Mitchell L. , Lee Shaoying N. , Allan Nick , Singh Sharat , Wahl Chris , Chuang Emil , Kelly Colleen , Styli Jack
Published: October 2019

INTRODUCTION:

Small Intestinal Bacterial Overgrowth (SIBO) is associated with abnormally high bacterial counts in the small intestine and clinical features such as diarrhea, constipation, abdominal pain, distension and bloating. A meta-analysis of studies of endoscopic samples from patients with suspected SIBO was performed to estimate the distribution of bacterial colony forming units (CFU) and identify the bacterial populations in these patients.

METHODS:

A literature search was performed to find studies of the jejunum or duodenum culture aspirates from patients with suspected SIBO using keywords: SIBO (or SBBO), culture aspirate and CFU. A total of 10 studies met the inclusion criteria. The CFU distribution was estimated using a log-spline smoothing technique in the statistical package R. Top bacterial population identified in aspirates of these patients was reviewed.

RESULTS:

The studies used in the meta-analysis including the number and type of subjects, the region where the culture aspirate sample was taken, and the type of CFU data presented was summarized in Table 1. A histogram of the estimated CFU distribution using the first five papers with actual CFU counts was shown in Figure 1. The spike at zero showed that approximately 26% of patients had sterile cultures. Sensitivity analyses using the first seven papers and all ten papers yielded similar estimated distributions to Figure 1, particularly in terms of the proportion of subjects with CFU counts between 104 and 106. The proportion of subjects in the tails of the distributions (sterile samples or CFU counts >1010) had larger variations between the three fitted distributions presumably due to differences in counting methodologies. The top bacterial species cultured and identified from jejunal aspirates was summarized in Table 2.

CONCLUSION:

Using a standard diagnostic threshold >105 CFU, only 24% of patients with suspected SIBO would test positive; while lowering the threshold to >104 CFU increases the positive call rate to 33%. As expected, bacterial culture identification was unable to clearly distinguish a single contributing organism. Limitations to this work are substantial and include variability in sampling regions, contamination, difficulty culturing and counting bacteria, lack of standardization in procedures and reproducibility. Given these limitations, there is consensus that novel tools are needed for evaluating patients with suspected SIBO.
1197 Prevalence of Celiac Disease in Patients Presenting With Short Stature: A Systematic Review and Meta-Analysis
Authors: Singh Achintya D. , Singh Prashant , Farooqui Naba , Strand Tor , Ahuja Vineet , Makharia Govind
Published: October 2019

INTRODUCTION:

Short stature is a common extra-intestinal manifestation of celiac disease (CeD). The proportion of patients with short stature having CeD varies. We conducted a systematic review and meta-analysis to assess the prevalence of CeD in patients with presenting with short stature.

METHODS:

We searched Medline and EMBASE databases for the keywords 'celiac disease, coeliac disease, celiac, tissue transglutaminase antibody, anti-endomysial antibody, short stature and growth retardation'. All studies published from 1991 to February 2019 were included. Patients without any prior evaluation for short stature were classified as all-cause short stature, while previously evaluated patients, where no cause was found for short stature, were classified as having idiopathic short stature. Diagnosis of CeD was based on the European Society of Pediatric Gastroenterology, Hepatology and Nutrition guidelines. A random-effects model was used to pool the data. Risk of bias was assessed across each study using a validated tool developed for prevalence studies by Hoy et al (1).

RESULTS:

Seventeen studies including 3959 patients (1729 with all-cause short stature and 2230 with idiopathic short stature) were included. The pooled seroprevalence of CeD based on positive anti-tissue transglutaminase antibody, anti-endomysial antibody and antigliadin antibody was 11.5% (95% CI 2.34, 20.7; I2 = 47%) and 12.7% (95% CI 8.2, 17.3; I2 = 93.3%) for all-cause and idiopathic short stature (Figure 1), respectively. The pooled prevalence of biopsy-proven CeD was 7.2% (95% CI 4.44, 9.9; I2 = 77.7%) and 9.6 (95% CI 6.8,12.4) for all-cause (Figure 2) and idiopathic short stature (Figure 3), respectively. There was an overall moderate risk of selection bias and significant heterogeneity in the present studies. Statistical heterogeneity was partially due to differences in the diagnostic strategy (biopsy in seropositive individuals vs biopsy in all suspected patients), study design (retrospective vs prospective studies). Age, sample size did not influence the results on meta-regression analysis.

CONCLUSION:

Approximately 1 in 14 patients with all-cause short stature and 1 in 10 patients with idiopathic short stature have biopsy-confirmed CeD. Therefore, all patients with short stature should be evaluated for CeD.
1210 Implementation of Stress Ulcer Prophylaxis Appropriate Use Criteria in a Community Hospital
Authors: Beattie Michael , Pawlaczyk Barbara , Anderson Tara , Tauscher Samantha
Published: October 2019

INTRODUCTION:

Upper gastrointestinal stress ulcer formation is a potential risk for critically ill hospitalized patients. Due to this, SUP is an important preventative measure for at risk patients. Stress ulcer medications such as PPIs and H2 blockers do come with potential side effects.1,2 A widely accepted guideline was written by the American Society of Health System Pharmacists which along with similar variations continue to be used today.3,4 One such guideline has been implemented within the Ascension Health System (Figure 1). Despite guidelines, inappropriate administration continues to be a common problem. Studies show rates of inappropriate administration anywhere from 20 to 70 percent.5–9 A discrepancy in knowledge from providers leads to inappropriate prescribing of SUP medications. Administration of these laminated cards will improve appropriate administration of the medications.

METHODS:

Laminated cards were dispersed to fit on ID badges of IM and FP residents which following the Ascension SUP guidelines. Data was collected on all patients admitted under the core faculty of an IM or FP attending between 7/1/18–9/30/18 and 11/1/18–1/31/19. 10/1/19-10/31/19 constituted the run-in period. Patients were excluded if they had active diagnoses of GERD, PUD, H. Pylori. Eligible patients' charts were reviewed at random by using an online number generator. The A&P section of the H&P note was reviewed to determine if SUP was was appropriately administered, appropriately held, inappropriately administered, or inappropriately held. Any discrepancies were reviewed by the principal investigator. A t-test was performed to determine if statistical significance was achieved.

RESULTS:

There were 124 and 115 patients in the pre and post-intervention period respectively. There was an overall improvement of 5.64% (P = 0.21) after distribution of cards (Figure 1). Inappropriately given SUP use improved by 5.01% (P = 0.22). Inappropriately held SUP use improved by 0.61% (P = 0.78).

CONCLUSION:

Administration of cards improved appropriate prescribing. The cards provided a resource to aid in enhancing knowledge and on-the-go decision making. The availability of implementing these guidelines or similar such protocols using EMR may be more effective in reaching a wider audience of physicians and provide a consistent effect on prescribing habits.
1246 Patients With Eosinophilic Gastritis and/or Eosinophilic Gastroenteritis Endure a Lengthy Path to Diagnosis and Experience Persistent Symptoms After Diagnosis
Authors: Chehade Mirna , Gehman Lauren , Rasmussen Henrik S.
Published: October 2019

INTRODUCTION:

Eosinophilic gastritis (EG) and eosinophilic gastroenteritis (EGE) are chronic diseases characterized by elevated eosinophils in gastrointestinal (GI) tract biopsies. Patients with EG and/or EGE (EG/EGE) suffer from a decreased quality of life due to debilitating GI symptoms, a lengthy path to diagnosis, and lack of safe and effective treatment options. Here we utilize a large, highly representative claims database of ∼300 million US individuals to characterize the real-world diagnosis and management of adult patients with EG/EGE.

METHODS:

EG/EGE patients were identified by having ≥1 claim with a diagnosis code for EG and/or EGE (ICD-10-CM code K52.81) from Aug 2008 to Oct 2018 from Symphony Health's PatientSource® data. This analysis is focused on 3,458 unique adult patients (≥18 years) who had continuous claims data coverage for ≥3 years before and ≥1 year after EG/EGE diagnosis.

RESULTS:

Mean time from initial symptom presentation to EG/EGE diagnosis was 46.9 months; factors contributing to delayed diagnosis included delayed gastroenterologist referral, delayed endoscopy (Table 1), failure to diagnose on first endoscopy (39% of patients) and lack of routine biopsy/histopathology (65% of endoscopies). In the 12-month period following EG/EGE diagnosis, a majority of patients (56%) continued to experience GI symptoms, including abdominal pain, diarrhea and vomiting. Symptoms were documented by a healthcare provider at a mean frequency of 3.3 times per year. Overall, 32% of patients were treated with systemic corticosteroids (most commonly prednisone or prednisolone) and 6% received enteric-coated topical steroids (budesonide). Patients treated with systemic corticosteroids received a mean of 3.3 prescriptions per year, with the majority (59%) receiving more than one prescription per year. Persistence of GI symptoms was not related to treatment with systemic corticosteroids (Table 2).

CONCLUSION:

Patients with EG/EGE endure a lengthy path to diagnosis, and many continue to experience chronic, persistent GI symptoms after confirmed diagnosis despite frequent treatment with systemic corticosteroids. The lack of standard diagnostic processes and therapeutic options may prolong patient suffering due to uncontrolled symptoms. This study highlights the need for heightened disease awareness, standardized diagnostic criteria, and availability of safe and effective treatment options to improve the care of patients with EG/EGE.
1247 Development of a Patient Reported Outcome (PRO) Questionnaire to Assess the Symptoms of Eosinophilic Gastritis and Gastroenteritis (EG/EGE-SQ©)
Authors: Hirano Ikuo , Dellon Evan S. , Murray Joseph , Peterson Kathryn A. , Banderas Benjamin , Woolley J. Michael , Ollis Sarah , Foley Catherine , Love Emily , Shields Alan , Shaw Camilla , Rasmussen Henrik S.
Published: October 2019

INTRODUCTION:

Patients with eosinophilic gastritis and/or gastroenteritis (EG/EGE) experience significantly reduced health-related quality of life related to the symptoms and signs of their disease. There is a need to develop a PRO questionnaire for clinical research in EG/EGE. The objectives of this study were to develop a symptom questionnaire (drafted using literature and clinician input to determine preliminary measurement concepts) and then (1) identify, describe, and substantiate signs, symptoms, and impacts of EG/EGE from the perspective of adults with the condition via concept elicitation methods; and (2) evaluate the properties of the questionnaire and make modifications via cognitive debriefing methods.

METHODS:

Interviews were conducted, transcribed, coded, and analyzed. Eligible adults with EG/EGE first participated in a concept elicitation segment where they described their experiences with EG/EGE, continuing until saturation was achieved, adding symptoms to the draft symptom questionnaire as needed. This was followed by a cognitive debrief to assess the appropriateness of the draft symptom questionnaire, where patients assessed readability, comprehensibility, relevance, and comprehensiveness. The questionnaire was modified based on patient feedback, then re-evaluated to confirm its appropriateness.

RESULTS:

In total, 16 interviews were conducted and 24 signs and symptoms were reported during concept elicitation. The most frequently reported (Figure 1) were abdominal pain, nausea, diarrhea, vomiting, and abdominal cramping; while abdominal pain, nausea, and diarrhea were the most bothersome to patients. Saturation was achieved after 12 interviews. In the cognitive debriefing, revisions included the addition of a vomiting frequency item and revision of the early satiety item for clarity. Response options were modified to instruct the participants to assess each symptom “at its worst”. For the final version of the EG/EGE-SQ©, participants were able to read, comprehend, and provide appropriate responses, and reported that the resulting questionnaire was comprehensive for their condition.

CONCLUSION:

The results of this research support the content validity, including comprehensiveness and interpretability, of the EG/EGE-SQ© which offers the potential for use in clinical research to assess symptoms in patients with EG/EGE. Future research is needed to assess its psychometric properties including reliability and validity, responsiveness, and potential for use in pediatric populations.
1255 Chronic Peptic Ulcer Disease Resulting in Cholecystoduodenal Fistula
Authors: Dharmadhikari Neal D. , Roussel Breton , Piascik Daniel , Adrain Alyn L.
Published: October 2019

INTRODUCTION:

Cholecystoduodenal fistulas are rare communications between the gallbladder and duodenum. Though they are most often formed as a complication of cholelithiasis, duodenal ulcers are a less common etiology of bilioenteric fistulas. This case report shows this rare finding diagnosed with direct visualization by endoscopy.

CASE DESCRIPTION/METHODS:

A 75-year-old man with a medical history of atrial fibrillation, remote alcohol abuse, and diabetes presented with anemia. On presentation, his blood pressure was 92/45 and other vital signs were stable. A rectal examination revealed hematochezia and melena. His workup revealed a hemoglobin of 5.6 g/dl, BUN 64 mg/dl, and creatinine 3.76 mg/dl. He was appropriately resuscitated with blood transfusions. An endoscopy showed esophagitis and a non-bleeding cratered duodenal ulcer with pigmented material in the first part of the duodenum. This ulcer appeared to have several fistulous openings into another structure with bridges of tissue in between. A CT and an MRCP confirmed a duodenal ulcer with cholecystoduodenal fistula. He was treated conservatively with proton pump inhibitors (PPI) and had planned outpatient follow-up with surgery and gastroenterology.

DISCUSSION:

Endoscopy is the diagnostic gold standard for peptic ulcer disease (PUD) and is indicated in patients presenting with anemia and clinical evidence of gastrointestinal bleed. Cholecystoduodenal fistulas are an extremely rare complication of PUD. Unlike this case, most bilioenteric fistulas form as a consequence of gallbladder pathology, such as complications of cholecystitis or cholelithiasis, rather than PUD. Furthermore, this case is unusual in that bilioenteric fistulas are most often diagnosed by imaging rather than endoscopic visualization. This patient likely had chronic PUD that caused perforation and the eventual formation of the fistula. Uncomplicated cholecystoduodenal fistulas are often asymptomatic which can make them difficult to diagnose. Conservative management with PPIs is the preferred treatment for PUD-related bilioenteric fistulas and this patient was ultimately discharged on PPI therapy with outpatient follow up. This case highlights a unique endoscopic finding of a cholecystoduodenal fistula in a patient who presented without any complaints and found to have anemia and PUD. In addition, it supports PPIs as a conservative treatment for bilioenteric fistulas secondary to PUD.
1257 Pancreatic Pseudocyst-Portal Vein Fistula: A Rare Life-Threatening Complication of Pancreatitis
Authors: Ali Sara I. , Patel Jigar , Larson Scott
Published: October 2019

INTRODUCTION:

Pancreatitis is an acute inflammatory process that can results in activation of systemic inflammatory cascade. The pancreas is encased by vasculature which can be directly and indirectly affected. The aim of this case is to provide insight into a rare complication of pancreatitis.

CASE DESCRIPTION/METHODS:

35-year-old male with history of alcohol abuse presented to the emergency room with three days of severe epigastric pain. Denied symptoms of overt gastrointestinal bleeding. On admission, vital signs were temperature of 99.2°F, heart rate 115 beats/min, blood pressure of 120/72 mmHg. Initial laboratory evaluation demonstrated hemoglobin of 6.6 g/dL, lipase of 1,910 U/L, alanine transaminase 152 U/L and aspartate transaminase 167 U/L, alkaline phosphatase 681 U/L and direct hyperbilirubinemia 9.2 mg/dL. A computed tomography (CT) of the abdomen showed a large well-circumscribed cystic lesion with hypodense fluid in the peripancreatic C-loop with linear hyperdensity in the center, suggestive of a clot, and with direct communication to a dilated non-opacifying portal vein along with cavernous transformation. These findings were suggestive of a hemorrhagic pancreatic pseudocyst with fistulization of the main portal vein and portal vein thrombosis. The cystic lesion was compressing the common bile duct, measuring 1.1 cm, leading to hyperbilirubinemia. Portovenography did not show active opacification of the cystic lesion and, therefore, the cyst was percutaneously aspirated and 25 cc of light brown fluid removed. Fluid analysis revealed an amylase of 10,196 U/L. Given persistent hyperbilirubinemia, patient was taken for ERCP with biliary stent placement resulting in resolution of jaundice. His clinical course was further complicated by development of ascites and secondary peritonitis which was managed with antibiotics.

DISCUSSION:

Pancreatic pseudocyst with portal vein fistulization is an extremely rare complication of pancreatitis. The proposed mechanism of fistulization is believed to be due to high pancreatic enzyme contents of the pseudocyst eroding into adjacent structure. The release of digestive enzymes into a patent portal vein may directly cause intravascular thrombosis. Alternatively, it is hypothesized that fistulization usually occurs after portal vein thrombosis. No clear consensus exists on management with high mortality and morbidity secondary to hemorrhage, septic shock, and lipolysis. Our patient improved with conservative management of the pseudocyst with a decrease in cyst size.
1259 From Pancreatitis to Takotsubo: A Rare Complication of Acute Pancreatitis
Authors: Abe Temidayo , Ajose Taiwo , Chang Eric Y. , Atem Ngum Kikah , Abe Tolulope , Bilal Muhammad , Simien Melvin
Published: October 2019

INTRODUCTION:

Takotsubo cardiomyopathy or stress cardiomyopathy (TCM) is a transient reversible form of cardiomyopathy. It is characterized by reduced ejection fraction and signs of myocardial ischemia and often precipitated by acute emotional or physical stressors. We present a rare case of TCM in a postmenopausal woman triggered by acute alcoholic pancreatitis.

CASE DESCRIPTION/METHODS:

A 57-year-old female with a history of alcohol abuse and diabetes mellitus presented to the emergency department with a two-day history of severe diffuse abdominal pain with radiation to the back. Associated symptoms included nausea and vomiting. Vital signs were within normal limits. Physical examination was significant for a mildly tender abdomen. Laboratory findings revealed leukocytosis of 14.6 and lipase of 882. All other chemistry and complete blood count labs were within normal limits. CT abdomen without contrast revealed peripancreatic fat stranding suggestive of acute pancreatitis. The patient was admitted for IV fluid resuscitation and pain management. On day 2 of admission, the patient became dyspneic and desaturated to 82% on room air. Stat chest x-ray showed flash pulmonary edema. Bedside ultrasound revealed a dilated IVC. Troponin (0.97) and BNP (1627) levels were elevated, concerning for acute heart failure exacerbation. EKG revealed no acute ischemic changes. The patient was aggressively diuresised with significant improvement in respiratory status. Transthoracic echocardiography (TTE) revealed a left ventricular ejection fraction (LVEF) of 40% with basal segment hyperkinesis but apical akinesis consistent with stress-induced cardiomyopathy. Follow up coronary angiography revealed normal coronary vessels. The patient was started on guideline-based heart failure therapy and was discharged to home in stable condition. A repeat TTE obtained 4 months later revealed unchanged LVEF and persistent apical akinesis in the setting of persistent alcohol use. Guideline directed therapy was continued and the patient was counseled on alcohol cessation.

DISCUSSION:

Acute pancreatitis induced TCM is rare. Our case further confirms the heterogenicity of TCM, including non-classical stressors such as alcohol abuse which may delay myocardial recovery.
1279 Not Your Standard Food Impaction: An Unusual Presentation of Ampullary Obstruction
Authors: Malik Neena , Yang Julie
Published: October 2019

INTRODUCTION:

The following case highlights a rare cause of biliary duct obstruction from food impaction of a large duodenal diverticulum containing the ampulla.

CASE DESCRIPTION/METHODS:

A 74-year-old woman presented with abdominal pain. The patient reported acute onset of epigastric abdominal pain on the morning of presentation. Laboratory values were notable for an alkaline phosphatase of 807 U/L, an aspartate aminotransferase of 948 U/L, an alanine aminotransferase of 1245 U/L, and a total bilirubin of 3.7 mg/dL. CT abdomen and pelvis demonstrated marked intrahepatic and extrahepatic biliary ductal dilation with a common bile duct of 19 mm, as well as a 5 cm periduodenal cystic lesion containing a soft tissue density suggestive of a duodenal diverticulum, although the cystic lesion did not opacify with oral contrast despite the duodenal lumen containing contrast. An endoscopic retrograde cholangiopancreatography (ERCP) was performed. Once the duodenoscope was advanced into the duodenum, the ampulla was not identified, however a large diverticulum with impacted, solid food was seen. Multiple attempts were made to break the bezoar into smaller pieces with only partial success. The ampulla was thought to be entirely located within the diverticulum and was unable to be identified due to the obstructing bezoar, therefore, the ERCP was aborted. The patient underwent a repeat ERCP four days later. The food debris had partially cleared and the major papilla was seen on the rim of a large duodenal diverticulum. No biliary strictures or stones were seen and a plastic stent was successfully placed into the common bile duct.

DISCUSSION:

This case illustrates an uncommon presentation of a common medical problem. Approximately 75% of duodenal diverticula are located in the second portion of the duodenum and can be described as periampullary, if originating within 2 to 3 cm from the ampulla, or ampullary if containing the papilla. The true prevalence of periampullary or ampullary diverticula is not known, however, it is suggested that the prevalence ranges from 0.16 to 22%. Most duodenal diverticula are found incidentally on imaging or endoscopic examinations and are oftentimes asymptomatic, however complications can occur. Common complications include diverticulitis, hemorrhage, perforation, as well as obstruction, as seen above. This case demonstrates the possible, albeit rare, complications of duodenal diverticula and the need for awareness amongst gastroenterologists to avoid misdiagnosis and prompt treatment.
1298 Pancreatic Adenocarcinoma Presenting as Acute Large Bowel Obstruction
Authors: Abadier Michael J. , Abadier Andrew E. , Abadier Wahid J.
Published: October 2019

INTRODUCTION:

Acute large bowel obstruction is a rare presentation of pancreatic carcinoma with only 7 cases described in the literature. When located in the head of the pancreas, pancreatic adenocarcinoma commonly presents with abdominal pain, weight loss and jaundice. Pancreatic masses in the body and tail tend to have an insidious onset and may only present with vague abdominal pain. In the case described, a patient presenting with 2 weeks of constipation was found to have a large bowel obstruction in the setting of locally invasive pancreatic adenocarcinoma.

CASE DESCRIPTION/METHODS:

A 64-year-old woman with past medical history of chronic constipation presented to the emergency department with a chief complaint of constipation for 14 days. During these 14 days the patient had developed increasing abdominal distension as well as nausea, vomiting and abdominal pain. Vital signs were unremarkable except for a heart rate of 132. Physical examination was significant for an uncomfortable appearing woman with a diffusely tender and distended abdomen. Laboratory studies showed a leukocytosis of 16.2/uL. CT scan of the abdomen revealed findings suggestive of a primary colon carcinoma of the splenic flexure with upstream colonic obstruction and likely invasion of the pancreatic tail and spleen. General surgery and Gastroenterology were consulted who recommended colonoscopy for evaluation of the presumed mass at the splenic flexure, however, on the day following admission the patient's clinical status deteriorated. The patient was taken for emergent exploratory laparotomy at which time a markedly distended cecum and right colon were noted. The mass was found to involve the splenic flexure posteriorly as well as the tail of the pancreas and spleen. The patient underwent En Bloc resection of the splenic flexure, spleen and pancreatic tail. Pathology revealed moderately differentiated pancreatic ductal adenocarcinoma and the patient was started on FOLFIRINOX chemotherapy.

DISCUSSION:

There have been 3 cases resulting in large bowel obstruction due to local invasion and 4 cases causing obstruction in the setting of metastatic disease. In this case report, we describe an acute obstruction caused by local invasion of pancreatic tail adenocarcinoma. Usual suspects of large bowel obstruction include colorectal carcinoma, volvulus, adhesions, strictures from diverticulitis and hernias. We believe that although rare, once should consider pancreatic carcinoma as part of the differential for large bowel obstruction.
1313 B Cell Lymphoma Masquerading as a Pancreatic Mass With Pancreatitis
Authors: Cox Michael , Darwin Peter , Sood Asheesh , Ayre Rebecca
Published: October 2019

INTRODUCTION:

We present a case of a 42 year old female with Stage IV B cell lymphoma initially presenting with acute pancreatitis.

CASE DESCRIPTION/METHODS:

A 42 year old female presented to the ER with acute pancreatitis. Initial CT Imaging demonstrated a mass in the pancreatic head concerning for pancreatic adenocarcinoma and diffuse lymphadenopathy concerning for metastatic disease. EUS demonstrated peripancreatic lymphadenopathy with invasion into the pancreatic head. After initial treatment of the pancreatitis, diagnostic workup found non-Hodgkin's lymphoma obstructing the pancreatic duct. Despite her extensive tumor burden the patient had no symptoms prior to her presentation with acute pancreatitis. Her Ca19-9 was elevated, probably secondary to her recent acute pancreatitis. Her tumor responded to dose adjusted R-EPOCH (Rituximab, Etoposide, Prednisone, Oncovin, Cyclophosphamide, and Hydroxydaunorubicin).

DISCUSSION:

Non-Hodgkin's Lymphoma secondarily involving the pancreas initially presenting as acute pancreatitis is extremely rare. Only about 0.5% of all pancreatic tumors are lymphomas, and although 50% of patients with non-Hodgkin's lymphoma present with extranodal disease, pancreatic involvement represents only about 0.2% to 2% of cases. Primary pancreatic lymphomas are extremely rare but more often present with acute pancreatitis than secondary pancreatic non-Hodgkin's lymphomas. To our knowledge, there are less than 15 reported cases of non-hodgkin's lymphoma with secondary involvement of the pancreas presenting as acute pancreatitis. This case demonstrates the need to keep the differential diagnosis broad in the evaluation of pancreatic masses causing pancreatitis even in what seems to be a straightforward case.
1319 The Elephant in the Room: A Rare Cause of Gastric Outlet Obstruction
Authors: Murthi Mukunthan , Murali Rangan
Published: October 2019

INTRODUCTION:

Gastric outlet obstruction (GOO) is characterized by the inability of the gastric contents to pass beyond the proximal part of duodenum. We describe an unusual case of GOO caused by compression of the duodenum by gall bladder hydrops (also called gallbladder mucocele). This is only the fourth such case reported in literature.

CASE DESCRIPTION/METHODS:

The patient is a 59-year-old healthy Caucasian male who presented to the ER with complaints of persistent nausea and non-bilious vomiting for 2 weeks. He also had mild but persistent abdominal pain for the same duration and retrosternal burning pain for over 1 week. The patient had no previous medical or surgical history except for chronic gastroesophageal reflux disease treated with Prilosec. On physical examination, the patient had right upper quadrant tenderness with positive Murphy's sign. His routine lab workup revealed a high WBC count. Other lab values were normal. He underwent ultrasonogram which showed a distended gallbladder measuring 10 cm. CT scan revealed the enlarged gallbladder appearing to compress the duodenum. His upper gastrointestinal endoscopy showed LA grade C erosive esophagitis and a normal looking second portion of duodenum. He subsequently underwent laparoscopic cholecystectomy. The surgery specimen showed distended gallbladder measuring 12 cm in length with thinning of the walls and a 1 cm stone in the body. He had complete resolution of his symptoms after surgery and remained asymptomatic during his follow-up two weeks later.

DISCUSSION:

Gall bladder mucocele is most commonly due to prolonged obstruction of the cystic duct by gallstones. Acalculous cholecystitis can also lead to mucocele formation. Long-standing gallbladder outlet obstruction can lead to the collection of bile. Resorption of bile salts by gall bladder mucosa occurs over time, resulting in accumulation of clear watery and mucoid residue. Ultrasonography is extremely sensitive for diagnosis. The standard treatment is laparoscopic cholecystectomy, with open cholecystectomy an alternate in large-sized gallbladders. In poor surgical candidates, percutaneous drainage of the gallbladder may be considered. Among the three previously reported cases where the distended gallbladder caused GOO, one was treated with percutaneous biliary drainage as the patient was unfit for surgery and one other case was treated with laparoscopic cholecystectomy. The third case was treated initially with medical therapy leading to resolution of symptoms followed by cholecystectomy.
1321 A Choledochodoudenal Fistula Without Gallstones: A Case Report
Authors: Patel Reema , Abidian Mohamed Modar , Mehta Ripple , Patel Mitesh R.
Published: October 2019

INTRODUCTION:

Choledochoduodenal fistulas (CDFs) are abnormal connections that form between the common bile duct and the duodenum. CDFs are rare and result from biliary tract diseases like biliary tract stones and/or infections, peptic ulcer disease, Crohn's disease and surgery. They are more common in elderly patients. CDFs may present with cholangitis-like symptoms and the diagnosis is confirmed with endoscopic retrograde cholangiopancreatography (ERCP). Treatment include therapeutic ERCP or surgery.

CASE DESCRIPTION/METHODS:

Our patient was a 31 year-old Hispanic female who immigrated recently from El Salvador. The patient presented with symptoms of right upper quadrant pain along with nausea/vomiting and low grade fever. Initial laboratories results were remarkable for white blood cell count (WBC) 14.3 × 109 L, acetate aminotransferase (AST) 493 U/L, alanine aminotransferase (ALT) 438 U/L, total bilirubin 2.4 mg/dl, direct bilirubin 0.56 mg/dl, and Alkaline phosphatase 192 U/L. Abdominal ultrasonography showed non-specific gallbladder wall thickening with dilation of the intrahepatic and extrahepatic bile duct (common bile duct diameter of 1.2 cm), and no gallbladder stones (Figure 1). The patient was admitted to the floor and started on broad-spectrum intravenous antibiotics. An urgent ERCP demonstrated a 3 mm choledochoduodenal fistula seen superior to the major papilla. The fistula was draining purulent materials (Figure 2). The common bile duct (CBD) was dilated to 12 mm with no filling defects (Figure 3). The biliary tree was drained and no stones were found (Figure 3). To ensure adequate biliary drainage, a 10 Fr × 5 cm plastic stent was placed into the CBD (Figure 3). Soon, patient clinical and laboratory profile dramatically improved and was discharged two days later with plan for outpatient follow-up.

DISCUSSION:

We are reporting a unique case of CDF that developed spontaneously in a patient who has no significant past medical history. No underlying pathology like biliary tract stones was found during the ERCP. This case may raise a question that CDFs could be sometimes idiopathic with no predisposing factors. Spontaneous CDFs are uncommon especially in young population. Only few cases in young patients had been reported in literature. The youngest patient reported in literature was a 6-year-old female who had an unusual case of recurrent cholangitis due to CDF.
1322 A Known Complication With a Delayed Presentation: A Rare Case of Biloma Formation Post-Cholecystectomy
Authors: Bergagnini Isabella , Alexandre Cassidy , Okeke Francis , Zlatanic Jusuf
Published: October 2019

INTRODUCTION:

Biloma is an uncommon complication post cholecystectomy with a reported incidence of approximately 0.3-1.5%. While biloma formation is typically seen within weeks of surgery, there are very few documented cases of biloma formation seen years after an uncomplicated cholecystectomy, as seen in the case below.

CASE DESCRIPTION/METHODS:

A 35-year-old female with a medical history of cholelithiasis requiring cholecystectomy eight years prior presented with worsening dull right upper quadrant pain with early satiety and abdominal distention for two months. Vitals were stable with her exam notable for a palpable abdominal mass. Labs revealed a mild transaminitis. MRI demonstrated dilated bile ducts and a large 16.1 cm cystic lesion in the gallbladder fossa consistent with a biloma. 1.5 liters of proteinaceous material was drained by interventional radiology. Cultures and cytology were negative for an infectious or malignant process. HIDA scan revealed a bile leak for which she underwent an ERCP where two biliary stents were placed for a segmental duct leak. The patient clinically improved and was discharged home on antibiotics. Two outpatient ERCPs were performed, the first revealing a persistent small leak requiring stent exchange and the subsequent ERCP three months later demonstrating complete closure of the leak.

DISCUSSION:

A biloma is a demarcated collection localized outside the biliary tree often secondary to iatrogenic, traumatic and even spontaneous injury to the biliary tree. With the introduction of laparoscopic cholecystectomy, incidence of biliary injury has increased from 0.1% to about 0.3-1.5%. The pathophysiology is often secondary to either a leakage of bile from an improper closure of a cystic duct stump, transection of an accessory bile duct or duct of Luschka, or rarely from inadvertent injury of the segmental ducts. Presentation varies and can manifest with abdominal pain, nausea, fever and if large enough can result in obstructive jaundice. Diagnosis is typically 1-2 weeks post-surgery with few cases reported years post-op as seen here. Management is dependent on the size of the biloma and leak. Large bilomas often require percutaneous catheter drainage combined with ERCP with sphincterotomy and biliary stenting whereas small bilomas are treated conservatively. If refractory to endoscopic intervention, surgery may be warranted. We present this case to raise awareness of this uncommon, pathologic entity to help facilitate prompt diagnosis and treatment to avoid poor outcomes.
1338 A Rare Case of Duodenal Windsock Diverticulum; Simultaneous Biliary, and Small Bowel Obstruction
Authors: Bashir Muhammad H. , Gonzalez Lilly , Lescaille Yaniuska , Gallagher Bridget , Cheung Derrick
Published: October 2019

INTRODUCTION:

Windsock intraluminal duodenal diverticulum (IDD) is rare congenital anomaly due to incomplete recanalization of foregut during embryogenesis. Most of the IDD are found incidentally and rarely cause symptoms. More common symptoms associated with IDD are nausea, abdominal pain and abdominal fullness. Rarely IDD can cause small bowel obstruction (SBO), pancreatitis and biliary obstruction.

CASE DESCRIPTION/METHODS:

This is the first reported case in literature of a windsock diverticulum causing SBO and biliary obstruction. A 44 year old man with no prior medical and surgical history presented to our hospital with acute onset abdominal pain, nausea, vomiting and inability to pass flatus or bowel movement for 3 days. Patient was clinically jaundiced and initial lab work up showed a total bilirubin level of 13.0 mg/dl. A CT abdomen and pelvis showed complete duodenal obstruction with suspected etiology of duodenal intussusception as well intra and extrahepatic biliary ductal dilatation (Figure 1). After NG decompression, patient underwent an upper endoscopy and small bowel enteroscopy with findings of a false lumen in second portion of duodenum showing focal areas of mucosal ulcerations but no intussusception was seen (Figure 2). An EUS was performed which did not show any intramural or extraluminal mass lesions. An ERCP was attempted for biliary obstruction but was unsuccessful due to lack of localization of ampulla of vater. Later during the endoscopic procedure, large amount of fresh bile flow was noted in the distal portion of duodenum. False lumen mucosal biopsies were reported negative for malignant cells. Patient's bilirubin level quickly and persistently trended down toward normal range post EGD. Clinically, his symptoms of bowel obstruction resolved completely. He underwent an upper GI series which showed contrast filling of large duodenal diverticulum which further confirmed the diagnosis of large windsock duodenal diverticulum (Figure 3).

DISCUSSION:

Windsock diverticulum is a true intraluminal diverticulum. In rare cases it can cause serious complications including SBO and biliary obstruction. ERCP can be challenging in case of ampullary proximity to diverticulum. Timely recognition and intervention is necessary for improved clinical outcomes. Endoscopic intervention for diagnosis and management is necessary. Endoscopic diverticulectomy can be a less invasive option for prevention of recurrence of IDD related complications especially especially in case of close proximity of ampulla to IDD.
1340 Variable Effect on the Sphincter of Oddi From Narcotics
Authors: Salas Noain Jesus M. , Gudipally Sindusha , Zheng Shengnan , Minupuri Arun , Amaral Rafael , Kinachtchouk Oleg
Published: October 2019

INTRODUCTION:

Several studies have shown an increase in biliary pressure after administration of narcotics. Direct sphincter of Oddi (SO) manometry has demonstrated that the sphincter of Oddi is particularly sensitive to all narcotics including morphine, meperidine, pentazocine, fentanyl, and codeine. Opiates are known to increase the phasic wave (via mu receptors) as well as basal pressure (via non-mu receptors) of the SO. This case report illustrates a possible difference in affinity among narcotics to these receptors leading to SO dysfunction.

CASE DESCRIPTION/METHODS:

54 years old male with a history of knee meniscal repair presented to the emergency department with epigastric pain associated with nausea and vomiting for one day. The patient described the pain as severe, sharp, and worsening with food intake. He denied alcohol use, illicit drug abuse, or taking any medication. He had a lipase of 200 U/L, with normal transaminases and bilirubin. Physical exam revealed severe tenderness on the epigastric area. CT showed acute edematous interstitial pancreatitis. Ultrasound of the liver and HIDA scan demonstrated a patent cystic and common bile duct. The patient was started on IV fluids and IV morphine. The patient reported slight relief of abdominal pain with low doses of IV morphine. Therefore, the frequency and dose of morphine were increased. Interestingly, the patient reported acute worsening of the epigastric pain a few minutes after administration of higher morphine doses lasting for approximately 2 hours. Laboratory studies drawn during pain exacerbation showed no elevation of transaminases or lipase. IV morphine was discontinued resulting in immediate abdominal pain relief. Upon further questioning, the patient reported recent use of oxycodone and tramadol for knee pain without any side effects from these medications.

DISCUSSION:

Opiates have been reported to incite biliary colic pain and their effect on the SO represents the most likely etiology. Our patient showed a particular susceptibility to morphine, but not to other narcotics previously prescribed suggesting a possible variable effect on the OD from different narcotics. It is worth noting that our patient denied cholecystectomy, a known risk factor that predisposes to SO dysfunction. In conclusion, SO dysfunction should be considered in patients with pancreatitis reporting worsening of abdominal pain while on opioids. SO manometry is contraindicated during acute pancreatitis, therefore discontinuation of the narcotic helps guide diagnosis.