bluuebunny/crossref_metadata_2025 huggingface dataset:
2480 Nivolumab-Induced Hepatitis and Vesiculopustular Skin Rash in a Patient With Metastatic Melanoma
Authors: Khan Abdul Moiz , Naseer Usman , Shahzad Sheikh Raza , Wazir Ali , Rahman Haider , Mehdi Syed
Published: October 2019

INTRODUCTION:

The advent of immunotherapy has been hailed as a breakthrough in cancer treatment. However, it comes with a multitude of immune mediated adverse effects. Gastrointestinal adverse effects include hepatitis and colitis. Immunotherapy related hepatitis can range from asymptomatic elevation of liver enzymes (grade 1) to decompensated liver failure (grade 4).

CASE DESCRIPTION/METHODS:

82 years old male with stage IIC Malignant Melanoma of right posterior diagnosed in 2014, treated with wide excision. In December 2016, PET scan revealed right chest wall lesion, treated with re-excision. c-kit and BRAF were negative. In June 2017, PET scan showed metastatic disease involving lung, pancreas, gluteus maximus and left flank. The patient was started on Nivolumab. After 7 cycles, the PET scan became negative for any metastatic lesions. After 8 cycles, he had a severe morbilliform, vesiculopustular rash secondary to Nivolumab. Skin Biopsy showed a lymphocytic infiltrate with scattered eosinophils and numerous neutrophils. High dose prednisone was started with tapering for 3 months. Nivolumab was temporarily held and resumed after a good response to steroids. After 14 cycles, the patient developed malaise, fatigue, nausea and mild abdominal pain. ALT was 393, AST 302, ALK 164. Bilirubin was 1.1. Hepatitis A, B, and C testing were negative, anti-liver kidney microsomal antibody and anti-mitochondrial antibody was negative, acetaminophen level was normal, CT and Ultrasound of the liver were negative for metastatic lesions or other hepatic pathology. No recent change in medication or alcohol use was reported. As per ASCO guidelines, hepatitis was classified as Grade III (ALT and AST >5-20 times the upper limit of normal). The patient was started on 100 mg prednisone daily with tapering for 2 months. Liver enzymes normalized and symptoms resolved. Nivolumab was discontinued. PET scan 6 months from the last cycle showed disease in remission.

DISCUSSION:

Treatment of immunotherapy induced hepatitis depends on severity. Immunotherapy can be continued in grade 1, temporarily held in grade 2, and permanently discontinued in grade 3 and 4 as per guidelines. High dose steroids (prednisone 1-2 mg/kg) with tapering serve as the mainstay of treatment. Mycophenolate or azathioprine can be considered in refractory cases. However, it needs further research whether immunotherapy can be re-trialed in patients with grade 3 toxicity, who have responded well to the steroids, and would potentially benefit from a repeat trial.
2482 Scrotal Gallstones: A Not-So-Silent Gallbladder Perforation With Streptococcus sanguinis Peritonitis
Authors: Shenoy Abhishek , Stratton Leland , Buerlein Ross C. , Henry Zachary
Published: October 2019

INTRODUCTION:

Gallbladder perforation (GBP) is rare and potentially life-threatening. Diagnosis is difficult, and high index of suspicion should be maintained for a patient presenting with cholecystitis. Prompt operative consideration for GBP is recommended. Gallstone disease is more common in patients with cirrhosis, though risk of morbidity and mortality with surgery is often high. We present a case of GBP complicated by peritonitis to illustrate the complexity of managing this condition in a patient with comorbid cirrhosis.

CASE DESCRIPTION/METHODS:

A 58 year-old man with alcohol-related cirrhosis (Child Pugh C) presented with fatigue, abdominal pain 2 weeks after a large volume paracentesis (LVP), LLQ approach with US. He was afebrile with a distended abdomen, jaundice, and lower quadrant tenderness. Ascitic fluid analysis showed 27 k/μL WBC with 90% neutrophils, initially concerning for peritonitis secondary to bowel perforation from the recent LVP. CT imaging was consistent with gallstones in the pelvic ascites fluid, and a large left hydrocele with stones in the scrotal sac (Figures 1–3). Diagnosis was presumed peritonitis secondary to GBP, though ultrasound and HIDA scan were negative for a gallbladder wall defect or active bile leak. Peritoneal fluid cultures grew Streptococcus sanguinis, and the patient improved with IV antibiotics. Repeat LVP and fluid analysis showed reduced WBC count. Cholecystectomy and peritoneal washout were deferred due to surgical risksin the setting of decompensated cirrhosis. Unfortunately, he developed mixed septic/hemorrhagic shock from a duodenal ulcer bleed and expired shortly thereafter.

DISCUSSION:

This case exemplifies the complexity in diagnosing and managing GBP in a patient with decompensated cirrhosis. Were it not for his high peritoneal fluid WBC and recent LVP prior to admission, it would be reasonable to suspect spontaneous bacterial peritonitis, CT imaging would be deferred and his GBP unrecognized. Therefore, maintaining high suspicion for GBP in a cirrhotic patient with severe peritonitis or concern for cholecystitis is recommended to avoid complications of GBP. This case also highlights the difficulty in treating GBP, or any symptomatic gallstone disease, in a decompensated cirrhotic where surgery is high risk. This patient's initial stability and decompensated cirrhosis led to deferral of operative consideration, leaving his peritoneal stones as a nidus for infection. His GI bleed was felt to be unrelated, but his septic shock expedited his decompensation.
2483 Amoxicillin-Induced Eosinophilia in Portal Tracts—A Rare Case of Idiosyncratic Acute Cholestatic Hepatitis
Authors: Bhardwaj Gaurav , Haider Tehseen , Timsar Ali Kazerouni , Tow Clara
Published: October 2019

INTRODUCTION:

Drug induced liver injury (DILI) accounts for approximately 10 percent of all cases of acute hepatitis. Amoxicillin/clavulanic acid induced liver injury is a well-recognized complication but amoxicillin alone has rarely been linked with clinically significant idiosyncratic liver injury. It is exceedingly uncommon to see eosinophilic penetration of portal tracts with amoxicillin induced liver injury.

CASE DESCRIPTION/METHODS:

A 21 year old obese woman presented with jaundice preceded by fever and right upper quadrant abdominal pain for 1 week. She had completed a 10 day course of amoxicillin for an ear infection 3 weeks back. She denied any alcohol, acetaminophen, herbal medications, recent travels or exposure to sick contacts. She had scleral icterus and tender hepatomegaly with no rash on exam. Serum AST, ALT and ALP were moderately elevated with peaks of 216 U/L, 296 U/L and 466 U/L respectively. Serum bilirubin peaked at 13.1 mg/dL with direct component of 9.7 mg/dL. Blood differential count was significant for elevated eosinophils 0.8 k/uL (range 0.1-0.3 k/uL). Work up was negative for viral and autoimmune hepatitis. The levels of ceruloplasmin, alpha-1-antitrypsin and immunoglobulins were normal. Ultrasound and MRCP showed an enlarged fatty liver with no evidence of biliary ductal dilatation. Liver biopsy showed expanded portal tracts with marked inflammatory infiltrate composed predominantly of neutrophils with many eosinophils, and scattered lymphocytes and plasma cells. There was hepatocellular and canalicular cholestasis with no bile ductular reaction.

DISCUSSION:

The incidence of DILI with amoxicillin alone is 0.3 per 10,000 prescriptions compared to 1.7 per 10,000 prescriptions with amoxicillin/clavulanic acid. Risk factors are older age, female sex, pregnancy, high BMI and excessive alcohol intake. Signs and symptoms begin within 6 weeks of initiating amoxicillin, including nausea, abdominal pain, jaundice, fever, pale stools, dark urine, and pruritus. The mechanism of amoxicillin hepatotoxicity is unknown with possibility of idiosyncratic immune allergic reaction. Histologically liver injury appears most often as a cholestatic hepatitis and may have associated bile duct injury manifesting as extensive infiltration of the biliary epithelium with inflammatory cells accompanied by nuclear irregularity, cytoplasmic vacuolization and eosinophilia of the biliary epithelium. The primary treatment is the withdrawal of the drug.
2488 Severe Dengue Fever With Impending Liver Failure in Thalassemic Patient With Pregnancy: A Diagnostic Challenge
Authors: Rattanachaisit Pakkapon , Komolmit Piyawat
Published: October 2019

INTRODUCTION:

Dengue infection is a leading fatal arthropod-borne disease in the tropics. Gastrointestinal presentation of dengue fever (DF) includes abdominal pain, vomiting, jaundice, hepatomegaly and liver failure. The presentation in a patient with thalassemia, during pregnancy poses a clinical challenge in differential diagnosis between the severe form of dengue infection and a complication of pregnancy, HELLP syndrome.

CASE DESCRIPTION/METHODS:

A 36 years old female with thalassemia during 34 weeks of pregnancy was admitted due to fever with chills. She later developed dyspnea and uterine contraction on the third day of fever. The physical examination revealed body temperature of 39°C, marked pale conjunctiva, mild icteric sclera and mild hepatosplenomegaly. The initial investigation showed white blood cell count of 34020 × 106/L with lymphocytic predominance, hemoglobin of 9.8 g/dL, platelet count of 62000 × 106/L and INR 2.09. Liver function test revealed total bilirubin 4.4 mg/dL, direct bilirubin 3.4 mg/dL, aspartate aminotransferase (AST) 813 IU/L, alanine aminotransferase (ALT) 350 IU/L, and alkaline phosphatase (ALP) 180 IU/L. She underwent cesarean section due to fetal distress with the diagnosis of HELLP syndrome. After the operation, her fever persisted. The follow-up blood tests showed leukocytosis, worsening thrombocytopenia and high level of transaminase enzymes (AST 3285 IU/L and ALT 1279 IU/L). The following investigation showed hemolytic anemia and coagulopathy. No evidence of microangiopathic hemolysis was detected. The dengue NS1 antigen was positive. She was treated with intensive fluids replacement and intravenous N-acetyl cysteine. Her fever lasted for five days and abnormal blood tests become normal within 2 weeks.

DISCUSSION:

Concurrent DF in a pregnant woman with thalassemia poses difficulty in the diagnosis and might lead to a poor prognosis. Severe dengue infection can cause liver injury with severe thrombocytopenia and hemolytic crisis in thalassemic patients mimicking those occurs in HELLP syndrome. The clinical clues for diagnosis of DF in this situation include fever, thrombocytopenia and acute non-microangiopathic hemolytic anemia. However, awareness of the disease during an outbreak, especially in a rainy season, is probably the most important clue for an early diagnosis. Intensive fluids and hemodynamic management is the key for dengue treatment. Evidence of therapeutic role of N-acetyl cysteine or other liver support systems in DF with liver failure are limited.
2496 Management of Recurrent Ectopic Variceal Bleeding in Ileal Conduit With TIPS
Authors: Chittajallu Vibhu , Romero-Marrero Carlos
Published: October 2019

INTRODUCTION:

The simplest classification of portosystemic collateral veins classifies all non-esophagogastric varices as ectopic varices. Ileal varices are an example of ectopic varices formed from the ileal veins (tributaries of SMV) and draining into the mesenteric vessels. We present a case of an ileal conduit complicated by recurrent ectopic variceal bleeding amenable to a transjugular intrahepatic portosystemic shunt (TIPS) procedure.

CASE DESCRIPTION/METHODS:

A 45 year-old male with Hepatitis C and alcohol related cirrhosis complicated by portal hypertensive gastropathy and non-bleeding esophageal varices (EV) presented with a one month history of recurrent hematuria via his ileal conduit. He had a history of colon cancer stage IIB status post cystoprostatectomy and sigmoidectomy with ileal conduit in 2013. He had required three hospitalizations for his recurrent bleeding, needing multiple blood transfusions. Previous workup included a CT abdominal angiogram showing porto-systemic collaterals without active extravasation of contrast, an ileal conduit loopogram showing good functionality, and an ileal conduit endoscopy showing no visible ileal varices or active bleeding. On admission to our institution, he was hemodynamically stable and did not required additional blood transfusions. An abdominopelvic CT scan showed a normal ileal loop conduit and again small mesenteric portosystemic collaterals were evident. There was a high suspicion for ectopic varices in the ileal conduit, and a TIPS procedure was performed. A pre-TIPS portogram showed the presence of large ectopic ileal varices filled with contrast with resolution after TIPS placement. TIPS was successful with decrease of hepatic venous pressure gradient from 18 mmHg to 9 mmHg. He was discharged after TIPS procedure and has not required repeat hospitalization for hematuria.

DISCUSSION:

Ectopic varices account for up to 5% of variceal hemorrhage, and there is no consensus for therapeutic management. This patient had ileal conduit varices causing recurrent clinically significant hematuria. TIPS placement successfully controlled his recurrent ectopic variceal hemorrhage.
2497 Hydatid Cyst Masquerading as Appendicitis
Authors: Kumar Anila , Gollapudi Lakshmi Asritha , Lee Kyu-In , Newman Rebecca
Published: October 2019

INTRODUCTION:

Human echinococcosis (HE) is a zoonosis and can cause life-threatening tissue cysts in the liver. We present a case of an unusual presentation of hepatic echinococcosis diagnosed and treated in the United States (US).

CASE DESCRIPTION/METHODS:

A 23-year-old woman who emigrated from Ecuador to the United States presents to the ED with headaches, fevers and abdominal pain associated with vomiting and rigors. She denied sick contacts and recent travel. She noted 4-5 similar episodes in the past that self-resolved. Her vitals were significant for a fever of 102.3°F and heart rate in 120s. Her labs were significant for a WBC 14.8 k/mm3 but the comprehensive metabolic panel was within normal limits. Exam revealed a supple neck and right lower quadrant tenderness. Due for concerns of appendicitis, she got a CT A/P C+, which was significant for a 4.2 × 2.6 cm and 1.3 cm low-density lesion in the right hepatic lobe. She was started empirically on flagyl and ciprofloxacin and discharged the next day. An outpatient MRI confirmed a cystic neoplasm in segment 5 of the liver with septation. Serum workup included a negative echinococcus antibody and she was referred to a surgical oncologist. She underwent liver segment 4 and 5-6 tumor resections without any complications. Pathology revealed calcified echinococcal cysts with extensive necrosis and abscess formation suggestive of microscopic areas of rupture. She was started on albendazole and is doing well.

DISCUSSION:

Echinococcosis is a zoonotic disease, with a two-host lifecycle and occurs in humans when Echinococcus eggs infect the liver (70%) and lungs (20%). After ingestion of eggs, the embryos escape and penetrate the intestinal mucosa, enter the portal circulation and then are trapped in the liver. Human cystic echinococcosis (CE) is the most common type of HE. The greatest prevalence of HE is in temperate areas such as parts of South America, North Africa, Asia and Australia. Diagnosis is made on imaging by US, CT and MRI. Treatment includes surgical resection, percutaneous drainage and anti-parasitic agents. Although the vast majority of cases occur outside the US, cases within the US exist and are incidentally found. Despite progress in controlling echinococossis, this condition remains a public health problem in endemic countries and a cause of morbidity and mortality. It should be included on the differential of a patient from an endemic area found to have cystic lesions on liver.
2503 Cholestasis in a Patient With HNF-1B Mutation
Authors: Conner Michael , Baddour Nabil , Regenstein Fredric
Published: October 2019

INTRODUCTION:

Maturity Onset Diabetes of the Young, MODY5, is a syndrome characterized primarily by renal cysts, renal dysfunction and early onset diabetes caused by pancreatic atrophy and hepatic insulin resistance. Hepatocyte nuclear factor 1b (HNF1b) plays a key regulatory role in the organogenesis of tubular epithelia within the renal, pancreatic and biliary systems.

CASE DESCRIPTION/METHODS:

33-year-old woman presented to hepatology clinic with chronically elevated liver chemistries in a mixed hepatocellular/cholestatic pattern (Table 1). Abnormalities were first noted in her teens with symptoms of fatigue and pruritus. No history of liver-toxic medications. Medical history: pre-diabetes, polycystic ovarian syndrome with associated infertility issues, renal cysts. Surgical history: bladder/ureteral surgery as a child. Unremarkable social history. Father with ulcerative colitis. Work up included negative hepatitis panel, anti-smooth muscle ab, anti-mitochondrial ab, and ANA. Normal ceruloplasmin, copper, and ferritin. Sonogram with a 15.6 cm homogenous liver, cholelithiasis (resolved on repeat study), and bilateral renal cysts. Liver biopsy was essentially normal with minimal focal lobular chronic inflammation and mild sinusoidal congestion. Her medical history prompted genetic testing for HNF1B mutation, positive for heterozygous disease. MRI/MRCP revealed normal appearing bile ducts and pancreatic atrophy, consistent with the diagnosis.

DISCUSSION:

HNF1b deficiency compromises the functional integrity of human cholangiocytes by altering the structure of primary cilia. Roelandtet al. were the first to demonstrate aberrant cholangiocytes at the structural level in patients with HNF1b heterozygosity (Figures 1 and 2). The defects do not affect the structure of intra and extrahepatic ducts themselves, so patients may present with normal hepatic and biliary architecture. More overt biliary anomalies have been noted in HNF1b associated MODY5, with many carriers of the mutation demonstrating choledochal cysts. HNF-1b mutations should be considered in patients with cholestasis, late onset diabetes and renal cysts, particularly when standard work up does not reveal a cause for abnormal liver chemistries. While morbidity is associated with pancreatic and renal dysfunction, symptomatic management of cholestasis should be addressed. Further studies are needed to determine if surveillance is necessary to assess the development and potential malignant transformation of choledochal cysts.
2508 A Case of Graves Disease Presenting With Severe Hepatic Dysfunction
Authors: Imam Zaid , Odish Fadi , Hanna Angy , Tahhan Mamon
Published: October 2019

INTRODUCTION:

Cholestatic hepatitis attributed to thyroid disease is a rare presentation with only a handful cases reported in the literature. Often confused as a potential adverse effect of anti-thyroid therapy, this entity can prove to be elusive to diagnose and challenging to manage.

CASE DESCRIPTION/METHODS:

A 37-year old healthy male presented complaining of jaundice, pruritus, fatigue and significant weight loss over 3 months. His only medication was oxycodone for chronic back pain after a remote accident. Physical examination demonstrated scleral icterus with no hepatosplenomegaly or stigmata of chronic liver disease. Diagnostic evaluation demonstrated (1) Lymphocytic leukocytosis of 14,000 cells/mm3, microcytic anemia, normal platelet count, kidney function, serum albumin and INR, (2) mixed LFT pattern (R factor: 2.6) with marked cholestasis with ALP of 222 IU/L, AST of 132 IU/L, ALT of 192 IU/L, total bilirubin of 17.3 mg/dl with a direct fraction of 9.4 mg/dl (3) negative hepatitis, viral serologies, ANA, and AMA (4) elevated ferritin of 2,938 ng/ml with heterozygous H63D mutation, (5) normal MRCP (6) liver biopsy demonstrating cholestatic changes not compatible with autoimmune hepatitis, minimal iron deposition, and no evidence of fibrosis (7) TSH < 0.01, fT4 (free thyroxine) of 1.5, fT4 (free triiodothyronine) of 4.3 and strongly positive thyroid stimulating immunoglobulins, TSH receptor antibodies, and anti-TPO antibodies. A radioiodine uptake scan (RAI) was consistent with Grave's disease. The patient was started on methimazole, propranolol and underwent subsequent surgical thyroidectomy with complete resolution of his symptoms and near complete resolution of his hepatitis in 3 months duration.

DISCUSSION:

Thyrotoxicosis presenting with severe hepatic dysfunction can prove a challenging entity to treat. Challenges include potential hepatotoxic effects of methimazole, propylthiouracil or radioactive iodine, and the risks of inducing thyroid storm by performing a surgical thyroidectomy without appropriate pre-treatment. The case reported highlights the importance of recognizing liver injury secondary to thyrotoxicosis, and reports successful treatment with surgical thyroidectomy after pre-treatment with methimazole and propanolol.
2509 Role of EUS in Prostate Cancer Recurrence
Authors: Sharma Neil , Gopakumar Harishankar , Krishnakurup Jay
Published: October 2019

INTRODUCTION:

We describe the first documented case of the use of EUS for evaluation, biopsy, and placement of fiducial markers in the same setting by an advanced interventional endoscopist for recurrent prostate cancer.

CASE DESCRIPTION/METHODS:

A 56 yrs old Caucasian male with history of prostate cancer status post radical robotic prostatectomy in 2008. The pathology revealed moderately differentiated adenocarcinoma with focal mucinous change, Gleason Score 7. Stage T3a N0 M0. The right posterolateral 6 mm superficial to the apex, capsular incision were positive. Zero of the nine lymph nodes removed were positive. His post op PSA remained low till January of 2015. The PSA starts to show an upward trend from May 2017 and rose to 2.07 ng/ml in December 2017. He didn't have any clinical complaints. A PET scan in January 2018 was negative for recurrence. An MRI in February 2018 showed some enhancement of soft tissue in the prostatic bed favoring post-surgical changes (Figure 1). The patient was referred for EUS due to concerns regarding the rising PSA levels. We used a radial EUS to evaluate the prostatic bed, which was difficult due to post prostatectomy echogenic artifact. However we noticed a slightly prominent hypoechoic area in the prostatic bed (Figure 2). We then used a linear EUS scope (Figure 3) and a 22G core needle to biopsy this area, which on touch prep cytology was positive for adenocarcinoma. We then placed fiducial markers in the surgical bed under EUS guidance. Patient then underwent radiotherapy with complete response to treatment.

DISCUSSION:

Any rising PSA levels of any magnitude (biochemical recurrence) should be followed and evaluated further after prostatectomy to ensure complete cure of prostate cancer. Although different imaging modalities are available to tackle these issues, they lack specificity. It's a common practice to place fiducials in a prostate cancer prior to radiation treatment. The role of EUS in the surveillance and diagnosis of patients after prostatectomy has not been validated. Once patient undergo prostatectomy or radiation, the prostatic bed develop significant fibrosis. This is a challenge for future radiological imaging to identify the recurrent disease. A rising PSA level of any is worrisome in a prostatectomy patient and EUS guided FNB of the prostatic bed will be a great tool to issue accusation and, confirming the diagnosis. Furthermore the fiducials can be placed in the same session for stereotactic salvage radiation with limited peripheral injury.
2512  A Rare Late Complication After Roux-en-Y Gastric Bypass: Recurrent Hepatic Abscesses
Authors: Ahmed Zarir , Odufalu Florence-Damilola , Nazzal Mustafa , Prather Charlene
Published: October 2019

INTRODUCTION:

There are many rare late post-operative complications for Roux-en-Y gastric bypass (RYGB), but hepatic abscesses from enteric fistula formation is a rare complication. Herein we describe a case of recurrent hepatic abscess formation after a revision of a RYGB procedure

CASE DESCRIPTION/METHODS:

A 66 year-old female with a history of obesity status-post a RYGB in 2003 requiring revision with partial gastrectomy with GJ creation in 2017 presented to her PCP with abdominal pain, reduced appetite, fevers, and chills. She had several admissions for recurrent polymicrobial hepatic abscesses requiring prolonged courses of IV antibiotics after her revision. She had a temperature of 101.1 F, blood pressure of 101/55, heart rate 69. Labs revealed ALP of 280, ALT of 83, AST of 208, and WBC of 11.5. CT revealed an 11 cm abscess between the liver and diaphragm (Figure 1). She was started on antibiotics and interventional radiology did CT-guided abscess drain placement revealing green pus. An upper endoscopy revealed Roux-en-Y gastrojejunostomy anatomy with gastrojejunal anastomosis with healthy mucosa. Given her recurrent abscesses, there was concern that this was a biliary or intestinal fistulous tract causing the abscesses. Imaging with CT fistulogram demonstrated a fistulous tract in the bilio-pancreatic limb of the RYGB. She underwent exploratory laparotomy with findings of the gastric remnant which was adherent to the left lobe of the liver (Figure 2). The staple line of gastric remnant along with the fistula were resected and underwent successful repair. She has had no further recurrence of hepatic abscesses.

DISCUSSION:

Late post-operative of RYGB include enteric fistulas, cholelithiasis, marginal ulcers, small bowel obstruction, and nutritional deficiencies. However, hepatic abscesses from enteric fistula formation is a rare complication. Liver abscesses can seed from the biliary tree and liver parenchyma through the hepatic artery or portal venous system. Only 5-15% of infections are accounted from surgical trauma. The etiology of recurrent hepatic abscesses in our patient resulted from fistula formation at the gastric staple line leading to an exposure to enteric secretions. Given RYGB anatomy, accessing the gastric remnant is often difficult and at times never done. This case highlights the need for providers to continue to have a high index of suspicion of pathology occurring in the gastric remnant and to consider fistula formation.
2513 Endoscopic Management With an Over-the-Scope Gastric Clip of a Staple-Line Leak Following Sleeve Gastrectomy
Authors: Tawadros Augustine , Skole Kevin , Chau Wai Y.
Published: October 2019

INTRODUCTION:

Obesity has become a global epidemic with substantial socioeconomic and healthcare-related costs. Due to the limited utility of diet and behavior modification, there is tremendous interest in surgical weight loss strategies. Among those, sleeve gastrectomy (SG) has become the most commonly performed bariatric procedure. This is due to its efficacy and relative safety compared to other surgical options. However, post-SG leaks do occur. For example, staple-line leak (SLL) occurs in up to 3% of patients, most commonly at the proximal border of the staple line, near the esophagogastric junction. Usually, these leaks present in the early postoperative period, but there are increasing reports of SLL occurring months or even years after the initial surgery. Often, bariatric surgical complications are referred to tertiary centers for management. We present a case of a SLL managed at a community hospital.

CASE DESCRIPTION/METHODS:

A 38 year-old woman, with limited past medical history, presented 6 weeks after SG with a staple-line leak. Her immediate post-op period had been complicated by a peri-splenic abscess, which was managed with IV antibiotics (ABX) and percutaneous drainage (PD). Upper GI series (UGIS) at this time did not reveal a SLL. After clinical and radiographic resolution, the drain was removed. Several days later, the patient presented with nausea, vomiting, and non- bloody watery diarrhea. She was found to be febrile and tachycardic; labs, including a test for Clostridium dificile, were negative. A repeat CT scan confirmed an upper abdominal fluid collection. Subsequent UGIS revealed a SLL in the proximal stomach with a suture line fistula. After several weeks of NPO status, ABX and PD failed to lead to leak closure, the patient underwent endoscopy with successful placement of an Ovesco Over-the-Scope gastric clip (OTSC). Repeat UGIS confirmed fistula closure. After several weeks of additional conservative management, the PD was removed. Several months later, the patient remains stable.

DISCUSSION:

As the use of SG becomes more widespread, complications such as SLL will need to be addressed. Often, patients with SLL are referred to a tertiary center. We present a case successfully managed in a community hospital with the application of an OTSC. Practitioners who follow SG patients should be familiar with the indications and use of the OTSC.
2522 An Unusual Case of a Colo-enteric Fistula
Authors: Roccato Mary Kathryn , El Hage Chehade Nabil , Samarasena Jason , Sowa Piotr , Lee John
Published: October 2019

INTRODUCTION:

Entero-enteric fistulas are complications seen in patients with active Crohn's disease or history of extensive intra-abdominal surgeries. Presentations can be non-specific and include disease progression, rectal bleeding, or persistent febrile episodes. Upper and lower gastrointestinal endoscopy are used to diagnose entero-enteric fistulas. Contrast injection along with abdominal radiography can visualize and provide further anatomical details. In the following report, we present the case of a patient with pancreatic adenocarcinoma who presented with rectal bleeding. The diagnosis of colo-enteric fistula was made by fluoroscopy with contrast injection and pathology results.

CASE DESCRIPTION/METHODS:

A 62-year-old male with PMH of pancreatic adenocarcinoma treated with chemotherapy and whipple procedure complicated by multiple recurrences of liver metastases treated with radiofrequency ablation and excision of abdominal wall implants, who presented with rectal bleeding. On admission, EGD did not identify the source of bleeding, Colonoscopy showed a 4 cm ulcerated pocket at the hepatic flexure. Contrast injected into the pocket revealed a fistulous tract with an extra-colonic segment. Traversing the tract with the colonoscope revealed small bowel tissue. Biopsies of fistulous opening was consistent with necrotic tissue concerning for metastatic implants.

DISCUSSION:

To the best of our knowledge, most entero-enteric are caused by either active untreated Crohn's disease or as a result of multiple abdominal surgeries. This is a rare case of colo-enteric fistula formation due to metastatic pancreatic cancer. Few case reports show intra-colonic fistula formation due malignancy. Upon literature review, there are case reports of primary lymphoma leading to colo-enteric fistula formation. Diagnosis was difficult to achieve due to non-specific clinical presentation of chronic diarrhea. The fistula was diagnosed by computed tomography enterography (CTE) demonstrated a ileo-ileal fistula and ileo-colonic fistula. Ultrasound (US) showed small intestinal wall thickening and development of a fistula of the sigmoid colon due to malignancy. Although rare, enteric fistula formation due to malignancy should be suspected in patients with GI symptoms and history of metastatic disease.
2527 Posterior Perforation Arising From a Duodenal Diverticulum
Authors: Leung David , Gaddipati Kishore
Published: October 2019

INTRODUCTION:

Duodenal diverticulums (DD) are present in 6-22% of the general population on autopsy, however, it is uncommon to be symptomatic. We present a rare case of a patient who developed a posterior perforation of a duodenal diverticulum.

CASE DESCRIPTION/METHODS:

An 82-year old male presented with a chief complaint of weakness. On admission, the patient was found in septic shock, thought to be from pneumonia and started on antibiotics. Due to a lack of bowel movements over several days, a KUB was ordered and showed ileus of the proximal small bowel. The following day he developed large melanotic stools and laboratory workup revealed a hemoglobin of 5.6. The patient was resuscitated and underwent an endoscopy. A large ulcer covering 50% of the duodenal circumference with a large tract was discovered (Figure 1). A follow-up CT abdomen (Figure 2) demonstrated fluid and edema surrounding the pancreas, pneumoperitoneum, and fluid collection in the third portion of the duodenum. Additionally, a UGI with gastrografin (Figure 3) showed a diverticulum in the third portion of the duodenum with extravasation of contrast into the retroperitoneum indicating perforation. Surgery revealed a diverticulum of the second portion of the duodenum. The perforation was found to lead into the retroperitoneal space and directly into the body of the pancreas. Unfortunately, the patient would develop multi-organ failure secondary to fulminant septic shock and passed away.

DISCUSSION:

It is uncommon for duodenal diverticulums to be symptomatic with only about 10% doing so. They can present with upper abdominal pain, obstruction, ulcer, diverticulitis, perforation, and pancreatitis. Bleeding can occur but is rare. DD can be classified as primary acquired diverticula or secondary diverticula, which is caused by peptic ulceration. They are thought to be caused by herniation of the mucous membrane through the muscular coat at sites weakened by the passage of blood vessels or aberrant growth of pancreatic tissue. Perforations associated with duodenal diverticulums are typically located in the anterior portion of the duodenum or stomach however, spontaneous non-traumatic posterior perforation is a distinct clinical rarity, not commonly encountered. Posterior perforations tend to present late due to insidious onset. These ulcers perforate into the retroperitoneal space or lesser sac. Local inflammatory reaction and fibrosis of the adherent retroperitoneal space tend to seal off these perforations which may explain their vague symptoms.
2533 Primary Mesenteric Lieomyosarcoma: A Rare Case Report
Authors: Affas Saif , Zamorasifuentes Jose , Mendes Juliann , Barawi Mohammed
Published: October 2019

INTRODUCTION:

Sarcomas are a rare, heterogeneous group of neoplasms with varied histolopathological presentation, that share a common mesenchymal cell line origin. Soft tissue sarcomas tend to grow along tissue planes and can compress surrounding tissue, leading to the formation of pseudocapsules and finger-like projections that can infiltrate into adjacent tissue. Despite this, sarcomas rarely metastasize to regional lymph nodes. Sarcomas in the gastrointestinal tract encompass both gastrointestinal stromal tumors (GISTs) and leiomyosarcomas, which are rare neoplasms arising from smooth muscle cells and commonly misdiagnosed at GISTs. Mesenteric leiomyosarcomas usually present as a gradually enlarging, painless abdominal mass with associated symptoms usually arising from compression by the tumor.

CASE DESCRIPTION/METHODS:

A 68-year-old African-American female with history of hypertension, diabetes mellitus, and latent tuberculosis presented with decreased oral intake secondary to nausea, vomiting, and diarrhea for 2 days and unintentional 10-pound weight loss over a 2-month period. Physical examination revealed right upper quadrant tenderness. Computed tomography (CT) with IV contrast of the chest, abdomen, and pelvis showed a large right-sided solid mesenteric tumor causing extrinsic compression of the proximal and mid-portion of the right ureter with prominent right-sided hydronephrosis. CT guided biopsy revealed a smooth muscle neoplasm concerning for leiomyosarcoma with uncertain malignant potential. A right-sided ureteric stent was inserted to relieve extrinsic compression. An explorative laparotomy showed the tumor to be encasing the right ureter. Excision of the tumor along with right mid ureter was done with restoration of ureteric continuity via ureteroureteral anastomosis.

DISCUSSION:

Mesenteric leiomyosarcomas are rare and aggressive soft tissue tumors most commonly arising in the ileum. Biopsy is not recommended for local resectable tumors; however, it should be considered if metastatic disease is suspected or if preoperative imatinib is being considered prior to resection in the setting of a large locally advanced lesion. Treatment options depend on invasion of adjacent structures, including either local or en bloc resection. However, no nodal dissection is needed due to the rarity of nodal metastases.
2543 Duodenal Traditional Serrated Adenoma (TSA) Presenting as Small Bowel Intussusception
Authors: Urquhart Siri A. , Quinn Kevin P. , Alexander Glenn L.
Published: October 2019

INTRODUCTION:

Intestinal intussusception is the telescoping of a proximal into an adjacent distal segment of the gastrointestinal (GI) tract. Intussusception is rare in adults, accounting for less than 5% of all mechanical bowel obstructions. Approximately 80-90% of intussusceptions in adults are secondary to an underlying pathological process, including malignant lesions, polyps, or Meckel's diverticulum. Therefore, when intussusception occurs in adults, further investigation to determine the etiology is warranted.

CASE DESCRIPTION/METHODS:

A 48 year-old female without significant past medical history developed severe, episodic abdominal pain six to eight weeks prior to presentation with associated nausea and occasional emesis. Recent CT scan of the abdomen and pelvis with contrast demonstrated small bowel intussusception in the area of the ligament of Treitz (Figure 1). Laboratory investigations were notable for microcytic anemia. She was referred to gastroenterology and underwent extended esophagogastroduodenoscopy (EGD) which revealed a 4 cm mass in the fourth portion of the duodenum (Figure 2). Initial mucosal biopsy suggested a possible tubulovillous adenoma with low-grade dysplasia. She subsequently underwent surgical resection of the small bowel mass with duodeno-jejunostomy. Surgical pathology revealed a traditional serrated adenoma (TSA) with low-grade dysplasia forming a cluster of polyps ranging from 0.5 to 4.3 cm in size (Figure 3). She did well postoperatively and was discharged on post-operative day 6. She will be undergoing colonoscopy after recovering from surgical intervention.

DISCUSSION:

Of the three types of serrated adenomas, TSA is the least common, accounting for only 5% of serrated polyps. These are commonly found in the colorectum and have rarely been described in other portions of the GI tract. The first case of TSA of the duodenum was not described until 2004. More recently, TSAs have been detected throughout the upper GI tract. However, reports of TSAs causing small bowel intussusception have not been described. This novel case highlights the importance of considering this in the differential for any adult with proximal small bowel intussusception. Importantly, TSAs of the upper GI tract may represent more aggressive lesions with high malignant potential and should be excised to rule out the possibility of a developing malignancy.
2544 Black Speckled Duodenal Mucosa
Authors: Saleem Sheikh A. , Heisig David
Published: October 2019

INTRODUCTION:

Pseudomelanosis of the duodenum is characterized by a collection of pigment-laden macrophages in the tips of duodenal villi. It is a rare incidental endoscopic finding seen in elderly patients and is of unknown clinical significance. We describe a case of an elderly patient who presented with GI bleeding and was found to have pseudomelanosis duodeni.

CASE DESCRIPTION/METHODS:

An 83 yo Caucasian female with a history of hypertension, chronic kidney disease, hypothyroidism and atrial fibrillation presented to the hospital with hemodynamically stable GI bleeding. Her home medications included aspirin, furosemide, metoprolol, levothyroxine and coumadin. An EGD was done which showed black speckled appearance of the duodenal mucosa. The duodenal biopsy showed a mild inflammatory component in the lamina propria with focal aggregates of iron containing brown pigment laden macrophages. Review of her past medical records revealed that she had an UGI series done about two years ago which showed irregular duodenal mucosa concerning for small ulcers however the patient declined an endoscopy at that time.

DISCUSSION:

Pseudomelanosis duodeni was first reported by Bisordi and Kleinman in 1976 and is most commonly seen in elderly female patients. The exact pathogenesis of the condition is still unclear. It is seen in association with certain medical conditions such as hypertension, chronic kidney disease and diabetes mellitus. Unlike pseudomelanosis coli, pseudomelanosis duodeni does not have a known association with anthraquinone containing laxatives but is seen in conjunction with sulfur containing antihypertensive medications and iron supplements. It has been postulated that coupling of absorbed iron with sulfur from antihypertensive medications leads to the formation of iron sulfide, the dark color pigment which is then taken up by the macrophages. Pseudomelanosis duodeni on endoscopy has the characteristic appearance of flat, black-speckled pigmented mucosa. Biopsy is the gold standard for diagnosis, and this demonstrates aggregates of pigment laden macrophages in the apical portion of the duodenal villi. The diagnostic and prognostic significance of pseudomelanosis duodeni is unknown. To date there is no evidence that this condition is a precursor for neoplasia or any other progressive pathology. Therapeutic chelation or endoscopic follow-up for pseudomelanosis duodeni is not recommended.
2552 A Rare Case of Ileocecal Intussusception in a Young Adult
Authors: Patino Sanja , Akhter Sharmin , Hutton Anneka , Eisner Todd D.
Published: October 2019

INTRODUCTION:

Intussusception is a process in which a segment of bowel telescopes into the adjoining intestinal lumen. The pathophysiology is unclear but it is typically due to a pathologic lead point within the bowel, which is malignant in over 50% of cases. The clinical presentation of adult intussusception is non-specific, unlike the characteristic triad of abdominal pain, palpable abdominal mass, and bloody stool seen in pediatric patients. It is a rare cause of abdominal pain in adults, comprising only 5% of all intussusceptions.

CASE DESCRIPTION/METHODS:

A 29-year-old Peruvian male with no significant medical history presented with right lower quadrant abdominal pain and diarrhea for two weeks with an unintentional 15 pound weight loss. Abdominal CT demonstrated intussusception with likely underlying mass in the region of the ileocecal valve. Colonoscopy revealed an ileocecal mass (Figures 1 and 2) that was too large to pass with the endoscope. The patient subsequently underwent a right hemicolectomy and omental flap. Pathology of the mass showed diffuse large B-cell lymphoma (DLBCL), germinal center type. Further evaluation revealed a positive HIV test with a CD4 count of 29 cells/mL.

DISCUSSION:

Adult intussusception is a rare clinical entity and requires prompt imaging and diagnosis to prevent severe complications. A retrospective review of 44 cases found that ultrasound and CT resulted in a combined preoperative diagnosis rate of 95.5%. Literature review suggests surgical resection is the optimal management in adults given the high incidence of underlying malignancies. Controversy remains regarding the ideal surgical approach between primary resection versus reduction followed by resection. Several retrospective studies propose resection without reduction is the best approach for ileocecal intussusception to avoid potential intraluminal seeding or venous tumor dissemination. Our patient was diagnosed via CT and treated by surgical resection without complications. Further diagnostic workup revealed the etiology to be a DLBCL in the setting of HIV/AIDS. This case highlights the importance of identifying an underlying mechanism for the development of intussusception in young adults. The incidence of primary lymphoma in the small intestine is rare and accounts for 1-4% of all gastrointestinal malignancies and 10-20% of small intestine malignancies. Through this case presentation, we hope to contribute to the limited available data on cases of adult intussusception.
2563 When Considering a Broad Differential to Diarrhea and Joint Pain: Don't Forget About Whipple's Disease
Authors: Miller Justin A. , Chastant William C. , DiBuono Bryan D. , Galliano Gretchen E. , Raines Daniel
Published: October 2019

INTRODUCTION:

Whipple's disease (WD) is a rare systemic disease caused by bacteria Tropheryma whipplei and commonly overlooked as a diagnosis.

CASE DESCRIPTION/METHODS:

A 42-year-old man presented to the ED for intolerance chronic of diarrhea, lower extremity swelling, paresthesia, migratory monoarticular arthralgia, and weakness. Over 2 years he lost 60-pounds and had early satiety, intermittent dysphagia, and decreased concentration. Physical exam was remarkable for a scaphoid abdomen with mild diffuse tenderness, knee joint tenderness, lower extremity strength 4/5. Labs abnormalities: hemoglobin 6.5 g/dL, albumin 1.9, 25-OH vitamin D 5 ng/mL (nml > 30 ng/mL), CRP 25.4 mg/L. Bilateral lower extremity ultrasound showed a blood clot in the right deep femoral vein and bilateral baker's cysts. Colonoscopy and EGD examinations were unrevealing. Histologic exam of duodenum biopsies showed dilated fat vacuoles and a positive periodic acid-Schiff (PAS) stain confirming Whipple's Disease. Cerebrospinal fluid was negative and cognitive changes improved with electrolyte replacement. He was treated with a 14-day course of intravenous ceftriaxone followed by Bactrim doubled-strength twice a day. After intravenous antibiotics, the diarrhea resolved and he regained weight.

DISCUSSION:

WD most commonly affects men (86%), farmers (35%), and those with occupational exposure to soil or animals (66%). Transmission is thought to be fecal-oral since sewage workers are more prevalent carriers. Common symptoms are weight loss, arthralgia, diarrhea, and abdominal pain. Arthralgia is the sentinel symptom preceding others by ∼6 years. Less common include skin hyperpigmentation, endocarditis, and CNS symptoms (severe disease). Three diagnostic tests exist: PAS-staining, PCR of the 16S ribosomal RNA of T. whipplei, and immunohistochemistry (IHC) via rabbit anti-T. whippleiantibodies. Diagnostic criteria include: 1) small intestine biopsies positive on PAS stain for bacillus material in the lamina or 2 positive tests from other origins. Initial testing is done with EGD and duodenal biopsies submitted for PAS staining and PCR testing ± IHC. If extraintestinal symptoms, PAS staining and PCR testing ± IHC on tissue or fluid samples. CSF should be tested by PCR in all cases. After diagnosis, treatment starts with a 2-week course of IV of antibiotics (4 weeks if CNS infection or endocarditis) followed by one year of Bactrim. Relapse occurs in 17-35%, years later.