bluuebunny/crossref_metadata_2025 huggingface dataset:
2994 Hospital Outcomes of Gastric Cancer: A Nationwide Analysis
Authors: Rai Manoj P. , Bedi Prabhjot , Singh Tanveer , Kothari Shaili , Enofe Ikponmwosa
Published: October 2019

INTRODUCTION:

Gastric cancer is the fifth most common cancer in the United States. It carries a poor prognosis since it tends to be discovered at advanced stages, limiting the role of curative surgery. Hospitalizations for gastric cancer occur for medical and surgical management of disease or complications related to cancer. In this study, we analyzed the frequency of hospital admissions, in-hospital treatment outcomes and resource utilization for hospitalizations with a diagnosis of gastric cancer.

METHODS:

This is a retrospective cohort study using the 2014 National Inpatient Sample. Hospitalizations were included if they had a principal or secondary diagnosis of gastric cancer. The primary outcome was the number of hospitalizations per year. Secondary outcomes included: 1) Their demographic characteristics 2) Five most common reasons for hospitalization, 3) In-hospital mortality and 4) In-hospital resource utilization (length of hospital stay (LOS) and total hospitalization charges).

RESULTS:

We identified 43,365 hospitalizations for the management of gastric cancer. The 5 most common principal diagnoses for admission were: gastric cancer, gastric cancer in the cardia, malignant neoplasm of contiguous or overlapping sites of the stomach, malignant neoplasm of the pyloric antrum and septicemia. The demographics and hospital characteristics are presented in Table 1. The mean age was 65. 6 years. The majority of hospitalizations were white males in the lower two income quartiles with Medicare or private insurance. Most of the hospitalizations occurred in large urban teaching hospitals located in the Southern USA. The inpatient mortality rate was 7.3% (6.6%-8.1%). The average length of stay was 7.6 (95% CI 7.4-7.8) days. The mean total hospitalization charges were $73,867 (95% CI $70,750–$76,985), with a cumulative healthcare burden of $3. 2 billion.

CONCLUSION:

The use of inpatient services for gastric cancer was significant with around 50,000 hospitalizations per year. Older age group, male gender, and white population comprised the majority of the hospitalizations. Cancer care and sepsis accounted for the majority of hospitalizations. Hospital admission is associated with substantial mortality, along with a staggering cumulative in-hospital healthcare burden of $3.2 billion per year. Interventions aimed at decreasing hospital admission for management of gastric cancer have the potential to decrease both mortality and healthcare resource utilization.
2996 Proton Pump Inhibitors: Do We Practice What We Preach? A Quality Improvement Intervention
Authors: Shahnazarian Vahe , Kolli Sree , Nagaraj Savitha , Ramai Daryl , Reddy Madhavi
Published: October 2019

INTRODUCTION:

Timing in the administration of proton pump inhibitors (PPIs) plays an important role in their efficacy. Studies have demonstrated increased efficacy of PPIs when administered 30-60 minutes before the first meal of the day. Current default frequency for PPI orders at our urban community hospital is “daily,” which translates to a 10 am administration. This quality improvement study investigates the frequency with which PPIs are being ordered, and if they are being done in line with current recommendations.

METHODS:

The Plan-Do-Study-Act (PDSA) model was applied in order to determine whether there was a problem in PPI administration frequencies, and if so, how to address that problem. A retrospective and prospective electronic medical record (EMR) analysis was done. Data retrieved from that analysis included whether or not a PPI was ordered, which service it was ordered by, and the frequency at which it was ordered. Inclusion criteria included any inpatient in the hospital who had a PPI ordered. Exclusion criteria included any patient that was not an inpatient, did not have any PPI ordered, had a PPI ordered for more than once a day or had a PPI drip ordered. Statistical analysis was done with percentage change from baseline results.

RESULTS:

During a one month period (December 2018), every inpatient had a PPI frequency of daily. This meant the PPI would be given at 10 am. Based on the data, an EMR intervention was implemented where the default frequency for PPI administration was changed from “daily” to “before breakfast,” which meant it would be given at least 30 minutes before breakfast. A second report was run after the intervention for a one month period (March 2019), and it was noted that every single inpatient PPI ordered now had a frequency of “before breakfast.” This was a 100% improvement from the baseline.

CONCLUSION:

Quality improvement is not only important in improving healthcare systems but also in improving patient care. The PDSA model was applied here in order to correct an overlooked issue within our urban community hospital. Once the problem was identified, a simple EMR intervention was implemented. This change created 100% compliance with current recommendations, which led to improved patient care while not creating more work for the housestaff.
2997 Venous Thromboembolism Among Hospitalized Patients With Gastric Cancer: Insights From National Inpatient Sample 2004-2014
Authors: Gupta Kamesh , Handa Shivani , Goyal Hemant , Khan Ahmad , Sohail Abdullah , Desilets David
Published: October 2019

INTRODUCTION:

Venous thromboembolism (VTE) is common in patients with malignancies and is associated with significant morbidity and mortality. The occurrence of VTE has been recognized as an independent predictor of mortality in patients with gastric cancer (GC) in smaller studies. However, no nationwide data is available about the VTE-related hospitalizations in patients with GC.

METHODS:

We used the US largest database National Inpatient Sample (NIS) from 2004 to 2014 to identify adults (≥18 yrs) with GC who were hospitalized with VTE using ICD-9 codes. These included patients with both deep vein thrombosis (DVT) and pulmonary embolism (PE) but superficial thrombosis was excluded. We adjusted for baseline demographic characteristics (age, sex, race, insurance, income quartile, history of chemotherapy, Charlson’s comorbidity index) and hospital characteristic (teaching vs. non-teaching, hospital size) to find out the in-hospital outcomes (mortality, length of stay and total hospitalization charges). Regression analysis was used to calculate odds for the association.

RESULTS:

Out of the total 445,719 hospitalizations with GC, 22,658 (5.08%) were identified to be associated with VTE. Out of these, 14,056 were associated with PE and 8602 presented with DVT. There was no significant difference in the mean age or sex. However, patients presenting with VTE were more likely to be and possess private insurance (Table 1). Total inpatient mortalities for these GC patients were 908 in the VTE group vs. 38,096 in the non-VTE (adjusted OR- 0.69, 95% CI 0.59-0.81). On univariate analysis, age, male sex, no history of chemotherapy and Charlson's comorbidity index were associated with increased in-hospital mortality. GC patients admitted with VTE had a significantly lower length of stay (5.6 ± 0.1 days) as compared to GC patients were admitted for other reasons or did not have VTE (6.4 ± 0.03 days) (P = 0.000). Similarly, total hospitalization charges were also significantly lower for GC patients with VTE ($38,052 ± 1008 vs. $43,696 ± 583; P = 0.001).

CONCLUSION:

In this large inpatient cohort retrospective study on GC patients, hospitalizations with VTE did not confer any change in the rates of mortality. However, length of stay and hospitalization charges were significantly lower in VTE patients than those admitted for other causes which could be due to a targeted treatment approach for VTE. Male sex and higher comorbidity index are associated with more mortality rate.
2999 Is There Truth to the Numbers?
Authors: Zackria Rasiq , Ling Joseph T.
Published: October 2019

INTRODUCTION:

CA 19-9 is a tumor marker associated with pancreatic and biliary tumors that can be directly measured in the blood with a normal range of 0-37 units/mL. Other inflammatory conditions such as biliary obstruction can also cause an elevation, which can obfuscate the diagnostic and prognostic value of CA 19-9.

CASE DESCRIPTION/METHODS:

A 66-year-old male with no medical history presented with a 1-month history of abdominal pain, jaundice, and weight loss. He was febrile at 100.4 F. Bilateral conjunctival icterus, full upper body jaundice, hepatomegaly, and mild tenderness to deep palpation in the right upper quadrant and epigastric regions were noted on exam. Gallbladder ultrasound revealed significant common bile and intrahepatic duct dilation concerning for obstructive lesion with no gallstones and minimal sludge. Total bilirubin was 27 mg/dL. CA 19-9 was elevated at 9,272 units/mL. CT abdomen and pelvis with contrast confirmed severe common bile and intrahepatic duct dilation with CBD measuring up to 22 mm. MRCP revealed marked intrahepatic and extrahepatic biliary dilation with dilated CBD up to 24 mm and choledocholithiasis with the largest gallstone measuring 15 mm in the distal CBD. ERCP revealed CBD stricture and sphincterotomy was performed with temporary stent placement. Ceftriaxone and metronidazole were given for ascending cholangitis. Fine needle aspiration was done by EUS, which was negative for malignancy on pathology. Repeat MRCP showed improvement in dilation and CBD now at 14 mm. Repeat CA 19-9 was 193 units/mL. Of note, CT chest with contrast did not reveal any evidence of pulmonary metastasis, CEA level was normal, and hepatitis panel was negative.

DISCUSSION:

A CA 19-9 cutoff of greater or equal to 300 unit/mL have been reported to have a specificity of 87% for cancer in patients with cholangitis. However, an extremely elevated CA 19-9 level does not always equal cancer or correlate with tumor burden and should not be used as the sole criterion for a diagnosis of malignancy. Non-cancerous causes of elevated CA 19-9 include gallstones, cholangitis, bile duct obstruction, and pancreatitis. EUS was critical in obtaining tissue to exclude pancreatic and biliary cancer. CA 19-9 and total bilirubin levels dropped after CBD stent placement, supporting a diagnosis of cholangitis without tumor. This is a rare case of extreme tumor marker elevation caused by choledocholithiasis and cholangitis, which serve as a cautionary tale of not relying too heavily on numbers to treat the patient.
3000 A Diagnostic Dilemma: Ovarian Cancer or a Pancreatic Neuroendocrine Carcinoma
Authors: Abraham Fiyinfoluwa , Shiralkar Kaustubh , Younes Mamoun , Thosani Nirav , Dedania Bhavtosh
Published: October 2019

INTRODUCTION:

Small cell pancreatic neuroendocrine carcinoma (P-NEC) is in a group of malignancies described as Gastroenteropancreatic (GEP) NEC, and is an extremely rare neoplasm. We present a case of P-NEC with confounding findings of multiple ovarian and pancreatic masses.

CASE DESCRIPTION/METHODS:

A 33-year-old European female with history of ovarian cysts (∼4 cm × 5 cm) presented with a ten-day history of lower abdominal/pelvic pain with new onset ascites and weight gain. No family history of GI or gynecologic malignancy. A CT (Figure 1a,b) of her abdomen and pelvis showed ascites, multiple pancreatic hypodense lesions and enlarged cystic ovaries (10 × 11 cm). Subsequent MRI pancreatic protocol (Figure 1c,d), and an endoscopic ultrasound (EUS-FNB) was performed. MRI showed diffusely abnormal pancreas with multiple focal solid masses with T2 hyper intense, T1 hypo intense, and hypo-enhancing lesions on early post contrast phases with no pancreatic ductal dilation or cystic component. EUS confirmed multiple hypodense pancreatic lesions but the findings were not consistent with primary pancreatic malignancy. Cytopathology of gastric nodules (Figure 2) and the pancreatic FNB (Figure 3) showed small cell NEC with a Ki-67 proliferative index (PI) of 43%. Pathology showed infiltrative process with small blue cells and scant cytoplasm. The IHC was positive for synaptophysin, chromogranin, CD56, weakly positive for CAM5.2 and AE1/AE3, negative for TTF-1, PAX8, CD45, CDX2, ER, and inhibin. The diagnosis was pancreatic small cell NEC. The enlarged ovarian cysts were determined to be an incidental finding, and not a primary source of the malignancy.

DISCUSSION:

Generally, the well differentiated pancreatic neuroendocrine tumors (NET) are hormone secreting; however, the GEP NEC are a highly aggressive poorly differentiated carcinoma and designated as grade 3 tumors. Grading is based on the Ki-67 PI and mitotic count/index (Table 1). Our patient had GEP NEC given her Ki-67 PI was 43%. Chemotherapy and/or surgical resection are the two treatment options, but by the time of late diagnosis the goal of the treatment is generally palliative. Our case emphasizes the importance of pursuing accurate pathological diagnosis, role of EUS in management of pancreatic neoplasms and eliminating the confounding factors (eg ovarian cysts/masses).
3005 Pancreatitis: An Unusual Initial Presentation of Duodenal Adenocarcinoma
Authors: Lambert Karissa , Hamed Amira , Hamed Ahmed Said , Samuel Gbeminiyi , Khalid Hamza
Published: October 2019

INTRODUCTION:

Duodenal adenocarcinoma is rare. The clinical presentation is often nonspecific, and the diagnosis is made incidentally. We present a case of a 73 year old female presenting with pancreatitis, who was subsequently found to have duodenal adenocarcinoma.

CASE DESCRIPTION/METHODS:

73 year old african american woman with hypertension presented with persistent nausea and vomiting of two weeks associated with burning epigastric pain and ten pound weight loss. She was previously treated for dyspepsia without improvement. She denied alcohol or non-steroidal use. She reports use of chewing tobacco. She denied fever, hematemesis, melena, hematochezia, or change in bowel habits. On physical examination, she was hypotensive and tachycardic. She had dry mucous membranes and delayed skin turgor. Laboratory examination revealed an unremarkable complete blood count. Comprehensive metabolic panel was remarkable for hypokalemia of 2.8 mEq/L, bicarbonate of 37 mEq/L, elevated creatinine of 1.23 mg/dL, elevated alanine aminotransferase of 58 U/L, and an elevated lipase of 369 U/L. Due to persistent abdominal symptoms, computed tomography of the abdomen and pelvis with contrast was performed, which was suggestive of pancreatitis or duodenitis. Patient was admitted for presumed pancreatitis. Intravenous fluids and antiemetics were initiated. Electrolytes were repleted. Right upper quadrant ultrasound and magnetic resonance cholangiopancreatography was without evidence of gallstones, cholecystitis, or biliary obstruction. Esophagogastroduodenoscopy and subsequent endoscopic ultrasound was performed and demonstrated diffuse moderately congested mucosa and an ulcerated mucosa with moderate stenosis found in the third portion of the duodenum. Biopsies were taken, which later revealed adenocarcinoma. Patient was started on total parenteral nutrition and followed-up with surgical oncology.

DISCUSSION:

Considering the rarity of duodenal adenocarcinoma, an early diagnosis is crucial. Clinicians should be aware of the nonspecific clinical and laboratory presentation, such as in our patient who presented with pancreatitis. A higher degree of suspicion and thorough investigation can lead to prompt diagnosis and earlier management and treatment.
3007 Santorinirrhage Due to Hemosuccus Pancreaticus as a Rare Manifestation of Upper Gastrointestinal Bleeding
Authors: Ghavimi Shima , Nasir Umair M. , Panchal Dayna , Patel Neel , Hashemipour Reza , Ahlawat Sushil
Published: October 2019

INTRODUCTION:

Hemosuccus pancreaticus (HP), bleeding from the pancreatic duct into the gastrointestinal (GI) tract via ampulla of vater, is extremely rare. Some causes include pancreatitis, pseudoaneurysm of the peri-pancreatic vessels, or malignancy. The rarity with which this condition is encountered makes HP difficult to diagnose. We present a case of HP with bleeding from the minor duodenal papilla from a pancreatic pseudocyst.

CASE DESCRIPTION/METHODS:

A 39-year-old male with alcohol use disorder and chronic pancreatitis presented to the hospital with complaints of abdominal pain and melena. Labs showed significant anemia: hemoglobin, 6.90 g/dL. He was admitted for blood transfusions and further investigation. Endoscopic evaluation showed portal hypertension gastropathy, without evidence of gross bleeding. CT abdominal scan showed cystic lesions at the pancreatic tail and within the pancreatic body (Figure 1). Endoscopic ultrasound fine needle aspiration biopsy of the cystic lesion was done. Fluid analysis was consistent with pancreatic pseudocyst with elevated amylase. He was discharged home in stable condition with gastroenterology follow-up. He returned to the hospital with recurrent episodes of melena and transfusion-dependent anemia. He had IR guided transjugular intrahepatic portosystemic shunt from right hepatic vein to right portal vein. He continued to have episodes of melena with new coffee-ground hematemesis. Repeat endoscopy was performed with frank bleeding noted from the minor duodenal papilla (Figure 2). MRI was unable to confirm pancreas divisum due to pancreatic atrophy and poor visualization of the pancreatic duct. CT abdominal scan now showed hemorrhage within the two pancreatic cysts. Mesenteric angiogram was performed which showed pseudoaneurysm off proximal splenic artery and gastroepiploic artery both of which were embolized (Figure 3). His abdominal distension and pain improved significantly after the procedure with no more episodes of melena or hematemesis. He was discharged home without recurrence of symptoms.

DISCUSSION:

Our case illustrates the diagnostic dilemma of obscure upper GI bleeding. HP with bleeding from the duct of Santorini has been reported twice. All hemodynamically stable patients with HP should undergo endoscopic, radiographic, and angiographic evaluation. Therapeutic options consist of selective embolization or surgery. A multidisciplinary team approach with a precise protocol is paramount to drastically reduce the mortality and morbidity of patients.
3009 Importance of Prompt Diagnosing and Treatment of Type 1 Autoimmune Pancreatitis
Authors: Mion-Bet Daniele , Lattanzio Natalia , Kadaba Vikaran , De Urresti Miren
Published: October 2019

INTRODUCTION:

Type 1 Autoimmune Pancreatitis (AIP) is a rare cause of chronic pancreatitis that accounts for only 2% of chronic pancreatitis cases. Mainly presenting in males between ages of 50-70. This is IgG4 related disease. It commonly presents with abdominal pain, jaundice, and weight loss. AIP is primarily diagnosed clinically and later confirmed through radiological and serological studies. Because pancreatic cancer presents similarly but differentiates in treatment, it is important to distinguish between the two.

CASE DESCRIPTION/METHODS:

A 72-year-old male with a PMH of chronic pancreatitis presented for evaluation of loss of appetite, fatigue and 100 lb weight loss over the course of 7 weeks. He also admitted to two weeks of chills and diaphoresis, and denied abdominal pain, diarrhea or constipation. On admission, there was no jaundice present and vitals were unremarkable, except for a temperature of 102 F. Patient's labs were within normal limits, except for sodium 129, ESR 85, total bilirubin 1.3, AST 101, ALT 79, and ALP 364. CT showed the pancreas heterogeneous, an ill-defined mass, consistent with pancreatic adenocarcinoma. Furthermore it showed hepatomegaly with numerous low-density lesions consistent with hepatic metastases. Biopsy of the pancreatic mass displayed a storiform fibrosis pattern with an elevated IgG4 of 3.8 g/L, suggesting Type 1 AIP. Liver biopsy was negative for malignant cells. Patient was diagnosed with AIP and was discharged on a steroid regimen.

DISCUSSION:

Type 1 AIP is defined as a fibro-inflammatory process that often includes elevated IgG4 levels. Imaging can also reveal irregular narrowing of the pancreatic duct with diffuse or focal enlargement of the pancreas. It is important to distinguish between AIP and pancreatic cancer due to the different treatments and prognosis. A study found AIP to account for 27% of Whipple resections performed for suspected pancreatic adenocarcinoma. AIP has a benign clinical course and is highly responsive to steroids. An elevated IgG4 together with imaging studies are the most sensitive and specific finding; an IgG4 value of >2.8 g/L distinguishes AIP from other inflammatory or malignant conditions. Finally, the prompt diagnosis of AIP is important for appropriate follow up. Studies have demonstrated an increased risk of developing cancer of the stomach, prostate, colon and bile duct post diagnosis of AIP. A retrospective study of 108 patients with AIP, 18 cancers were found in 15 patients in the median follow-up period of 3.3 years.
3013 Fish Mouth Ampulla: Classic Main Duct Intraductal Papillary Mucinous Neoplasm
Authors: Patel Pratik , Jampala Nannaya , Regan Kara , Mudireddy Prashant
Published: October 2019

INTRODUCTION:

Intraductal Papillary Mucinous Neoplasms (IPMNs) were first identified in 1982 and there have been increasing rates of diagnosis of IPMNs in recent years with the improvement of imaging modalities. Due to the indolent course of IPMNs, many patients may initially remain asymptomatic for many years. IPMNs should be acted on quickly after diagnosis as they can progress to malignancy. We present a case of a patient who presented with symptoms similar to pancreatitis but was found to have a main duct IPMN with the classic fish mouth appearance of the ampulla.

CASE DESCRIPTION/METHODS:

A 62-year-old male presented to an outside hospital with epigastric abdominal pain and nausea. RUQ Ultrasound revealed normal liver and gallbladder with heterogenous echotexture within an enlarged pancreas. Abdominal CT Scan revealed a low density heterogenous, contrast enhancing, possibly multicystic lesion at the uncinate process and near the pancreatic head measuring 3.6 × 3.6 cm with dilation of the pancreatic duct. MRCP revealed a dilated pancreatic duct at 6 mm and a cystic appearing pancreatic mass involving uncinate process and portion of the right pancreatic head concerning for intraductal papillary mucinous neoplasm. He was transferred to our facility for formal Gastroenterology evaluation. EGD was performed and revealed a markedly dilated ampulla with mucinous discharge, with classic “fish mouth” appearance. The pancreatic duct was diffusely dilated from the tail to ampulla, up to 17 mm in the head/neck. A cystic lesion measuring 41 × 35 mm adjacent to the main pancreatic duct extending to the uncinate was noted. FNA was performed and pathology confirmed the diagnosis of main duct IPMN. He successfully underwent a Whipple procedure.

DISCUSSION:

This case illustrates the importance of recognizing a classic endoscopic feature of main duct IPMN: the fish mouth ampulla of Vater. There are three types of IPMNs: main duct, side branch and mixed. MD-IPMNs have the most malignant potential of the three and should be acted on promptly with surgical referral for resection. Approximately 65% of MD-IPMNs are malignant, compared to 20% for side branch IPMNs. Due to the indolent course of IPMNs, many patients will remain asymptomatic for many years. Eventually, patients will present with symptoms similar to pancreatitis. Despite the lack of clear consensus for management of pancreatic cystic lesions between multiple guidelines, all agree that MD-IPMNs should be surgically resected due to the high malignant potential.
3015 Pancreatic Ascites: A Rare Complication of Chronic Pancreatitis
Authors: Abbas Syed , Boroda Konstantin , Shahid Tamoor , Hertan Hilary
Published: October 2019

INTRODUCTION:

Pancreatic ascites is a rare complication of chronic pancreatitis. We present a case of recurrent pancreatic ascites refractory to medical management.

CASE DESCRIPTION/METHODS:

A 62-year-old man with alcohol related chronic pancreatitis thrombosis initially presented with abdominal pain which was treated as a chronic pancreatitis flare which was managed conservatively. CT showed a pseudocyst and a portal vein thrombus, for which he was started on therapeutic enoxaparin (Figure 1). EUS later showed the pseudocyst, along with calcifications and hypoechoic strands in pancreatic parenchyma (Figure 2). Subsequently, the patient had two more hospitalizations for chronic pancreatitis flares, but with new development of abdominal distention. CT confirmed the presence of a large intraabdominal and pelvic ascites. He underwent a diagnostic paracentesis revealing a SAAG less than 1.1, amylase level of 5954 U/L and a total protein of 3.1 mg/dl. Hence a diagnosis of pancreatic ascites was confirmed and portal hypertension was ruled out. The patient suffered rapid reaccumulation of ascites and required weekly paracentesis. He was treated with subcutaneous Octreotide, without improvement. Because of this, he underwent ERCP which showed leakage of contrast from the pancreatic duct (PD) (Figure 3). A PD stent was placed. After this he still developed ascites, but at a slower rate. Repeat paracentesis showed an amylase level of 291 U/L and subsequently 21 U/L.

DISCUSSION:

Minor PD injuries are common in acute pancreatitis resulting in peripancreatic fluid collections. The fluid collection is often contained and results in pseudocyst formation. Pancreatic fluid collections can also leak into the peritoneum leading to pancreatic ascites. The majority of cases occur in males in the 5th decade of life. Pancreatic ascites is primarily exudative with markedly raised ascitic amylase and protein content greater than 2.5 g/dl. Medical management includes diuretics and somatostatin analogs. If this fails, ERCP with PD stent placement is performed. This decreases intraductal pressure and diverts pancreatic secretion to the small bowel, thereby enhancing healing of the disrupted PD. Surgical therapy is recommended for patients with a lack of response to conservative therapy for 3-4 weeks or failure of endoscopic intervention. Our case report demonstrates the utility of endoscopic PD stent placement in patients with recurrent pancreatic ascites.
3016 Can Primary Biliary Cirrhosis Cause Bradycardia?
Authors: Awad Mohammed T. , Ghazaleh Sami , Reddy Aravind , Ghanim Marcel , Ye Feng , Nehme Christian , Alkhathlan Mujahed , Assaly Ragheb
Published: October 2019

INTRODUCTION:

Obstructive jaundice is a known cause of sinus bradycardia. It is usually attributed to the effect of bile salts on the electrophysiology of the heart and mainly on the SA node. But can Primary biliary cirrhosis cause bradycardia? Here, we are presenting a case of sinus bradycardia with a junctional rhythm that could be secondary to primary biliary cirrhosis.

CASE DESCRIPTION/METHODS:

A 65-year-old female with a history of primary biliary cirrhosis complicated by esophageal varices and recurrent ascites. The patient presented with a syncopal episode. The patient had a history of episodes of lightheadedness for several days before admission. Upon arrival at the hospital, the patient was bradycardiac with heart rate around 30 and she was hypotensive. She was given several doses of atropine and then she was started on dopamine drip. Initial EKG showed that the patient has a junctional rhythm. After reviewing the patient cardiac history, we found that the patient didn't have any heart issues before and she had a coronary angiogram done one year ago and showed normal coronaries. Medications were reviewed and showed that the patient was on Metoprolol 25 mg twice daily for anxiety and she was on it for more than 10 years and there were no recent changes in the dose. Labs showed that the patient had mild elevation is AST 41 IU/L and ALT 62 IU/L. Total serum bilirubin was 1.7 mg/dl (mildly elevated) and direct bilirubin was 0.7 mg/dl (mildly elevated). After beta-blocker was held, the patient heart rate improved, and dopamine drip was discontinued.

DISCUSSION:

This is a case of primary biliary cirrhosis who presented with symptomatic bradycardia. This patient was on beta-blockers for a long period of time and she didn't have any heart issues given her last coronary angiogram and echocardiogram were normal. We believe that one of the contributors of the patient bradycardia is the primary biliary cirrhosis itself as it can cause bradycardia which is believed to be secondary to bile salts. In conclusion, primary biliary cirrhosis should be considered as a cause of bradycardia and the use of metoprolol in those patients should be closely monitored as Metoprolol is primarily metabolized by the liver and can intensify the bradycardia.
3019 Solid Pseudopapillary Tumor of the Pancreas: A Typical Presentation in an Atypical Patient
Authors: Osho Azeez , Ayoola Rotimi , Ibrahim Mohd Elmugtaba , Cezar Carensa , Taddesse-Heath Lekidelu , Aduli Farshad
Published: October 2019

INTRODUCTION:

Solid pseudopapillary tumor (SPT) of the pancreas is a rare neoplasm. It accounts for 1% of all tumors of the pancreas. It is a benign tumor with a low malignant potential and a favorable prognosis. It typically presents in young women, and on imaging it can be seen as a large encapsulated mass with solid and cystic components. The female to male predominance is 10:1. The following case shows a typical presentation of SPT in a male patient.

CASE DESCRIPTION/METHODS:

A 25-year-old man from Guatemala with no medical history presented with epigastric pain, nausea, vomiting, weight loss and poor oral intake. The abdominal pain was stabbing, intermittent, and radiating to the back. Family, social and surgical history were negative. Vitals were normal. On physical examination he appeared dehydrated with epigastric tenderness and a palpable left upper quadrant mass. Labs showed normal chemistry, liver function tests, lipase, CA 19-9, CEA and CA 125. Complete blood count showed an elevated white blood cell count of 23,000. Computerized tomography revealed a 7.6 × 10 × 8 cm heterogenous mass in the distal body and tail of the pancreas, with solid, and cystic components and calcifications. The patient underwent esophagogastroduodenoscopy (EGD) and endoscopic ultrasound with fine needle aspiration (FNA) of the mass. EGD showed a small non-bleeding duodenal ulcer. Pathology on the FNA revealed SPT. The patient underwent a distal pancreatectomy and splenectomy with negative margins, and a normal spleen. Lymph nodes were negative for malignancy. The patient did well post operatively with resolution of his symptoms.

DISCUSSION:

SPT is a rare tumor predominately seen in females. In men it tends to occur at an older age with an aggressive behavior. The origin of SPT is not clear. 60% of SPT are found in the body and tail of the pancreas. SPT is primarily benign but about 15% exhibit malignant features such as metastasis or invasion of adjacent structures. The most common sites of metastasis are the liver and peritoneum. Typical presentation is a palpable abdominal mass with symptoms of abdominal pain, nausea, vomiting and early satiety. The histopathology of SPT reveals solid nests of poorly cohesive cells resulting in a pseudopapillary architecture with positive nuclear staining for beta catenin, positive immunostaining for CD10, CD56, vimentin; they are negative for chromogranin. Cystic fluid is often bloody with low CEA and low amylase. Surgical resection is curative. The five-year survival rate is 95%.
3022 Metastatic Colon Adenocarcinoma Presenting as a Hilar Obstructing Lesion Diagnosed With EUS-FNB
Authors: Arroyo-Mercado Fray Martin M. , Likhtshteyn Michelle , Haidary Tahmineh , Vignesh Shivakumar
Published: October 2019

INTRODUCTION:

Bile duct obstruction from periportal masses has a broad differential diagnosis.1 Cross-sectional abdominal imaging can help to detect periportal masses, but have low sensitivity in the diagnosis of proximal biliary and hilar lesions.2 Endoscopic ultrasound (EUS) allows for evaluation of periportal and biliary lesions and enables tissue diagnosis via fine needle biopsy (FNB). We present a case of a young patient who was presumed to have primary metastatic ovarian cancer; with EUS and ERCP guided sampling we arrived at a specific diagnosis of metastatic adenocarcinoma of colonic origin.

CASE DESCRIPTION/METHODS:

A 41-year-old female with a history of ovarian cancer s/p TAH and BSO and jejunal resection presented with painless jaundice, hematochezia, and high fever. Abdominopelvic CT scan showed a 2 cm mass in the region of the porta hepatis invading the portal vein and diffuse thickening of the rectosigmoid colon (Figure 1). Colonoscopy from a year prior was unremarkable, and subsequent colonoscopy was significant for hemorrhoids and hyperplastic polyps. Due to clinical suspicion for cholangitis, an ERCP was performed primarily for biliary drainage; a common hepatic duct (CHD) stricture and right hepatic duct dilation were found (Figure 2). Two 7 French 12 cm plastic stents were deployed across the common bile duct (CBD) stricture with their proximal end within the dilated right main hepatic duct. EUS showed a 2 cm lesion adjacent to the hilum that was invading the CHD and biliary bifurcation extending 1-2 cm distal and proximal to the bifurcation, portal, and hepatic artery. EUS-FNB demonstrated adenocarcinoma of jejunal origin based on cytokeratin markers (Figure 3).

DISCUSSION:

Specific diagnosis of periportal lesions involving the hilum of the liver is a limitation of cross-sectional imaging. EUS offers better visualization of the periportal region and enables tissue sampling for cytological or histological diagnosis. EUS-FNB has high sensitivity for diagnosis of lesions involving the common hepatic duct. It also enables assessment of vascular invasion and loco-regional staging, which is essential prior to therapy. Our case highlights, how EUS-FNB of a periportal lesion offered a specific diagnosis of metastatic colonic adenocarcinoma to the common hepatic duct. ERCP at the same session enabled biliary drainage that was essential prior to appropriate chemotherapy. The EUS FNB and ERCP with stent placement made a significant impact on the management of our patient.
3028 Glycogenic Hepatopathy Masquerading as Acute Relapsing Hepatitis: A Diagnostic Pitfall
Authors: Gallagher Bridget , El Younis Cherif
Published: October 2019

INTRODUCTION:

Glycogenic hepatopathy (GH) is a rare conditioned characterized by elevated liver enzymes, hepatomegaly with or without right upper quadrant pain, typically seen in poorly controlled diabetes type 1, rarely in type II. It is related to glycogen accumulation during periods of high blood glucose, and tends to resolve with improvement of glycemic control. The course of liver enzyme abnormalities is transient. We present a case of glycogenic hepatopathy masquerading as biliary stones.

CASE DESCRIPTION/METHODS:

A 54 year old female with no known liver, history of HTN, CVA and poorly controlled type 2 diabetes mellitus (T2DM), complicated by multiple episodes of DKA and hyperosmolar hyperglycemic state, presented to the hospital with abdominal pain, nausea, constipation and high liver enzyme abnormalities. This was preceded by an admission 2 months prior with hyperglycemia above 600, ketones, and similar liver enzyme abnormalities. Work up was initiated including liver US, CT scan, MRCP, viral and autoimmune serologies which were normal or negative (Graph 1). Liver biopsy in progress.

DISCUSSION:

The patient in this case report has risk factors for metabolic syndrome with HTN, BMI of 26, T2DM with poor control, with episodes of hyperglycemia, associated with peaks of liver enzymes that mimic hepatocellular or mixed injury, which resolved slowly with control of hyperglycemia, being completely normal between spikes. This pattern of presentation is typical for GH, a metabolic entity that was linked to poorly controlled diabetes, and is caused by transient accumulation of glycogen within hepatocytes that follows passive influx of glucose into hepatocytes utilizing hepatic glucose transporter-2. Long-term prognosis is unclear and may in recurrent cases progress to fibrosis and cirrhosis, similar to NAFLD. Clinical suspicion for GH is based on correlation between peaks of blood sugar and acute rise in LFTs as well as periods of normalization of LFTs corresponding to resolution of acute hyperglycemia. Recognition of this entity is highly significant, as not only direct the effort to correct the underlying metabolic abnormalities, it also avoids unnecessary and costly work up knowing its transient and self-limited course. Liver biopsy if confirmatory. Glycogenic hepatopathy is an underdiagnosed metabolic hepatopathy in the setting poorly controlled diabetes, completely reversible, and should be considered in patients with T1 or T2DM with risk factors for NAFLD who present with acute and relapsing hepatitis.
3040 An Uncommon Presentation of Post-Cholecystectomy Bile Leak in the Setting of Existing CBD Stent Successfully Managed With Metallic Stent Placement
Authors: Javaid Toseef , Al-Chalabi Ahmed , Tabassum Sadia , Sodeman Thomas , Nawras Ali
Published: October 2019

INTRODUCTION:

About 1% of patients undergoing cholecystectomy develop bile leaks. Bile leaks from cystic duct stump or from a duct of Luschka are the most common sites. Endoscopic biliary sphincterotomy and stent placement remains cornerstone in management of most post-operative bile leaks. We present an unusual case of post cholecystectomy bile leak from cystic duct stump in the presence of existing common bile duct stent.

CASE DESCRIPTION/METHODS:

A 48-year-old lady presented with 4 days history of worsening abdominal pain after cholecystectomy. She was admitted one week ago for acute exacerbation of chronic pancreatitis and underwent repeat ERCP. A plastic biliary and pancreatic stent was placed. She complained of RUQ pain and underwent HIDA scan which showed delayed gall bladder emptying suspicious for chronic cholecystitis. Given history of recurrent acute pancreatitis and chronic cholecystitis, cholecystectomy was recommended. Patient underwent laparoscopic cholecystectomy one week before this presentation. Abdominal exam on admission showed severe diffuse abdominal tenderness. X ray abdomen in ER showed non obstructive bowel pattern and possible ileus but no perforation. Labs showed WBC 13,000, TB 1.0, AST 11, ALT 20, ALP 186 and lactate 1.0. Given significant abdominal tenderness a CT abdomen and pelvis was done which showed moderate to large subcapsular and intraperitoneal fluid and 2 cm caudal migration of CBD stent with slight prominence of the adjacent common bile duct. HIDA scan showed collection of radionuclide activity along the inferior margin of the liver, increasing overtime, consistent with bile leak. A CT guided percutaneous drain was placed. Patient underwent ERCP 2 days after presentation. Cystic duct stump bile leak was seen which was treated with placement of 8 mm × 60 mm self-expandable fully covered metallic biliary stent (FCSEMS). Distal common bile duct stricture was again seen, measured 2.5 cm in length. Patient underwent repeat ERCP one month later with showed healed site of cystic duct stump leak.

DISCUSSION:

Presence of CBD stent does not preclude diagnosis of post cholecystectomy bile leak. In our case, CBD stricture, multiple previous endoscopic interventions and stent migration were reasons for failure to eliminate the transpapillary pressure gradient, thereby permitting preferential extravasation at the site of the leak. Further research is needed to establish role of FCSEMS in management of complicated biliary leaks especially in setting of CBD stricture.
3053 A Non-biopsied Mystery: Vasculitis or HSV Colitis?
Authors: Zghyer Fawzi , Wan David , Buffie Charlie
Published: October 2019

INTRODUCTION:

Ischemic Colitis is uncommon in patients with systemic lupus erythematosus (SLE). Herpes Simplex Virus colitis is also very uncommon and tends to occur in immunocompromised patients. Here we report a case of a patient with a lupus flare with ulcers in the colon and HSV esophagitis.

CASE DESCRIPTION/METHODS:

A 21-year-old female with a PMH of SLE complicated by lupus nephritis, thrombotic thrombocytopenic purpura, and factor XI deficiency admitted for nausea and low urine output. The patient was found to have an active SLE flare, complicated by Guillain-Barre syndrome. Ten days after admission, she was found to have BRBPR, loose stools and mild epigastric abdominal pain. She denied hematemesis. Clinical exam showed bright red blood and evidence of melena on digital rectal exam. Initial workup showed 1 g/dl hemoglobin drop. The patient's EGD revealed a non-bleeding distal esophageal ulcer which was biopsy proven to be herpetic HSV-1 esophagitis (Figure 1), and a single bleeding gastric angioectasia which was treated with argon plasma coagulation. Colonoscopy revealed multiple scattered small circumferential ulceration in the right colon suggestive of ischemic colitis which were not biopsied (Figures 2 and 3). The patient's GI bleed resolved, she was started on Acyclovir. She had complete resolution in her abdominal pain in a week.

DISCUSSION:

Vasculitis is one of the most commonly recognized complications of SLE. Ischemic colitis due to Intestinal vasculitis can often go unrecognized. The pathophysiology behind gastrointestinal ischemic colitis is the deposition of immune complexes in active disease which leads to tissue damage. Herpes simplex virus enteritis is a very rarely reported entity and tends to complicate the course of inflammatory bowel disease patients and immunocompromised patients. The case we are presenting is likely to be ischemic colitis secondary to SLE vasculitis. The segmental findings of ulcers on the right side of the colon suggest ischemia involving branches of the SMA and point towards SLE vasculitis as the vasculopathy leading to direct tissue damage and eventually ischemia. HSV colitis causes terminal diarrhea, and unlikely to be evident macroscopically. Nonetheless, the patient had active esophageal HSV and is on an aggressive immunosuppressive regimen, so high risk for disseminated HSV. Ultimately, colonic biopsies of the colonic ulceration would have confirmed a diagnosis, but given the overall clinical picture, SLE colitis is more likely.
3059 A Serious Case of Fecal Impaction
Authors: Bui Rosa
Published: October 2019

INTRODUCTION:

Fecal impaction is well described in the elderly and those with neurologic or psychiatric diseases, immobility, structural colon or anorectal abnormalities. Despite numerous laxatives on the market, chronic constipation remains a major problem. This case highlights fecal impaction, whether associated with underlying comorbidities or not, can lead to serious complications.

CASE DESCRIPTION/METHODS:

A 20 year old male presented with bilateral leg weakness and ataxic gait. CT scan showed massive stool burden in the rectum, distended to 11.3 cm by 10.4 cm. There was a resulting mass effect on the bladder and lumbar nerve roots. He underwent fecal disimpaction in the operating room under general anesthesia. Manual evacuation was performed followed by insertion of 32F chest tube and irrigation with normal saline, mineral oil and milk of magnesia. Post-op day 2, the patient was able to ambulate normally and was discharged.

DISCUSSION:

Causes of fecal impaction include colon cancer, strictures, adhesions, rectoceles as well as Hirschsprung's and Chagas disease. Manual disimpaction and enemas should first be attempted. If no success, rectal tube placement past the point of obstruction and irrigation, as in our case, is reasonable. Sigmoidoscopy is another option. Washout using oral laxatives can be attempted but is contraindicated with concurrent bowel obstruction. In extreme cases, decompressive laparotomy may be necessary. While any of these treatments can be attempted, prevention is key. Adequate fiber and hydration and biofeedback for anorectal dysfunction are crucial. Discontinuation of medications including opiates and anticholinergics are also important. If left untreated, complications include stercoral ulcer leading to hemorrhage, hydronephrosis, SIRS, bacteremia, perforation and even death. In a systematic review by Falcon et al., the most common complication was perforation, followed by obstruction, ulcer, and finally obstructive uropathy. Our case report is unique in identifying a young patient with such severe fecal impaction that led to neurologic compromise. Unfortunately, he never presented for outpatient followup and therefore no colonoscopy or anorectal manometry was done. Our patient could potentially have developed permanent neurologic sequelae, perforation and even death if treatment was delayed any further. This case highlights fecal impaction, whether associated with underlying comorbidities or not, can lead to serious complications therefore mandating prompt diagnosis and treatment.
3061 Solitary Brain Metastasis as the Initial Manifestation of Descending Colon Cancer
Authors: Yazawa Kentaro , Azuma Yuki , Kurokawa Tomohiro , Tsurita Giichiro , Shinozaki Masaru
Published: October 2019

INTRODUCTION:

Brain metastasis of colon cancer is often accompanied by metastasis to other organs, and the prognosis is poor. However, long-term survival is reported in some solitary brain metastasis cases. We present a case of descending colon cancer with brain metastasis and relatively long survival after surgery.

CASE DESCRIPTION/METHODS:

Having suffered from amnesia, dysgeusia and headache for 2 weeks, a 58-year-old woman visited a nearby hospital. With a projected tumor in the right occipital brain, she was referred and then admitted to our hospital. A CT scan showed a descending colon tumor, while the PET/CT scan showed fluid accumulation in a right brain tumor and a descending colon lesion. An open resection was indicated to remove a 35 × 40 mm brain tumor, followed by colonoscopy 7 days later, with the scope unable to pass through the entire circumferential tumor. Histopathologic diagnosis confirmed moderately and highly differentiated adenocarcinoma of the colon and moderately differentiated adenocarcinoma of the brain. This indicated colon cancer spread to the brain. The patient was treated with total brain irradiation of 30 Gy/10 times. With no evident distant metastases, she underwent left hemicolectomy 27 days after the brain surgery, removing a nearly 2-cm omental nodule neighboring the tumor. The serosa showed that the main lesion (a non-exposed type-2 tumor of 40 × 50 mm) retracted surrounding tissue. It mainly comprised moderately differentiated adenocarcinoma and poorly differentiated adenocarcinoma at the infiltration tip. Vascular invasion into the subserosa (SS) was observed with five lymph node metastases (N2) and adenocarcinoma in omental nodules (P1). Experiencing a good postoperative course and after treatment with chemotherapy, the patient survived 20 months after the brain surgery without evident brain metastasis relapse, despite liver metastasis 7 months after surgery.

DISCUSSION:

Although rare (0.4-1.8%), brain metastases have a high metastasis rate (82%), resulting in a low one-year survival rate after diagnosis (16%) and poor prognosis. However, long-term survival is frequently reported in cases with solitary brain metastasis. Resection is indicated for brain metastasis of colon cancer when life prognosis is longer than several months; excision causes no serious neurological symptoms; and brain metastasis spreads to no other organs or is well controlled. Surgical treatment, therefore, was considered suitable for our patient.