bluuebunny/crossref_metadata_2025 huggingface dataset:
2978 Hypothyroidism Is Associated With Lower Mortality in Hospitalized Patients With Cirrhosis
Authors: Panchal Dayna , Khawaja Umar Sharif , Choi Catherine , Motlaghazadeh Yasaman , Nasir Umair M.
Published: October 2019

INTRODUCTION:

The liver is involved in the synthesis of thyroid binding proteins, the peripheral conversion of T4 to T3, and thyroid hormone conjugation and excretion. Consequently, liver dysfunction is associated with a decrease in thyroid hormone levels. Previous studies have supported thyroid hormone levels to have a predictive role for survival in critically ill patients. Here, we seek to evaluate if hypothyroidism influences survival in hospitalized patients with cirrhosis.

METHODS:

The National Inpatient Sample (NIS) is an inpatient database comprising approximately 20% of all inpatient admissions to hospitals in the United States. From the database, we collected data from hospitalized patients with cirrhosis listed as primary or secondary diagnosis and divided them into two subgroups: those with a diagnosis of hypothyroidism and those without. We reviewed and compared the two groups for mean hospital length of stay in days, Charlson comorbidity index as well as rates in mortality. IBM Statistical Package for the Social Sciences (SPSS) was used for statistical analysis.

RESULTS:

A total of 338, 990 cases of patients from the 2012-2014 NIS database had cirrhosis as primary or secondary diagnosis. 35,135 of these patients (10.36%) had hypothyroidism. The mean length of hospital stay in patients with cirrhosis and hypothyroidism was 5.1 days and 4.9 days for those without hypothyroidism. Charlson comorbidity index was significantly higher (P < 0.05) in cirrhotic patients with hypothyroidism. In the patients with cirrhosis, the mortality was 4%. In the subgroup with hypothyroidism, the mortality was 3.2% while the other subgroup without hypothyroidism was 4.1%. After adjusted for age, sex, race, and the Charlson comorbidity index, the group of patients with hypothyroidism had lower mortality (OR: 0.74, 95% CI (0.7-0.8).

CONCLUSION:

Our results show that cirrhotic patients with hypothyroidism had a higher comorbidity but a lower rate of mortality in the hospital than those without hypothyroidism. A review of the literature showed no consensus of suppressed total thyroid hormone level and its association with mortality. Some studies demonstrate that lower fT3 levels are directly associated with severity of liver disease and that lower fT3 was associated with higher mortality risk in the ICU setting. Further studies should be done to explore this association.
2979 Transoral Outlet Reduction With Endoscopic Suturing for Weight Regain in Gastric Bypass Patients: Preliminary Results From a Single Center in Puerto Rico
Authors: Marzan-Loyola Adriana , Gregory-Gonzalez Federico , Micames-Caceres Carlos
Published: October 2019

INTRODUCTION:

Roux-en-y gastric bypass (RYGB) is currently one of the most common and effective weight loss procedures. The goal of bariatric surgery is not only to maximize weight loss but also to improve quality of life and attain nutritional health by reversing obesity-related comorbidities. Although RYGB is highly effective, weight regain or insufficient weight loss is common after the procedure. Insufficient weight loss and/or weight regain after bariatric surgery is commonly due to dilatation of the gastrojejunal anastomosis (GJA), thus reducing the restrictive capacity of the RYGB. For this reason, endoluminal interventions such as the Transoral Outlet Endoscopic Reduction (TORe) for GJA reductions have emerged as an alternative to invasive surgery revision.

METHODS:

Post-RYGB patients who experienced inadequate weight loss or significant weight regain and underwent TORe at Bella Vista Hospital in Puerto Rico were analyzed.

RESULTS:

A total of nine consecutive post-RYGB patients (mean age 53.7 yrs) underwent TORe a mean of 9.3 years after surgery. Average maximum weight loss was 85 lbs and average weight regain 47.9 lbs. Average weight was 233.1 lbs with an average body mass index (BMI) of 41.2 kg/m2 at the time of TORe. The average diameter of the GJ anastomosis prior to TORe was of 29.8mm (dilated diameter defined as >15 mm). After TORe the average diameter of the GJA was reduced to 6.1 mm with an average reduction of 23.7 mm (79.5% reduction). In 100% of cases the diameter of GJA was reduced to less than 12 mm. Five patients underwent pouch gastroplasty during the same session as TORe. No complications related to TORe were reported and all patients tolerated well the procedure. Follow up was provided to 9/9 patients at one month, 6/9 patients at three months and 3/6 patients at six months after the procedure with an average weight loss of 16.8 lbs, 32.6 lbs and 26.3 lbs, respectively.

CONCLUSION:

This clinical study, although limited by a small population size and the absence of a control group for comparison, suggests that TORe by endoscopic suturing may represent a safe and effective alternative for post-RYGB patients with insufficient weight loss and/or weight regain. Prospective studies with increased number of patients in our population are warranted to confirm these results.
2980 Obesity Does Not Increase Risk of Mortality in Necrotizing Pancreatitis
Authors: Bhurwal Abhishek , Tawadros Augustine , Pioppo Lauren , Reja Debashis , Sarkar Avik , Shahid Haroon , Tyberg Amy , Kahaleh Michel
Published: October 2019

INTRODUCTION:

Obesity is considered an independent risk factor for increased severity of acute pancreatitis. However, the association of obesity with acute necrotizing pancreatitis and the impact on outcomes of necrotizing pancreatitis is sparsely described. Therefore, we aimed at impact of obesity on necrotizing pancreatitis in terms of inpatient mortality, length of stay and hospitalization charges.

METHODS:

This was a retrospective study utilizing the 2016 National Inpatient Database for all principal discharges of acute pancreatitis in obese patients more than 18 years of age utilizing ICD 10 codes. Primary outcomes were incidence of necrotizing pancreatitis in obese patients. Secondary outcomes were mortality, impact on healthcare utilization between the two cohorts. Multivariate analysis was utilized to adjust for confounders for evaluation of predictors of mortality. Poisson regression was performed for length of stay and hospitalization charges.

RESULTS:

Among total of 288,479 discharges with principal diagnoses of Acute Pancreatitis, 13.83% were associated with obesity. Acute necrotizing pancreatitis was associated with only 0.8% of the obese population with pancreatitis. There were no significant differences in terms of age, gender, ethnic differences in obese and normal BMI cohort. Acute kidney injury in necrotizing pancreatitis was more frequently observed in obese patients. There were no increased odds of mortality in obese patients with necrotizing pancreatitis as compared to patients with normal BMI after adjustment of confounders. Increasing age and male gender were significantly associated with increased odds of mortality in necrotizing patients. The length of stay was not significantly different in either of the cohorts (11.72 days vs 14.53 days). However, hospitalization charges were significantly higher in obese patients with necrotizing pancreatitis (27,867$ vs 44,113$, P 0.02).

CONCLUSION:

Even though obesity is an independent risk factor for severity of acute pancreatitis, incidence of obesity with necrosis was infrequent from a National Cohort. Acute kidney injury was more common in setting of obesity with necrosis which might explain the increased severity. However, obesity did not independently increase the odds of mortality in setting of necrotizing pancreatitis. Increasing age and male gender in setting of necrotizing pancreatitis leads to increased mortality. Further studies are warranted to elucidate the association of gender and necrotizing pancreatitis.
2983 Impact of Proper History Taking Upon Healthcare Cost
Authors: Saleem Saad , Weissman Simcha , Bleibel Wissam
Published: October 2019

INTRODUCTION:

The most important action that a healthcare provider can take to establish an accurate diagnosis is to elicit a precise history from the patient, however its the most neglected part. In this modern world, physicians rely on machines for diagnosing the pathology. In this study, we evaluated the outcome of proper history taking on establishing a diagnosis and its effect on hospital length of stay and cost.

METHODS:

A cross-sectional analysis was conducted using the de-identified data from the national health database, the Healthcare Cost and Utilization Project (HCUP). We identified the hospital encounters for “Spontaneous bacterial peritonitis (SBP)” using international classification of Diseases (ICD-9) diagnostic codes from 2011 to 2014. We assessed the prevalence of abdominal pain in the inpatient SBP cohort and determined whether the prevalence of abdominal pain varied with hospital stay and cost. The inclusion criteria included age between 30-60 years, history of liver cirrhosis, and ascites. Exclusion criteria included a history of dementia and hepatic encephalopathy as these patients were unable to provide history on admission. P-values less than 0.05 indicated a statistically significant association. Age was compared with Student T-test, and Categorical factors were compared with Chi-square tests. Data were analyzed using SPSS.

RESULTS:

A total of 1,854 SBP inpatient admissions were identified with prevalence of abdominal pain (history) 3.61%. Demographics between abdominal pain and without it included; age - mean with standard deviation (SD) 49.40 + 11.04 yrs vs. 55.15 + 22.10 yrs (P = 0.16), sex - male 47 (70.1%) vs. 1212 (67.8%), length of stay (mean with SD) 4.82 + 3.03 yrs vs. 6.25 + 5.44 yrs (P = 0.03), number of diagnosis on discharge (mean with SD) 15.78 + 5.2 vs. 14.87 + 5.1 (P = 0.15), number of procedures (mean with SD) 2.03 + 2.139 vs. 2.30 + 2.121 (P = 0.3) and hospital charges (mean with SD) $31757.79 + $23904 vs. $47650 + $58501 (P = 0.02).

CONCLUSION:

This study concluded that the proper history taking streamlined the patients into the accurate diagnosis and management of the disease, reducing the hospital length of stay and healthcare cost. Through our study, the awareness will spread in the healthcare society about the significance of the history and physical examination, therefore, decreasing the healthcare cost.
2995 Gastrointestinal Upset: Could E-Cigarettes Be the Cause?
Authors: Debnath Dipanjan , Singh Pratiksha , Rao Vanjarapu Jagan Mohan , Wert Yijin , Shrimanker Isha , Goel Siddharth , Nookala Vinod , Cheriyath Pramil
Published: October 2019

INTRODUCTION:

In the United States, use of electronic cigarette (EC) has seen an exponential rise with 12.6% of adults using an EC at least once in their lifetime, with use differing by age, sex, and race. The level of nicotine exposure with EC is highly variable with its liquids containing 14.8 to 87.2 mg/ml of nicotine. Its use has been documented to be associated with adverse effects on the respiratory, nervous, cardiovascular, and gastrointestinal (GI) system. Common adverse effects on the GI system include xerostomia, oral mucositis, tongue discoloration, gingivitis, gum bleeding, nausea, vomiting, heartburn, and altered bowel habits.

METHODS:

A retrospective review of the National Health and Nutrition Examination Survey (NHANES) data between 2015-16 was conducted. Data regarding the use of EC and a history of vomiting and diarrhea over a period of 30 days were analyzed. Additionally, data regarding age and sex were analyzed. A P-value of < 0.05 was considered statistically significant. Continuous and categorical variables were analyzed using the two-sample t-test and the Chi-Square test, respectively. All the analyses were done in SAS 9.4 (SAS Institute, Cary, NC).

RESULTS:

A total of 944 participants were included in the study. Of these, 261 participants (males 62.84%) used EC at least one day and 683 participants (males 54.76%) never used EC, during the preceding 30 days. Amongst EC users (n = 261), 10.73% had a stomach or intestinal illness manifesting as vomiting or diarrhea that started during those 30 days compared to 8.64% who never used EC during the same period (n = 683). However, the results did not reach statistical significance (P = 0.3208).

CONCLUSION:

Conflicting views exist regarding the effects of EC on the GI tract. Our study demonstrated an association between EC consumption and vomiting and diarrhea. The study results are to be viewed taking into consideration the limitations of a smaller sample, shorter duration, existing comorbidities, and undefined nicotine content in the EC. Although recent studies have shown no effect of EC on the oral or gut microbiota, our study findings could be attributed to EC induced alteration of motility or irritation of the GI tract. However, further studies are required to establish a causal relationship and enunciate the mechanism by which EC components affect the GI tract. Careful consideration and diligence about the health effects of EC is required before it is assumed to be safe as a cigarette substitute or as a means of smoking cessation.
3006 Levofloxacin: Beyond Tendon Ruptures
Authors: Sahami Nima , Poudel Rosina
Published: October 2019

INTRODUCTION:

Fluoroquinolones have long been an antibiotic of choice for their broad spectrum coverage. The medical community is well aware of its common side effects such as tendon rupture and Qt prolongation. However, there have been documented life threatening hypoglycemic episodes associated with Fluoroquinolones when used concurrently with oral hypoglycemic agents. Severe hypoglycemia may not be evident in this population after a single dose, but multiple factors when present concurrently places these patients at risk of life threatening hypoglycemic events.

CASE DESCRIPTION/METHODS:

Patient is a 52 year old female with a past medical history of T2DM on glimepiride and metformin, CKD-IIIa, OSA, HTN, HFpEF, presented with AMS for 1 day. On arrival BG was 22 and patient was only responsive to painful stimuli which temporarily resolved with 2 amps of D50. Two days prior patient was treated with levofloxacin for a URI. Patient endorsed decreased oral intake, decreased urine output for 2 days, and taking scheduled 20 mg of Lasix BID for heart failure. Review of systems was otherwise negative and patient was compliant with medications. Shortly after admission, patient started having severe hypoglycemia despite repeated doses of D50 and D 10 ggt was initiated. Pertinent lab findings revealed reduced renal function. After the initial 16-40 hours required for clearance of glimepiride, patient still required D10 drip to maintain euglycemia. At this point we other causes of sustained hypoglycemia such as insulinoma, exogenous insulin use, and levofloxacin induced hypoglycemia were entertained. A hypoglycemic agent screen, insulin levels, c-peptide were consistent with endogenous increase of insulin. Fifty five hours after last dose of levofloxacin blood glucose levels were stabilized and patient was D10 drip was discontinued and subcutaneous insulin was initiated. Renal function returned to baseline and patient was discharged on metformin and lifestyle modifications.

DISCUSSION:

The mechanism of fluoroquinolones induced hypoglycemia is thought to due to stimulation of pancreatic beta cells causing hyperinsulinemia and interference with the CYT P450 enzymes leading to supratheraputic levels of antihyperglycemic agents such as glimepiride. These factors in conjunction with reduced renal function create the perfect storm which can precipitate life threatening hypoglycemia. Thus, Fluoroquinolones induced hypoglycemia should be on the differential in diabetic patients recently treated for URI infections.
3010 Duplicated Gallbladder: A Rare Cause of Recurrent Cholecystitis in a Hispanic Woman
Authors: Bello Fatimah O. , Rivas Cynthia , Tijani Aramide , Rivera Arturo Suplee , Cantazaro Brandon , Rapoport Grigoriy , Herrera Henry R.
Published: October 2019

INTRODUCTION:

Duplicated gallbladder (DG) is a rare congenital anomaly, affecting approximately 1 in 4000 births. Few reports exist describing acute cholecystitis in DG patients, with even less case reports of chronic cholecystitis. In this case we present a case of CC in a Hispanic woman with a DG.

CASE DESCRIPTION/METHODS:

A 49-year-old Hispanic woman with a history of dyslipidemia and diabetes presents to the ED with a 5-hour history of 10/10 crampy, mid-epigastric, non-radiating abdominal pain associated with subjective fevers, nausea and non-bloody, non-bilious vomiting. Patient had similar pain episodes in the past requiring hospital admissions. She was hemodynamically stable with a physical exam remarkable for moderate distress from pain and significant epigastric and right lower quadrant abdominal tenderness on palpation. Laboratory exam was significant for WBC- 12 th/uL (N: 4.8-10.9 th/uL), hemoglobin - 9.0 gm/dL (10.8-14.7 gm/dl) and ALP- 133 IU/L (N: 34-104 IU/L). Urinalysis was positive for WBC, bacteria, leukocyte esterase and nitrite. Abdominal ultrasound, CT abdomen and HIDA scan were suggestive of a DG. The patient was taken for a cholecystectomy. In the OR she was found to have a DG with 2 fundi merged at the Hartman's pouch, likened to the Boyden's vesica fellea divisa classification type. Pathology results revealed chronic cholecystitis and cholesterolosis in the DG. Patient continues to maintain significant clinical improvement post-surgery and she continues to be under close follow-up.

DISCUSSION:

CC is defined by the histopathologic appearance of chronic inflammation of the gallbladder and is believed to develop due to the presence of gallstones, although cases of acalulous CC also exist. As in our case, patients typically present with pain, however pain severity and liver enzyme alterations do not usually correlate with disease presence. To the best of our knowledge, no similar cases have been reported in the Hispanic population. In patients presenting to the ER, a high index of suspicion is recommended to improve overall patients' outcomes especially in patients presenting with multiple disease processes.
3012 Pancreatic Ascites in a Patient With Thromboembolic Disease
Authors: Ali Birmaji , Fahim Peter , Kindel Robert
Published: October 2019

INTRODUCTION:

Pancreatic ascites is a rare condition characterized by abdominal pain, weight loss and progressive ascites. It is a complication of pancreatic duct disruption leading to leakage into the peritoneal cavity. The epidemiology is not well studied, which makes diagnosis challenging for clinicians.

CASE DESCRIPTION/METHODS:

A 54-year old female with a history of alcohol abuse, alcoholic cirrhosis, and chronic pancreatitis with pseudocyst presented to the Emergency Department with pleuritic chest pain, right calf pain and swelling for several days. She also had chronic abdominal pain, nausea, vomiting and poor appetite with 10-pound weight loss in 3 months. Her pseudocyst was routinely followed up with no significant change. The patient's significant vitals included BMI of 14.45 kg/m2, tachypnea and tachycardia. Physical examination revealed epigastric tenderness, abdominal distension and right calf swelling. Significant labs included hypoalbuminemia 1.3 g/dL, D-dimer 13.68 mcg/mL and Pro-calcitonin 19.92 mcg/L. CTA of chest revealed bilateral pulmonary emboli with right heart strain. Lower extremity duplex was positive for right femoral DVT. Patient was subsequently started on heparin infusion. A CT scan of abdomen and pelvis revealed an unchanged 2.2 × 1.1 cm pseudocyst in head of pancreas. Diagnostic paracentesis showed fluid analysis of albumin 0.5 g/dl, protein 1.4 g/dl and elevated amylase 836 U/L. The SAAG score was 0.8, which was clinical congruent with pancreatic ascites. MRCP identified the pseudocyst having a thin tubular extension along anterior pancreatic body. ERCP with pancreatic duct sphincterotomy and stent placement did not provide clinical improvement. EUS visualized a 6.6 cm fluid collection between stomach and spleen, with the pseudocyst was 1 cm adjacent to the gastric wall. It was aspirated and metal stent was placed to dilate entry into pseudocyst via endoscopic cystogastrostomy. The fluid content was finally suctioned out. The patient clinically improved and was discharged on warfarin. The stent was removed a month later.

DISCUSSION:

This case illustrates the importance of immediate paracentesis in diagnosing pancreatic ascites, a rare and potentially fatal condition if left untreated. Diagnosis is made with elevated fluid amylase, low SAAG score and clinical picture congruent with chronic pancreatitis with accompanied pseudocyst or severe acute pancreatitis. Early endoscopic intervention has shown highly successful at reducing mortality, hospital length of stay and recurrence.
3014 A Rare Case of Fioricet-Induced Acute Pancreatitis
Authors: Sonpal Niket , Olaosebikan Kikelomo
Published: October 2019

INTRODUCTION:

Acute pancreatitis is the inflammation of the pancreas leading to a very severe line of symptoms of which a very prominent one is excruciating abdominal pain; it is a common acute surgical presentation in the western world. The organ which has an important role in digestion due to hormone production including insulin (Santhi et al 2019). The annual incidence of acute pancreatitis is ∼20-40/100,000 population (Dhiraj Yadav et al 2014). About 40% are due to gallstones, 25.6% idiopathic, 22% alcohol induced and 3.9% post ERCP (Nesvaderani, M. et al 2015). Fioricet (Butalbital-Acetaminophen-Caffeine), a medication used in tension headaches due to the combination of acetaminophen for pain, caffeine to increase effects of acetaminophen and butalbital a sedative which helps to decrease anxiety and cause relaxation. We present a case of a female suspected to have acute pancreatitis due to fioricet.

CASE DESCRIPTION/METHODS:

A 46-year-old female with a BMI of 27 came to the ED with complaints of epigastric abdominal pain which had started the day before, radiates to back and right flank pain with the severity of 10/10 on the pain scale with associated nausea and with no vomiting. Previous history of Kidney stones, cholelithiasis (with a cholecystectomy), Hypothyroidism and Migraines for which she had been on Fioricet for over five years and takes the medication with the frequency of attacks. The patient denies any history of drinking and alcohol or drug abuse, with a known allergy to Hydrocodone. Ultrasound showed no acute pancreatitis, Ct Imagining with i.v contrast depicted acute pancreatitis, although labs showed; amylase-43, lipase-226, ast- 35, alt- 30, total bilirubin-0.3, WBC- 16.6 (left shift). To rule out autoimmune activity due to the history of hypothyroidism, Immuno-serology showed; Igg- negative, Ana- negative. An MRCP was performed showed no evidence of intra and extra-hepatic duct dilation, heterogeneous signal intensity was noted around the pancreas, compatible with pancreatitis. With all arrows pointing at the medication Fioricet.

DISCUSSION:

In conclusion, one of the active ingredients acetaminophen is documented as a class II medication (medications implicated in more than 10 cases of acute pancreatitis) (Trivedi CD et al 2005) due to the evidence stated above, we need to be cautious with long term therapy of fioricet in patients with chronic migraine and implement better screening techniques to avoid such complications which could lead to a more devastating outcome.
3018 Not Only Bullets Kill in War: A Case Report of Klatskin Tumor in a Veteran
Authors: George Justin , Alkayali Talal , Campdesuner Victoria , Ramos-Chaves Belissa , Wiese-Rometsch Wilhelmine
Published: October 2019

INTRODUCTION:

Cholangiocarcinoma (CAA) is a rare GI malignancy in the United States with a reported incidence of 1-2 per 100,000 person. Classification is based on location within the biliary tree with 50% of cases occurring at the perihilum. CAA located at the bifurcation of the common hepatic duct are called Klatskin tumors. Curative treatment is by complete resection versus palliative approach to non-resectable tumors.

CASE DESCRIPTION/METHODS:

77 year old male veteran with history of CAD, DM II, and CKD III presented to the emergency department with sudden onset, painless jaundice associated with 20 pound weight loss, fatigue, and loss of appetite over the past 3 months. He appeared cachetic, jaundiced with scleral icterus noted. Abdomen was nontender without organomegaly. Diagnostic studies revealed ALP 1056, AST 266, ALT 416, and direct bilirubin 12. Abdominal US revealed cholelithiasis without biliary tract dilation or gallbladder wall thickening. MRCP showed obstruction at the hepatic hilum at the confluence of the left and right hepatic lobes with moderate intrahepatic bile duct dilation. ERCP revealed diffuse biliary ductal dilation with a mass in the common bile duct. EUS guided fine needle aspiration of the mass at the common hepatic duct was done. Bloodwork showed elevated levels of CEA. Complete staging showed a portocaval lymph node. Medical and surgical oncology teams agreed that the tumor was unresectable. Palliative gemcitabine and cisplatin were initiated.

DISCUSSION:

Risk factors for the development of CAA include hepatitis B, C, and primary sclerosing cholangitis. Vietnam war Veterans have unique risk factors including exposure to Agent Orange and parasitic infections including Clonorchis sinensis and Opisthorchisviverrini. Our patient spent 14 months on a naval base outside Cambodia. He admits exposure to raw and freshwater fish. The causal relationship between the two liver flukes and CAA is well documented. Of the 700 claims made to the Department of Veterans Affairs (VA), 75% have been rejected. Pilot prospective studies performed by the VA have shown exposure to these parasites in Vietnam veterans. To date, there is no commercial serologic test in the US to identify previous exposure to these parasites. Our case raises the question whether these veterans are at increased risk of CAA and whether there is any utility in screening for CAA in this population. Further studies are needed to establish whether this unique population is at increased rates for CAA.
3020 A Case of Necrotizing Pancreatitis Post-Cardiac Surgery and Exposure to Sulfamethoxazole-Trimethoprim
Authors: Ji Hyun , Lee Paul , Hafdahl Luke
Published: October 2019

INTRODUCTION:

Necrotizing pancreatitis is a serious complication of acute pancreatitis with high morbidity and mortality. We present a case of a 58 year old male diagnosed with necrotizing pancreatitis after cardiopulmonary bypass surgery and exposure to sulfamethoxazole-trimethoprim (TMP/SMX).

CASE DESCRIPTION/METHODS:

A 58 year old man presented with one week of jaundice and dyspnea. His history is significant for a recent cardiac surgery with coronary artery bypass grafts (CABG) and aortic valve repair (AVR) with a prolonged cardiopulmonary bypass time (CPBT) aortic cross-clamp time (ACCT). After the surgery, he was prescribed a course of TMP/SMX for an unknown indication. On assessment, he denied any other symptoms and had no history of alcohol use. He was hemodynamically stable with physical examination notable only for generalized jaundice. Lab findings were significant for hemoglobin 6.2 g/dL, WBC 19 × 10(9)/L, K 5.8 mmol/L, BUN 82 mg/dL, Cr 2.82 mg/dL, total calcium 6.7 mg/dL, serum glucose 110 mg/dL, total/direct bilirubin 8.7/6.8 mg/dL, alkaline phosphate 503 U/L, ALT 343 U/L, AST 640 U/L, lipase 540 U/L, and triglycerides 212 mg/dL. CT of the abdomen showed acute necrotizing pancreatitis. He was treated with fluid resuscitation and antibiotics. ERCP was deferred as his cholestasis was thought to be due to extrinsic compression. His course was complicated by hemorrhagic conversion, acute renal failure, shock liver and gastric ischemia. Ultimately, he expired on hospital day 20.

DISCUSSION:

Drug-induced pancreatitis accounts for 0.1-2% of cases of acute pancreatitis. Although TMP/SMX is classified as a potential cause of pancreatitis, the data is sparse with limited reported cases and a broad latency period ranging from 3 days to 20 years. Acute pancreatitis has also been described as a complication of cardiac surgery with an incidence of 0.4% per prior report. Notably, many of these patients are often asymptomatic, which makes early diagnosis of utmost priority. Factors that increase the risk of developing pancreatitis include prolonged CPBT/ACCT and combined CABG and valve repair, possibly related to splanchnic ischemia. Given that our patient with a recent cardiac surgery received a culprit antibiotic within several weeks of presentation, it is unclear whether TMP/SMX, cardiac surgery, or a combination caused our patient's episode of acute pancreatitis. Although rare, each of these factors should be considered when determining the cause of pancreatitis.
3023 Necrotizing Pancreatitis Following Ampullary Biopsy Without Biliary Cannulation
Authors: Stepanek Rachel , Bilal Mohammad , Parupudi Sreeram
Published: October 2019

INTRODUCTION:

Patients with familial adenomatous polyposis (FAP) have an almost 100% lifetime risk of developing colorectal cancer (CRC). In addition, they are at increased risk for developing cancers in the duodenum and ampulla. While pancreatitis is a known complication of ampullary manipulation, it typically presents within hours and is relatively mild. We present a unique case of a patient with FAP who underwent an excision biopsy for a diminutive ampullary adenoma and presented with necrotizing pancreatitis 12 days following the procedure.

CASE DESCRIPTION/METHODS:

A 70-year-old male with a history of FAP and CRC who is status post-total abdominal colectomy was found to have a 2-cm sessile polyp on the lateral wall of the duodenum and a diminutive ampullary polyp (Figure 1) on surveillance esophagogastroduodenoscopy (EGD). The lateral polyp was removed via piecemeal endoscopic mucosal resection. The ampullary polyp was cautiously removed via biopsy excision with an attempt to biopsy along the left lateral margin deliberately away from the tentative pancreatic duct orifice. Both lesions were tubular adenomas. The patient did well for 12 days post-procedure until he presented to the emergency department for epigastric pain, nausea and vomiting. On presentation, serum lipase was 2000 U/L. A CT scan of the abdomen showed necrotizing pancreatitis with an 11-cm peripancreatic fluid collection. The patient denied alcohol use, and imaging did not reveal any cholelithiasis. Serum triglycerides and IgG-4 levels were within normal limits. The patient was admitted, managed with intravenous hydration and early nutrition, and was discharged on hospital day 10. CT abdomen pelvis performed 3 months later showed an 8-cm pancreatic fluid collection consistent with walled-off necrosis (WON). The patient is completely asymptomatic and is being followed clinically with plan for repeat imaging in 3 months.

DISCUSSION:

Acute pancreatitis is a common complication following endoscopic retrograde cholangiopancreatography (ERCP), but is exceedingly rare without attempts at biliary/pancreatic duct cannulation. In our case, the patient developed necrotizing pancreatitis following an excision biopsy of a diminutive ampullary adenoma without any attempts at cannulation of the ampulla. Patients need to be adequately counseled about the risks of severe pancreatitis, and a high level of suspicion should be maintained for up to two to three weeks after a procedure.
3026 Rare Complication of Chronic Pancreatitis: Chronic Portal Vein Thrombus Causing Pre-Hepatic Portal Hypertension
Authors: Elbanna Ahmed , Aishwarya Shyamraj , Mustafa Al-Shammari , Watson Andrew , Pompa Robert , Gordon Stuart
Published: October 2019

INTRODUCTION:

Portal vein thrombosis (PVT) is an uncommon complication of chronic pancreatitis. PVT more commonly occurs as a complication of acute pancreatitis and is an indicator of severity of disease. Patients with chronic pancreatitis can develop a pre-hepatic portal hypertension (HTN) in the setting of PVT. These patients are at risk for variceal hemorrhage. Early identification and management is critical.

CASE DESCRIPTION/METHODS:

A 34 year old female with a history of familial hypertriglyceridemia leading to necrotizing pancreatitis complicated by PVT in the past presented with sudden onset dizziness. She was documented to have a history of liver cirrhosis. On presentation to the outside hospital (OSH), patient was hypotensive and was noted to have a 5 g drop in Hb compared to baseline. She was transferred to the ICU and required support with blood transfusions and vasopressors. EGD at OSH demonstrated grade 1 non-bleeding esophageal varices and portal hypertensive gastropathy. Patient was transferred to our institution for TIPS evaluation. On presentation to our institution, patient remained hemodynamically stable. Examination was consistent with ascites and a R sided pleural effusion, which was confirmed by imaging. She underwent a work-up for chronic liver disease, which was negative. Her ascitic fluid volume was insufficient for paracentesis. Thoracentesis was performed with removal of 1.4 L of transudate consistent with hepatic hydrothorax. Her course was complicated by worsening jaundice. She subsequently underwent liver biopsy with hepatic venogram and pressure gradients. Biopsy did not show evidence of cirrhosis and hepatic venogram was consistent with pre-hepatic portal HTN. MRCP demonstrated dilated common bile duct and main pancreatic ducts. ERCP demonstrated stenosis in the main bile duct, which was treated with plastic stent placement. Following endoscopic intervention, patient's jaundice dramatically improved. TIPS was deferred given patient's history of PVT as well as limited efficacy in the absence of cirrhosis.

DISCUSSION:

Among reported cases of pre-hepatic portal HTN, chronic PVT secondary to chronic pancreatitis is rare. More commonly, splenic vein thrombus is described, resulting in a sinistral portal HTN with a predominance of gastric varices. Therapeutic considerations for pre-hepatic portal HTN are mainly focused on the prevention of variceal hemorrhage. Medical and endoscopic therapy is the standard of care. TIPS is an option for refractory cases.
3029 Complications from Hypertriglyceridemia-Induced Acute Pancreatitis
Authors: McKitish Kristin , Lee Clara , Sotiriadis John
Published: October 2019

INTRODUCTION:

Pancreatitis accounts for 275,000 hospital admissions annually. While alcohol consumption and gallstones are responsible for the majority of cases, hypertriglyceridemia accounts for only 7%. Most are treated successfully with intravenous hydration, pain control and triglyceride-lowering agents but complications do occur 15% of the time. We present a case of one such complication.

CASE DESCRIPTION/METHODS:

A 40-year-old previously healthy female presented with a 12-hour history of nausea and severe LUQ abdominal pain. She was admitted with acute pancreatitis secondary to hypertriglyceridemia. Labs revealed a lipase of 3653 U/L and triglycerides of 6160 mg/dL. Abdominal CT scan confirmed acute pancreatitis. She was treated supportively with aggressive IV hydration. Repeat imaging 5 days later showed a large fluid collection inferior to the gastric antrum, an extensive amount of free fluid layering the abdomen and a small to moderate left pleural effusion. Eventually her symptoms due to the evolving pseudocyst improved and she was discharged on day 22 with Fenofibrate and Omega-3-Acid Ethyl Esters. Six days later she was admitted for sepsis secondary to infected pancreatic pseudocyst. CT showed an extensive multi-locular fluid collection and worsening left pleural effusion. Ultrasound-guided drainage was performed and cultures reported E. coli. Antibiotics were tailored but patient remained hypotensive and tachycardic. At that point the patient underwent a diagnostic laparoscopy, which was converted to Roux En Y pancreatic cystjejunostomy for continuous drainage. Repeat imaging on post-op day one demonstrated an interval decrease in size of fluid collection. Eventually the patient was discharged home in stable condition.

DISCUSSION:

While pancreatitis due to hypertriglyceridemia remains common, life threatening complications are rare. Aggressive supportive care is the mainstay of therapy with early surgical intervention as needed.
3030 Klatskin Tumor: Dive in to Take a Closer Look…
Authors: Mulat Baruh , Shahid Tamoor , Figueredo Carlos , Hertan Hilary
Published: October 2019

INTRODUCTION:

Malignant tumors of the biliary tract are rare and highly lethal. Further sub classification of Cholangiocarcinomas defines Klatskin tumors, as extrahepatic bile duct tumors involving the hepatic duct bifurcation with distinct finding on dedicated imaging.

CASE DESCRIPTION/METHODS:

An 80-years-old former smoker female was referred by outpatient neurologist for unintentional 30-40 lb weight loss over 6 months, jaundice and abnormal LFTs. Her examination was unremarkable. Patient was found to have abnormal LFTswith ALP of 1210 U/L, GGT 1350 U/L, AST 388 U/L, ALT 300 U/L, TB 2.5 mg/dL (DB of 2.1 mg/dL). Tumor markers were grossly normal including CA 19-9 of 5 U/ml, CEA of 5 ng/mL and AFP of 5 ng/ml. CT abdomen and pelvis with IV contrast showed moderate to significant intrahepatic biliary ductal dilatation with a caliber change at the level of the porta hepatis, where there is abnormal soft tissue extending centrally to the liver. These findings are worrisome for Klatskin type tumor. Diagnostic EUS was started, however aborted once an infiltrating mass found in the gastric body causing luminal gastric narrowing restricting passage of EUS scope. Biopsies obtained from gastric mass, showed adenocarcinoma, poorly differentiated with signet-ring cell features and Helicobacter pylori positive stain.

DISCUSSION:

Despite progress, gastric cancers in the United States are still being diagnosed at an advanced stage, when become symptomatic and often incurable stage. Unintentional weight loss, early satiety and occasionally vague epigastric pain are often the presenting symptoms of an already advanced cancer. Gastric ulcers and H. Pylori infection have been shown to be precursors with potential carcinogenic effect. More unusual presentations give signs and symptoms secondary to direct extension of the tumor to nearby organs (most common to liver), or distant metastases to liver, peritoneum, Virchow's node (Supraclavicular lymph node), Periumbilical nodule (Sister Mary Joseph's node, or a left axillary node (Irish node). When metastases to liver are present, they are often diffuse or multifocal and rarely unifocal. Our case is interesting as the initial CT imaging was highly suggestive of a rare and lethal Klatskin tumor type of cholangiocarcinoma. The final decision to pursue a tissue diagnosis with a high risk procedure (EUS) was aborted by a surprising finding of a locally advanced gastric adenocarcinoma.
3031 Severe Acute Pancreatitis Secondary to Topical Cannabinoid Use
Authors: Ahuja Ashish C. , Aijazi Muaz
Published: October 2019

INTRODUCTION:

Acute pancreatitis is one of the most frequent gastrointestinal causes of hospital admission in the US. While almost 80% of cases are associated with alcohol or gallstones, the remainder often remain idiopathic with no identifiable cause. Here, we present the case of 74-year old male who presented with severe pancreatitis after topical cannabinoid use who eventually expired from complications of the disease.

CASE DESCRIPTION/METHODS:

74 year-old male with history of HTN, ischemic cardiomyopathy, stage 3 CKD, multiple strokes and lumbar spinal stenosis presented with sudden onset of abdominal pain. The pain began one day prior and was described as a sharp sensation in the epigastrium radiating to the chest. It was associated with dry heaving but no vomiting. The patient was having non-bloody diarrhea since the pain began. No fevers, but chills and diaphoresis were present. He denies any recent alcohol use and is s/p cholecystectomy. He endorses recently using topical cannabinoid oil for chronic low back pain. He was afebrile on arrival but hypertensive to 214/97. His labs were remarkable for WBC 23, H&H 17/54, lipase 47082, Cr 1.56, Tbili 1.9, ALT 210, AST 330, Alk Phos 211, EtOH level <5. CT abdomen/pelvis showed moderate acute, interstitial pancreatitis with small, non-loculated fluid collections. Despite aggressive fluid resuscitation, the patient required pressor support and was intubated. Abdomen US revealed no pancreatic or biliary dilation and surgically absent gallbladder. His condition continued to worsen and Nephrology initiated CRRT for anuric renal failure. He developed atrial fibrillation with hypotension requiring continuous amiodarone infusion. H&H began to drop and DIC developed rapidly. The patient expired after 10 days.

DISCUSSION:

After extensive work-up, no specific etiology was found for acute pancreatitis in this patient. The recent use of topical cannabinoid oil for chronic back pain showed a temporal correlation with the patient's medical condition and was thought to be the inciting factor leading to this patient's demise. Given the increased availability of cannabis in managing chronic pain, patients should be aware of the association between cannabis and acute pancreatitis. Additionally, health care providers should include cannabis (including all marijuana varieties and methods of consumption) in the differential diagnosis of acute pancreatitis cases with unknown etiology.
3033 Acute Pancreatitis Complicated by Pancreatic Pseudocyst and Splenic Hematoma, Management Considerations
Authors: Zarrin Arash , Choksi Vivek , Sorathia Sufian , Kasmin Franklin , Priyadarshni Shivani
Published: October 2019

INTRODUCTION:

Pancreatic duct disruption is a known complication of pancreatitis which leads to the formation of pancreatic pseudocysts, pancreatic ascites, and high amylase pleural effusions. Pancreatic pseudocysts migrate along with the pancreatic tissue and rupture either into surrounding organs or into the free peritoneal cavity. Splenic complications of pancreatitis are rare and include splenic vein thrombosis, splenic artery rupture, splenic rupture or infarction, and splenic hematoma.

CASE DESCRIPTION/METHODS:

39 y/o alcoholic male admitted for acute pancreatitis. Imaging revealed pseudocysts and ascites. Initially, he improved with supportive care but abdominal pain recurred owing to splenic rupture with resultant splenic hematoma. Splenic artery coiling was employed to stop bleeding. He returned for recurrent abdominal pain and new chest pain with interval increase in size of pseudocyst and interval development of pleural effusion. EUS revealed a multiloculated pancreatic pseudocyst, as well as pancreatic duct disruption. Transgastric drainage of the pseudocyst was performed with an Axios stent. Repeat endoscopy at interval showed complete resolution of the cyst.

DISCUSSION:

Studies estimate the incidence of pancreatic pseudocyst rupture into the spleen at a rate of up to 1.1% of patients with acute pancreatitis. Another study of patients with chronic pancreatitis reports splenic pseudocyst as the most common lesion, followed by splenic rupture and hematoma. A more recent study of 500 men with chronic alcoholic pancreatitis found that only 2.2% develop splenic complications with intrasplenic pseudocyst being the most common lesion, followed by splenic rupture and subcapsular hematoma. Findings associated with the highest risk of developing splenic complications included pancreatic tail necrosis, distal pseudocyst, or splenic vein occlusion. Previously, the mainstay of treatment for splenic hematoma was splenectomy with distal pancreatectomy. However, with the advent of advanced endoscopic procedures, patients are safely managed with splenic artery embolizationand EUS guided pancreaticogastrostomy or percutaneous drainage. Endoscopic drainage and percutaneous drainage of symptomatic pseudocysts are preferred to surgical management. Furthermore, recent reviews show that endoscopic drainage is superior to percutaneous drainage with lower rates of reintervention, shorter hospital stays, and need for less follow-up imaging.
3034 Acute Pancreatitis in a Patient With a Choledochal Cyst
Authors: Yang Grace H. , Apfel Tehilla , Shulik Oleg
Published: October 2019

INTRODUCTION:

Biliary cysts, also called choledochal cysts, are cystic dilatations that may occur singly or in multiples throughout the biliary tree. Cysts may be congenital or acquired and have been associated with a variety of anatomic abnormalities. The incidence of biliary cysts in Western populations has been estimated to be 1:100,000 to 1:150,000. Biliary cysts are associated with an increased risk of cholangiocarcinoma, pancreatic cancer, and gallbladder cancer. Malignancy is more common in patients who are older and in those with Type I and II cysts. As such, surgical resection is necessary. Due to stasis of bile flow in the cyst, other well-known complications include choledocholithiasis and pancreatitis.

CASE DESCRIPTION/METHODS:

A 35-year old woman presented to the ED with epigastric pain and lipase elevation to 700. She reported a history of a congenital hepatic cyst and previous history of cholecystectomy as a child. Over the last 2 years, she had been admitted to other hospitals for similar complaints. Initial ultrasound of the abdomen revealed common bile duct (CBD) dilatation to 2.3 cm with a filling defect of 1.5 cm. MRCP showed intra- and extra-hepatic dilatation and confirmed evidence of a filling defect in the CBD concerning for multiple intraductal and intracystic stones. The patient was conservatively managed while in the hospital and was discharged with close outpatient follow up. The following week, she underwent a Roux-en-Y hepaticojejunostomy. She was found to have a Type 1c choledochal cyst and an abnormal pancreaticobiliary junction.

DISCUSSION:

The approach to management of patients with biliary cysts depends on the cyst type. Patients with Type I, II, or IV cysts usually undergo surgical resection of the cysts due to the significant risk of malignancy, provided they are good surgical candidates. Type I and IV cysts should be completely resected with creation of a Roux-en-Y hepaticojejunostomy. The presence of an abnormal pancreaticobiliary junction (APBJ) increases the risk of malignancy, especially gallbladder cancer. Our patient had already had a cholecystectomy as a child. Patient continued to do well post-operatively without recurrence of her symptoms.