bluuebunny/crossref_metadata_2025 huggingface dataset:
1303 More Than Meets the Eye: Pancreatic Panniculitis as Presenting Sign of Invasive Pancreatic Adenocarcinoma
Authors: Gladys-Oryhon Jordan , Langhals-Totino Paige , Chaudhary Dhruv , Thakkar Shyam
Published: October 2019

INTRODUCTION:

Despite its first description by Chiari in 1883, pancreatic panniculitis remains an atypical manifestation of pancreatic disease, appearing in only 0.3-2% of patients. Although the pathogenesis remains unclear, biopsy-proven subcutaneous liquefactive fat necrosis has implicated elevated lipase, amylase, and trypsin in dissemination and subcutaneous deposition/lipolysis, manifesting as edematous, erythematous superficial nodules of the lower extremities, thigh, and buttock.

CASE DESCRIPTION/METHODS:

A 91-year-old male presented with 2-week history of painful erythematous nodular rash of bilateral anterior lower extremities. Rash began as small singleton lesion, approximately 1 cm each in size, which grew in diameter with progressively worsening tenderness. Outpatient punch biopsy revealed lobular fat necrosis and local inflammatory infiltrate, consistent with pancreatic panniculitis. Labs were significant for amylase 1026 U/L (ULN 100), lipase of 4366 U/L (ULN 78), CA 19-9 1600 U/mL, and CEA of 9.4 ng/mL. CT-abdomen/pelvis without contrast showed a normal appearing liver, atrophic pancreas with 1.5 cm cystic structure at the pancreatic head, and a 9 mm cystic structure within the pancreatic body. EUS/ERCP for suspected choledocholithiasis with concomitant malignancy revealed 5 mm dilation of the main pancreatic duct with associated 21 mm × 17 mm mass of mixed solid and cystic consistency with multiple anechoic lesions throughout the pancreas suggestive of cysts. Fine needle biopsy revealed invasive ductal adenocarcinoma with associated high grade intraductal papillary mucinous neoplasm. He completed staging work-up and underwent Whipple Procedure with negative margins.

DISCUSSION:

Although a rare dermatologic manifestation of underlying pathology, pancreatic panniculitis serves as a herald of severe pancreatic pathology. Subcutaneous biopsy of suspicious lesions is invaluable in identifying the etiology and ultimately diagnosing underlying pancreatic pathology. Histologic evaluation following punch biopsy of nodules reveals liquefactive fat necrosis, surrounded by a neutrophil-rich mixed inflammatory infiltrate with pathognomonic “ghost cells”. Treatment of the underlying disease process can lead to resolution of the nodules. Our patient presented with pancreatic panniculitis as the initial manifestation of internal occult malignancy in the absence of typical symptoms. Prompt recognition and biopsy of suspicious nodules led to an expedient diagnosis of locally resectable disease.
1304 The Great Mimicker: Leptospirosis
Authors: Alegre-Boschetti Sergio M. , Betancourt-Guzmán Natalia , Fernández Carlos , De Jesús Henry , Magno Priscilla
Published: October 2019

INTRODUCTION:

Leptospirosis is the most prevalent zoonotic disease with higher incidence in the tropical regions. Humans are infected after direct contact with urine of an infected animal or environmental exposure. Most infections are asymptomatic and self-limited while a severe life-threatening infection, known as Weil's disease, occurs in about 10% of patients. Among those with severe disease, hepatitis, acute kidney injury, myocarditis, and rarely, acute pancreatitis can develop. We herein report a case of an acute pancreatitis as an uncommon presentation of severe leptospirosis.

CASE DESCRIPTION/METHODS:

71-year-old male patient with past medical history of hypertension, diabetes mellitus, presented with complaints of abdominal pain, myalgia, nausea as well as vomiting for seven days prior to admission. Patient has not been able to tolerate food due to nausea and severe diffuse abdominal pain. Initial physical examination was remarkable for dry oral mucosa and jaundice. Laboratory evaluation demonstrated microcytic anemia with Hgb 9.4 g/dL, WBCs in 9.7 × 10-3/ul with neutrophil predominance, and acute thrombocytopenia. A complete metabolic panel showed a severe direct hyperbilirubinemia with normal liver enzymes and an increased creatine, 1.5 times baseline. Lipase levels were three times upper limit that along with presenting symptoms suggested an acute pancreatitis. Further examination with an abdominal sonogram revealed a diseased acalculus gallbladder with a positive Murphy sign and no obstruction of the biliary tree. Initial clinical diagnosis of severe acute pancreatitis was made, however, findings of non-obstructive jaundice along acute renal failure raised the suspicion of Weil's disease. Acute medical care included intravenous ceftriaxone with adequate clinical response. During admission Leptospira IgG titers were positive with specificity of 100%. Following treatment with ceftriaxone the patient was uneventfully discharged home to complete oral doxycycline therapy for a total of seven days.

DISCUSSION:

Leptospirosis in Puerto Rico accounts for approximately 50% of all the cases reported in the United States. It is of foremost importance to be aware of the diverse clinical manifestations of Weil's disease, often, confused with a viral illness. Unusual etiologies can lead to common complaints in this case an acute pancreatitis; therefore, early identification and acute care management of infectious diseases can positively influence patient's outcome.
1306 Endoscopic Mucosal Resection of Pancreatic Rest Presenting as a Submucosal Nodule in the Gastric Antrum
Authors: Bahirwani Janak , Duarte-Chavez Rodrigo , Mehta Sagar V. , Tayel Hussam , Tayel Hesham , Matin Ayaz
Published: October 2019

INTRODUCTION:

Pancreatic rest (PR) is defined as ectopic pancreatic tissue outside the normal pancreatic parenchyma, with a vascular and nerve supply separate from the pancreas itself and has a prevalence of 0.55-14%. It is believed to arise during rotation of the foregut, when fragments of the pancreas become separated from the main body and are deposited at ectopic sites.

CASE DESCRIPTION/METHODS:

An 82-year-old male with a history of GERD presented with episodes of epigastric abdominal pain of 2 month duration that did not improve despite PPI therapy. He denied any other symptoms such as bleeding, weight loss or change in bowel habits. Physical examination revealed a non-distended abdomen and mid-epigastric tenderness. An EGD performed for evaluation of GERD 3 years prior found an antral nodule. A repeat EGD was done this time for evaluation of the epigastric pain and showed a mobile submucosal nodule in the antrum measuring 7-8 mm, unchanged from before. EUS was performed for further evaluation and showed a hypoechoic gastric submucosal lesion, arising from the muscularis mucosa, 8 mm in size. No high-risk features were present. The area was resected using EMR and the defect was closed with clips. The EUS also showed a cystic dilation of the pancreatic duct in the pancreatic head measuring 5 mm, suspicious for main duct IPMN. Results from the EMR biopsy demonstrated heterotopic pancreatic tissue with focal low grade pancreatic intraepithelial neoplasia (PanIN), with clear margins and reactive gastropathy with focal intestinal metaplasia. There was resolution of the abdominal pain after the procedure. A repeat EGD/EUS will be done in 1 year. MRI will be performed in 6 months for surveillance of the pancreatic duct dilation.

DISCUSSION:

PR can be found virtually anywhere along the GI tract, but they are typically found in the stomach along the greater curvature and antrum. Although usually asymptomatic, the most reported symptom is mid abdominal pain. Complications of gastric ectopic pancreas include acute or chronic pancreatitis, necrosis, pseudocyst, gastric outlet obstruction and rarely carcinoma. PanIN is neoplastic epithelial proliferation that occurs in the small caliber pancreatic ducts; it is divided in 3 degrees based on architectural and nuclear atypia and has potential progression to invasive ductal adenocarcinoma. In our case, PanIN 1 was found on histology and the lesion was completely resected. PR should always be considered when evaluating a submucosal lesion of the GI tract.
1309 Multi-Drug Resistant Burkholderia Cepacia Infected Pancreatic Pseudocyst
Authors: Rawi Sarah , Mago Sheena
Published: October 2019

INTRODUCTION:

Burkholderia Cepacia is a gram negative bacillus that is most commonly associated with pneumonia in the immunocompromised, most specifically in the cystic fibrosis population. Pancreatic cysts have about 13.5% prevalence and are classified between non-neoplastic and neoplastic. Infected pseudocysts are non-neoplastic and a complication of pancreatitis.

CASE DESCRIPTION/METHODS:

A 45-year-old male with a past medical history of substance abuse, diabetes mellitus, and acute pancreatitis two weeks prior to admission presented to the ED unresponsive and hypoglycemic. Vitals were stable and physical exam was unremarkable on admission. With increased alertness he began endorsing epigastric abdominal pain, back pain, and early satiety. He then became febrile. Initially his labs were significant for: total bilirubin of 1.6 mg/dL, ALT 46 U/L, AST 65 U/L, and alkaline phosphate of 357 U/L. During the course of admission, his abdominal pain and satiety worsened, and his abdomen became distended. He became septic without a clear source. He underwent CT A/P, which demonstrated an 18.5 × 10.3 cm pseudocyst containing debris, thought to be a complication from his recent pancreatitis. The patient underwent CT guided biopsy for drainage and cultures, which grew MDR B. Cepacia. He was also found to have B. Cepacia bacteremia. The patient was started on Ceftazidime for a 2-month course. Unfortunately, after drainage the patient continued to have symptoms and his bilirubin peaked at 5.9 mg/dL and AP peaked at 1855 U/L. This led to a cyst gastrostomy stent placement via EUS. Two weeks later, a biliary sphincterotomy was performed by ERCP with stent removal and a single segmental biliary stricture was found in the lower and middle third of the main bile duct. Repeat CT A/P two weeks after the ERCP and one month after the start of antibiotics, showed a decrease in the size of the cyst to 8.5 × 3.2 cm and the patient's symptoms were improving.

DISCUSSION:

This was a unique case of a common complication of pancreatitis. Although infected pseudocysts are associated with mixed anaerobes and aerobes, B. Cepacia has not been commonly reported. To the best of our knowledge, this is the first case to be associated with B. Cepacia infected pseudocyst. As such, there is value in including uncommon MDR organisms in the differential for infected pseudocysts. Moreover, as this patient was immunocompetent, this poses an area of future study, as this patient's IVDA history may be an essential risk factor for these organisms.
1310 A Rare Case of Biliary Pancreatitis Caused by Ampullary Somatostatinoma in a 46-Year-Old Female
Authors: Kloska Michal , Vaze Reema , Buckshaw Ricky , Shah Hiral
Published: October 2019

INTRODUCTION:

Somatostatinoma is a rare neuroendocrine tumor predominantly found in the pancreas and the duodenum and only in 3% of cases within ampulla of Vater. Affected people usually present with abdominal pain, GI bleed, obstructive jaundice or when metabolically active with somatostatin syndrome (DM, diarrhea, cholelithiasis). Somatostatinoma is typically a large malignant tumor usually with metastatic disease on presentation.

CASE DESCRIPTION/METHODS:

This is a case of a 46-year-old female with a medical history of cholecystectomy, fatty liver and diabetes mellitus who presented with a two-day history of scleral icterus, clay-colored stools and dark urine. On initial evaluation, she was afebrile and normotensive. Her lab work was consistent with acute pancreatitis (lipase 2498 U/L) as well as an obstructive biliary disease (ALP 1210 U/L; bilirubin 6.3 mg/dl; AST 157 U/L; ALT 153 U/L). CT scan of the abdomen showed a 1.5 cm bulbous irregular ampullary lesion and moderate intra-and extrahepatic as well as pancreatic duct dilation. Further evaluation with EUS revealed a 12 mm × 12.7 mm hypoechoic mass of the ampulla and FNA was obtained. ERCP revealed dilated bile ducts with the possibility of subtle stricture in the distal most portion of the CBD. Brushings were performed and 10 mm × 60 mm fully covered biliary metal stent was deployed with resolution of patient's symptoms and improvement of her liver enzymes. Cytology results from the stricture were negative for malignancy. EUS FNA was positive for neoplastic cells immunoreactive with synaptophysin and somatostatin. Unfortunately, the patient did not follow up until she developed abdominal pain 2 years later. Repeated CT of the abdomen showed 0.9 × 0.6 cm mass in periampullary region decreased in size from previous CT. ERCP revealed epithelization and tissue regrowth in the stent. Two 7 Fr, 7 cm Boston Scientific double-pigtail stents were placed through the previous metal stent with successful decompression. Pancreaticoduodenectomy is scheduled with surgical oncology.

DISCUSSION:

Somatostatinomas, especially in the ampullary region, may present as painless jaundice leading to acute biliary pancreatitis. Interestingly, even after patient was lost to follow up for 2 years, she did not develop metastatic disease which is usually found with first presentation of the disease. Nevertheless, due to high metastatic potential every case when possible should be treated radically and pancreaticoduodenectomy is the treatment of choice.
1312 A Prognosis Worse Than Pancreatic Adenocarcinoma—Metastatic Pancreatic Adenosquamous Carcinoma
Authors: Dharmavaram Gourisree , Shah Raj , Katz Jeffry
Published: October 2019

INTRODUCTION:

Adenosquamous carcinoma of the pancreas (ASCAP) is a rare subtype of pancreatic cancer with estimated incidence of 1% to 4% among all pancreatic cancers. We report a case of this infrequently encountered tumor.

CASE DESCRIPTION/METHODS:

An 80-year-old man with hypertension, hyperlipidemia, social drinking (2 drinks/week), and tobacco abuse (24 pack years) presented with epigastric pain radiating to the back. Abdominal CT scan showed inflammatory pancreatic changes that were consistent with acute pancreatitis. CA 19-9 at this time was 222. MRCP revealed hypointense calcifications at the pancreatic head and uncinate process with numerous peripancreatic pseudocysts (largest 2 cm), favoring a diagnosis of acute on chronic pancreatitis. He was treated conservatively, improved, and was discharged home. He presented two months later with worsening epigastric pain and a 17-pound weight loss. CA 19-9 was now increased to 725. Repeat MRCP demonstrated persistence of pseudocysts and new 0.9 mm stricture at the mid-CBD with dilation of proximal CBD to 11 mm. EUS with FNA showed a 13 × 20 mm solid lesion with cystic component in the pancreatic head, showing squamous cell carcinoma. EGD showed gastric stenosis at the pylorus, and prepyloric gastric biopsy had tumor cells positive for CK7, CDX2, D2-40 and ERG, consistent with invasive adenocarcinoma with lymphovascular invasion. Further review of pathology with mucicarmine stain showed that the pancreatic tumor had a small adenocarcinoma component with predominant squamous differentiation, concluding metastatic ASCAP as the final diagnosis. Given his age and diagnosis, the patient received hospice. He survived 37 days from the time of initial presentation.

DISCUSSION:

ASCAP is thought to develop from squamous metaplasia related to inflammation from chronic pancreatitis. Our patient's presentation was atypical showing radiologic changes of chronic pancreatitis despite only one prior episode of acute pancreatitis. The prognosis of ASCAP is worse compared to pancreatic adenocarcinoma (PDAC) with reported median survival of 7 months. Additionally, aside from the risk factors of smoking, older age, and male gender, also associated with the more common PDAC, no other specific risk factors exist for development of ASCAP. Given the rarity of this diagnosis and the rapid deterioration of our patient, further information on pathogenesis and serum markers of ASCAP is necessary for improved risk stratification and better treatments for this poorly understood entity.
1315 Groove Pancreatitis as a Rare Complication of TACE
Authors: Mirza Zeyn , Estremera Rodolfo , Martin-Ortiz Jose
Published: October 2019

INTRODUCTION:

Transarterial chemoembolization (TACE) is often performed for hepatocellular carcinoma. Side effects can occur due to arterial ischemia and cytotoxicity from chemotherapy delivery. TACE can be complicated via inadvertent embolization of arteries supplying the liver, gallbladder, stomach and pancreas. The association of acute pancreatitis with TACE is rare. The proposed mechanism involves regurgitation of embolic beads from the hepatic artery into the arterial supply of the pancreas. Acute pancreatitis can develop up to 15 days after TACE. Herein we present a case of groove pancreatitis occurring after TACE. Groove pancreatitis is a rare variant of focal chronic pancreatitis affecting the area between the head of the pancreas, duodenum, and the common bile duct. Functional and anatomical obstruction of the minor papilla from viscous pancreatic secretions leads to impaired pancreatic enzyme outflow and proliferation of Brunner's glands causing pancreatitis. Imaging may show a submucosal mass which may confound the diagnosis since pathologies including leiomyoma, gastrointestinal stromal tumor and ampullary carcinoma may have similar imaging findings. Groove pancreatitis remains largely unfamiliar to most physicians thus making its true incidence a challenge.

CASE DESCRIPTION/METHODS:

This is the case of a 69-year-old male patient with multicentric hepatoma secondary to chronic Hepatitis C, status-post TACE who presented to ER with a nine-day history of epigastric abdominal pain and nausea. The patient had received TACE nine days prior and was admitted with the diagnostic impression of acute pancreatitis. The physical exam was remarkable for flank pain, negative murphy's sign. Labs showed stable hemoglobin and platelet levels. Liver chemistry showed a mixed pattern with AST minimally elevated and ALT at 102, Alk Phos at 225, Amylase slightly elevated at 135 and lipase elevated at 161. Imaging studies showed acute pancreatitis with possible necrotic collection of 2.1 cm at the pancreatic head and uncinate process, duodenitis, mild gallbladder wall thickening and no ductal dilation. Likely etiology was pancreatitis secondary to recent TACE.

DISCUSSION:

Pancreatitis is a rare complication of TACE. Although elevated pancreatic enzymes may be seen in up to 40% of TACE cases, the incidence of symptomatic pancreatitis after TACE is low at 2%-4%. Despite this low incidence, it is a complication that one should be aware of in patients undergoing TACE procedure given its high morbidity and mortality.
1324 Recurrent Pancreatitis Associated With Pancreas Divisum and Rare Solid Pseudopapillary Neoplasm of the Pancreas
Authors: Ratra Atul , Block Geoffrey
Published: October 2019

INTRODUCTION:

Pancreas Divisum (PD) is a benign congenital anomaly found in approximately 4-10% of general population. Rare cases of acute pancreatitis associated with PD and pancreatic tumors have been described. While most common causes of pancreatitis are gallstones and alcohol use, uncommon causes such as anatomic/genetic variants and malignancies of the pancreaticobiliary system should be investigated especially in case of recurrent cryptogenic pancreatitis. We present a case of recurrent pancreatitis in a patient with pancreas divisum and rare solid pseudopapillary neoplasm of the pancreas.

CASE DESCRIPTION/METHODS:

A 65-year old woman with past medical history of psoriatic arthritis on methotrexate therapy and no family history of pancreatitis was evaluated for recurrent pancreatitis. Patient had at least eight episodes of acute pancreatitis from 2011 to 2019. Patient denied any alcohol/tobacco history. Serum triglycerides/calcium were not elevated. Genetic causes were excluded. Imaging ruled out gallstones but showed presence of pancreas divisum. Endoscopic ultrasound (EUS)/Endoscopic retrograde cholangiopancreatography (ERCP) in 2016 was negative for stricture, focal mass or lesions. In April 2017, patient underwent repeat EUS/ERCP with stent placement into the minor papilla for presumed stenosis. However, that resulted in an exacerbation of her symptoms and the stent was subsequently removed. Patient continued to have recurrent acute pancreatitis and underwent repeat EUS in August 2018 which showed an 8 × 8 mm pancreatic genu mass adjacent to the Santorini duct. Biopsy was consistent with rare, slow growing solid pseudopapillary neoplasm (SPN) of the pancreas. Patient underwent pancreaticoduodenectomy in 2019. Pathology confirmed SPN. Patient has had no further episodes of pancreatitis.

DISCUSSION:

Pancreas Divisum (PD) results from failure of fusion of ventral and dorsal pancreatic ducts during embryogenesis. It has been controversial whether PD by itself causes recurrent pancreatitis. Clearly, in our patient, addressing the PD alone did not resolve her symptoms of recurrent pancreatitis. Sporadic hemorrhage within the SPN and intermittent compression of the Santorini duct was the likely cause of recurrent pancreatitis in our patient. Patients with cryptogenic recurrent pancreatitis should be evaluated periodically for the presence of slow growing tumors that may not be evident on initial imaging and may be the cause of recurrent pancreatitis in such patients.
1354 It's Not Always PSC: An Intriguing Case of IgG-4 Sclerosing Cholangitis
Authors: Ali Sara , Hammad Nour , Hakim Christopher M. , Iskendarian Ziyad
Published: October 2019

INTRODUCTION:

IgG4-related disease has a broad spectrum of clinical manifestations, when it involves the biliary tract it is termed as IgG4-associated cholangitis. It is the most frequent extra-pancreatic manifestation of type 1 autoimmune pancreatitis and shares clinical and radiographic features with Primary Sclerosing Cholangitis however differentiation is important.

CASE DESCRIPTION/METHODS:

71-year-old female with a known history of recurrent pancreatitis and cholangitis status post laproscopic cholecystectomy presented to the hospital with abdominal pain and obstructive pattern of LFTs. Previous ERCPs had revealed common bile duct stricture and a stent had been placed. Prior CT, ultrasound and MRCP all were consistent with findings of pancreatitis with pancreatic duct dilation along with dilation of the intra-hepatic ducts. Endosonographic imaging of the pancreas demonstrated a markedly abnormal pancreas However CA19-9 was normal. She underwent repeat ERCP with biliary dilatation revealing multiple biliary strictures and underwent stent placement in the common bile duct and right hepatic duct. Cytology did not reveal malignant cells and core liver biopsy showed preserved hepatic architecture with no evidence of fibrosis. Features of autoimmune hepatitis are not identified. She presented in a couple of months with similar abdominal pain and ERCP revealed a new 2 cm hepatic duct stricture which was stented. Due to recurrent strictures in the biliary system with failed response to recurrent endoscopic stenting a multi disciplinary decision was made to repeat liver biopsy which revealed very dense lymphoplasmacytic inflammatory infiltrates, numerous lymphoid follicles and obliterative phelebitis similar to findings noted in type I autoimmune pancreatitis. IgG-4 liver stains performed highlighted multiple positive plasma cells establishing the diagnosis of IgG4-sclerosing cholangitis. She was started on steroids and noted to have improvement in her liver enzymes.

DISCUSSION:

The differentiation of IgG4-related sclerosing cholangitis from primary sclerosing cholangitis and bile duct carcinoma is often difficult however necessary as the former is steroid responsive where as the latter are not. Serum IgG-4 levels are highly predictive for IgG-RD. Tissue acquisition is absolutely essential for the diagnosis. We present a challenging case where due to non-conclusive histological evidence the diagnosis was delayed and later a portal-based inflammatory nodule was seen which is a characteristic feature of this disease.
1367 A Rare Feat: Successful ERCP Treatment of Mirrizi's Syndrome After Failed Surgery
Authors: Shiralkar Malan , Voaklander Rebecca , Walker Courtney , McVay Tyler , Sossenheimer Michael
Published: October 2019

INTRODUCTION:

Mirizzi's syndrome (MS) is a rare complication, occurring in around 1% of all cholecystectomies and affecting around 0.1% of all patients with gallstones (GS). MS occurs when an impacted GS in the neck of the gallbladder (GB) or cystic duct (CD) causes compression of the common bile duct (CBD) or common hepatic duct (CHD), resulting in obstruction and potential progression to a cholecystocholedochal fistula. MS is usually managed by surgery. We report a rare case of a critically ill patient who was successfully cleared of obstructing stones via ERCP after failed surgery, allowing the patient to undergo subsequent successful heart transplantation.

CASE DESCRIPTION/METHODS:

A 42-year-old male with a history of coronary artery disease and ischemic cardiomyopathy presented with cholangitis due to CBD obstruction. Despite successful ERCP duct clearance, he was deemed not to be a surgical candidate due to severe cardiac morbidities. Months later he represented with cholangitis and was found on ERCP to have a CBD/CHD obstruction due to a large stone, originating from the CD, which was filled with many large stones. He underwent an attempt of GB resection. However, safe GB resection was precluded due to profound adhesions, complete tissue plane loss, and extensive fibrosis. GB wall debridement and removal of multiple large gallstones was surgically attempted to alleviate the CBD/CHD obstruction. A follow-up ERCP for stent removal showed persistent MS, thereby precluding the patient from heart transplant listing due to persistent cholangitis risk. Three subsequent ERCPs with aggressive SpyScope exploration of the CBD/CHD and CD, electrohydraulic shockwave as well as mechanical basket lithotripsy within the CD, and basket and balloon stone fragment removal resulted in complete clearance of all CD and CBD/CHD stones. Shortly afterwards, the patient presented with decompensated heart failure and underwent successful heart transplantation.

DISCUSSION:

MS presents a significant challenge to clinicians. The treatment is surgical, although inflammation, adhesions, and associated tissue plane distortion pose a challenge to even the best surgeon with an increased risk of bile duct injury. ERCP allows for diagnostic confirmation and biliary drainage via stent placement to alleviate the obstruction and cholangitis. We describe the successful implementation of ERCP as definitive therapy by utilizing a multitude of tools to clear the CD, CBD/CHD stones after failed surgery.
1368 Hilar Inflammation Mimicking a Klatskin Tumor
Authors: Shiralkar Malan , McKenzie Patrick , Lynch Keisa , O'Hara Ryan , Cizman Ziga , Sossenheimer Michael
Published: October 2019

INTRODUCTION:

Hilar cholangiocarcinomas or Klatskin tumors (KT) pose significant diagnostic challenges; 15% of resections for KT prove to be non-malignant. Inflammatory, infectious, and other etiologies mimic radiological features of KT. A high index of suspicion is needed to avoid hepatic resection and associated morbidities while aggressively excluding KT.

CASE DESCRIPTION/METHODS:

A 64-year-old male who presented with jaundice, unintentional 50 lb weight loss, and fatigue was found to have bile duct dilation on ultrasound. A CT confirmed severe right and left hepatic duct dilatation with abrupt cutoff due to a 4 cm infiltrative hilar mass involving the right and left hepatic ducts, and extending into the common hepatic duct. Work-up for causes of jaundice (autoimmune hepatitis, hemochromatosis, alpha-1 antitrypsin deficiency, viral hepatitis, celiac sprue, autoimmune cholangiopathy) via ANA, AMA, F-actin, IgG, IgG4, HFE mutation, TIBC, ferritin, A1AT, tTG, hepatitis serologies was negative. Over 12 weeks, 3 ERCPs failed to confirm KT via biopsies, cytology, and fluorescence in situ hybridization (FISH). A severe proximal common hepatic duct stricture was found on initial ERCP, which was dilated and stented. ERCP with Spyscope showed hepatic bifurcation stricture improvement. This stricture was biopsied and again brushed, dilated and stented. A third ERCP showed further improvement in stricture and otherwise normal intra- and extra-hepatic ducts. Dilation to 8 mm was performed without further stenting. Cytology and FISH were negative for KT. Two CT guided biopsies of the mass were also negative for KT and failed to show biliary ductal thickening or clear evidence of the prior noted hilar mass. Two MRCPs, 7 months apart, showed significant improvement of right and left bile duct confluence stricturing, felt to represent fibrous tissue and scarring.

DISCUSSION:

Despite improvement in cross sectional imaging, advances in interventional radiologic and endoscopic modalities, differentiation between benign and malignant hilar biliary stenoses remains a major challenge. Up to 20% of hilar resection show chronic fibrosing inflammation without evidence of KT. We aggressively pursued this concern with 3 ERCPs (cytology, FISH, biopsy with Spyscope), and 2 CT guided biopsies. CT and MR showed radiologic improvement of the mass and lack of evidence of KT. Exclusion of autoimmune disease or other etiologies allowed a diagnosis of idiopathic inflammation, thus avoiding surgery.
1375 Osteoclast-Like Giant Cell Carcinoma of the Pancreas: Case Series
Authors: Pallante Angeline , Hansel Stephanie
Published: October 2019

INTRODUCTION:

Osteoclast-like giant cell carcinoma of the pancreas (OGCP) is an extremely rare type of pancreatic neoplasm representing less than 1% of all pancreatic cancers. Due to its rarity, sufficient knowledge is lacking regarding the natural history of the tumor, its prognosis, and treatment recommendations.

CASE DESCRIPTION/METHODS:

We were respectively able to identify four confirmed cases of OGCP at our institution. Table 1 provides details of each case. Case 1: A 69 year-old male presented with left lower quadrant pain similar to prior pain associated with diverticulitis. The pain did not resolve with antibiotics. Imaging revealed a 1.2-cm non-enhancing mass in the pancreatic tail. Case 2: A 77 year-old male presented with a 7-month history of epigastric discomfort and weight loss. Imaging revealed a 9-cm pancreatic head mass. Case 3: A 65 year-old male had a PET scan for diagnosis of sarcoidosis. A new 1-cm pancreatic tail nodule was revealed. He denied GI symptoms. Case 4: A 65 year-old male reported 8-weeks of abdominal cramps, loss of appetite, and weight loss. CT imaging revealed a 13-cm pancreatic mass with extension into his liver.

DISCUSSION:

OGCs resemble giant cell tumors of the bone. OGCs are non-neoplastic cells that are reactive in nature and are massively recruited to the neoplasm which is a hallmark of this tumor. Patients typically present in their sixth to eight decades of life. The clinical presentation is like that of other large pancreatic masses. These masses typically occur in the body and tail of the pancreas; they are well vascularized and frequently hemorrhagic. They can be diagnosed by image-guided FNA or biopsy. Surgery remains first-line therapy for OGCP's. Unfortunately, once the tumor invades surrounding organs, such as the liver, the mortality rate significantly increases. Treatment is difficult in these patients as they are typically not healthy enough to begin chemotherapy. Gemcitabine remains the chemotherapy agent of choice, as most physicians treat OGCPs similarly to adenocarcinomas given the lack of literature guidance.
1377 Gastric Necrosis Associated With Necrotizing Pancreatitis
Authors: Mulki Ramzi , Shah Rushikesh , Qayed Emad
Published: October 2019

INTRODUCTION:

Acute pancreatitis may lead to local complications and systemic toxicity. Gastric necrosis is a rare complication with only few cases reported in the literature. Herein we present a case of severe acute necrotizing pancreatitis acute complicated by gastric necrosis.

CASE DESCRIPTION/METHODS:

Our patient is a 42-year-old male with a history of idiopathic recurrent necrotizing pancreatitis who presented with severe epigastric abdominal pain, nausea and vomiting. Previous imaging revealed pancreatic necrosis in the body and head of the pancreas and extensive splanchnic thrombosis. Labs showed normal blood count, lipase and complete metabolic panel. CT of the abdomen during this admission revealed large volume ascites and total pancreatic necrosis and multiple areas of low attenuation in the expected location of the pancreatic head and body (Figure 1). Despite supportive care and antibiotics, he was unable to tolerate oral intake. On day 14 he developed hematemesis and hypotension. His hemoglobin dropped to 9.3 g/dL from 13.3 g/dL. An abdominal x-ray revealed a curvilinear lucency overlying the left lateral upper stomach suggestive of gastric pneumatosis. Upper endoscopy showed erythema, edema, and severe ulcerations with black necrotic mucosa in the inferior and posterior walls of the stomach. The anterior wall was relatively spared with clear demarcation of ischemic and viable mucosa (Figure 2). Gastric biopsies confirmed gastric necrosis. The patient's hemodynamic status worsened, and he required vasopressor support. Further interventions were deferred given his comorbidities and worsening hemodynamic status, and he was discharged to hospice care.

DISCUSSION:

Gastric necrosis is a rare complication of acute pancreatitis and occurs due to severe reduction in gastric mucosal blood flow. This can be secondary to thrombosis of large vessels such as the celiac trunk or attributed to microcirculatory vasospasm due to the release of thrombogenic and inflammatory mediators. The development of gastric necrosis leads to further clinical deterioration in a clinically ill patient. Despite its rarity, gastric necrosis should be suspected in the setting of severe pancreatitis in patients with signs of gastrointestinal bleeding and clinical deterioration.
1388 Dose Increment-Associated Liraglutide-Induced Acute Pancreatitis
Authors: Al-Salameh Nizar , Shah Ruchit N. , Khara Harshit S.
Published: October 2019

INTRODUCTION:

Diabetes mellitus has been shown to increase the risk of developing acute pancreatitis (AP). Liraglutide is a glucagon-like peptide-1 (GLP-1) agonist used for the treatment of diabetes. Liraglutide has emerged as a preferred agent for the treatment of type II diabetes for its cardiovascular protective features and safety profile. One of the potential adverse effects of liraglutide is acute pancreatitis but we present an intriguing case of dose increment associated liraglutide-induced acute pancreatitis.

CASE DESCRIPTION/METHODS:

A 53-year-old female with a medical history pertinent for type II diabetes mellitus presented to the hospital with 2-days of epigastric abdominal pain, nausea, and non-bilious emesis. Her liraglutide dose had been increased 2 days prior to her symptom onset from 1.2 mg to 1.8 mg. Physical exam revealed epigastric discomfort on palpation without peritoneal signs. Lipase was 240 U/L (normal: 16-63 U/L), CRP 16 mg/L (normal: 0-5 mg/L), normal LFTs, and triglycerides were 148 mg/dL (normal: <200 mg/dL). Abdominal ultrasound and CT of the abdomen showed no evidence of biliary pathology. In the absence of alcohol use, absence of biliary pathology with normal LFTs, or other medical conditions, the patient was diagnosed with acute pancreatitis, likely secondary to liraglutide after a recent dose increment. She was treated with supportive measures and discharged home with cessation of the medication with no symptom reoccurrence.

DISCUSSION:

GLP-1 agonists such as liraglutide, are thought to cause acute pancreatitis by inducing a pro-inflammatory state within the exocrine pancreas. During the clinical phases of liraglutide, there were 8 reported events of acute pancreatitis. Liraglutide was found to have higher incidence of acute pancreatitis of 1.6 cases/1000 patient year exposure (PYE) vs 0.7 cases/1000 PYE which included other oral diabetic agents such as glimepiride, rosiglitazone, insulin glargine, sitagliptin, and exenatide. For diabetic patients on GLP-1 analogs admitted with acute pancreatitis, it is therefore important to consider the medication or its dose adjustment as a possible cause, especially in the absence of other common etiologies. This was a rare presentation of dose adjusted liraglutide induced acute pancreatitis.
1396 Viral Acalculous Cholecystitis: A Rare Extrahepatic Manifestation of Hepatitis A
Authors: Arroyo Yadis M. , Mony Shruti , Agrawal Saurabh , Bertran-Rodriguez Carlos E. , Pagan Andrea
Published: October 2019

INTRODUCTION:

Hepatitis A (HAV) is the most common form of acute viral hepatitis worldwide with an incidence of 0.6 reported cases per 100,000 population in the United States. Typical clinical symptoms include nonspecific prodromal symptoms such as fever, malaise, weakness, anorexia, nausea, vomiting and abdominal pain. Atypical features of HAV include recurrent hepatitis, prolonged cholestasis and extrahepatic manifestations. Acalculous cholecystitis (ACC) is an extremely rare extrahepatic manifestation of HAV. We present a unique case of acute hepatitis A presenting as ACC in an adult male with IV drug use.

CASE DESCRIPTION/METHODS:

A 50 year old male with a history of active IV heroin use and treated hepatitis C presented with nausea and RUQ abdominal pain for 3 days. On admission, laboratory findings were remarkable for AST of 2574 U/L, ALT of 3214 U/L, ALP 321 U/L and total bilirubin of 4.0 mg/dl. On physical examination patient was afebrile and hemodynamically stable with normal bowel sounds, soft abdomen, mild RUQ tenderness to deep palpation and Murphy's sign negative. CT abdomen demonstrated an edematous gallbladder wall with mild pericholecystic fluid and fat stranding, CBD diameter 4.0 mm (Figures 1 and 2). General Surgery believed his overall clinical picture to be due to acalculous cholecystitis and recommended non-operative management. Patients IgM Hepatitis A returned positive, Hepatitis B and C non-reactive. Thus, his findings were attributed to an active hepatitis A viral infection. He was treated conservatively with intravenous fluids and pain control. On discharge the patient remained afebrile, abdominal pain had resolved and liver function tests had normalized.

DISCUSSION:

Acute Hepatitis A with gallbladder involvement has been described in approximately 50 to 98% of adults. Although the etiology remains unclear, the invasion of the gallbladder by HAV and cell-mediated immunologic response have been proposed in the pathogenesis of HAV induced cholecystitis. The treatment is mainly conservative, as ACC due to HAV is transient and improves with resolution of viremia. Thus, patients do not require surgical interventions, unless they develop severe complications from ACC including gangrene and empyema. Our case demonstrates the importance of having a high clinical suspicion for HAV, especially in patients with known risk factors. Physicians should be cognizant of Hepatitis A and its rare extra hepatic manifestation, such as acalculous cholecystitis in order to avoid unnecessary surgical interventions.
1401 The Pancreatic and Pancytopenic Predicament
Authors: Ahmed Bilawal , Chaudhary Omar , Shah Shil , Mustafa Mazhar , Sonpal Niket , Okwesili Byron
Published: October 2019

INTRODUCTION:

Systemic lupus erythematosus (SLE) is a multisystem disease, that may affect multiple organ systems in the body.

CASE DESCRIPTION/METHODS:

15 yo female patient presented with chief complaints of abdominal pain, nausea, vomiting & nonbloody diarrhea. Onset of abdominal pain started 4 days prior to admission, localizing to the RUQ on day 2. Associated symptoms of nonbloody diarrhea & nonbloody/nonbilious vomit for 4 days. No contributory past medical history or past surgical history. Patient denies any drug allergies. On general physical examination, a fine lacy rash noted on all 4 extremities. Vitals T 37.9, HR 104, RR 18, BP 99/58. No guarding/rigidity & no masses/organomegaly were appreciated. CBC revealed pancytopenia with a platelet count of 115 (150-400 × 103/uL), Hb 8.5 (12-15 g/dL) & WBC 1.5 (4.5-13 × 10^3/uL). Lipase was 489 u/L and LDH was 2392 u/L. Other laboratories, including CMP, lipid panel, CRP, and pregnancy test, were all within normal limits. Patient was admitted with diagnosis of pancreatitis with pancytopenia and supportive treatment with investigative studies was initiated. Bone marrow biopsy was unequivocal. New laboratory test results indicated positive IgG and IgM antibodies to Brucella, Rickettsia, Ebstein Barr Virus and Parvovirus, complicating the diagnosis. Patient started on doxycycline empirically. Rheumatology consulted most likely etiology to be SLE and await Lupus Panel Results. ESR was 74 mm/hr, positive antinuclear antibody (ANA) 1/640, positive anti doublestranded DNA Antibody 1/320, positive anti Smith antibody, negative rheumatoid factor, C3 < 40 mg/dL, Lipase 2784 u/L, fecal occult bkood test positive. Following lab results and clinical course, the diagnosis of Systemic Lupus Erythematosus was made on day 4 of admission. Steroids were initiated, and the patient's status was observed closely. Lipase continued to rise to 8,136 u/L which prompted MRCP. MRCP showed extensive changes of pancreatitis with upper abdominal fluid, no organized collection or dilation of ducts. Also noted was extensive wall edema of the gallbladder with no filling defect. Lipase began trending down on day 2 of steroids. CBC corrected to within normal limits. Patient reported feeling better and continued improving.

DISCUSSION:

This case aims to facilitate diagnosticians in the evaluation of patients presenting with rare manifestations of SLE. SLE should be considered in cases of pancreatitis when common etiologies have been ruled out & symptoms are not residing despite appropriate treatment.
1405 Bevacizumab-Linked Acute Pancreatitis: A Case Report
Authors: Albagoush SARA , McGuire Shannon , Buaisha Haitam M. , Mukherjee Sandeep
Published: October 2019

INTRODUCTION:

Bevacizumab is a recombinant humanized monoclonal antibody which inhibits vascular endothelial growth factor. It has been added to chemotherapy for the treatment of various solid tumors including cervical cancer, ovarian cancer, renal cell cancer, colon cancer, and glioblastoma. Several side effects have been attributed to bevacizumab of which the most common are hypertension, bleeding, infection, fatigue. However, one case of bevacizumab- linked acute pancreatitis has been reported in the literature in combination with cisplatin and gemcitabine for metastatic ovarian cancer as reported by Onder et al.

CASE DESCRIPTION/METHODS:

We herein present the case of a 78-year-old man with metastatic colon cancer treated with Leucovorin, 5- fluorouracil and irinotecan plus bevacizumab. After seven days of treatment, he suffered nausea, vomiting, and loss of appetite followed by epigastric and right upper quadrant pain. Imaging studies demonstrated evidence of acute pancreatitis and a pancreatic pseudocyst. As hypertriglyceridemia, hypercalcemia, alcohol and biliary etiologies and trauma were excluded, the most likely etiology of the patient's pancreatitis was felt to be an adverse reaction to bevacizumab.

DISCUSSION:

To date, this is the second bevacizumab-linked acute pancreatitis reported in the literature and the first in a patient with metastatic colon cancer. Due to the widespread use of bevacizumab in patients with a variety of malignancies, it is important that health care providers be aware of acute pancreatitis as a possible side effect of bevacizumab. Our aim is to raise awareness among gastroenterologists and other medical professionals to consider acute pancreatitis as a possible side effect of bevacizumab.
1408 A Tail of Acute Diarrhea
Authors: Mohamed Abdalla , Abboud Rachel , Estifan Elias , Cavanagh Yana , Adib Sami , Barham Shaker , Botros Youssef , Grossman Matthew , Baddoura Walid , Christian Derick
Published: October 2019

INTRODUCTION:

VIPomas are neuroendocrine neoplasms arising from the pancreas in 90% of the cases reported, while the remaining 10% occur in other tissues of neural crest origin. The symptoms found are secondary to an excessive secretion of vasoactive intestinal peptide (VIP) including profuse watery diarrhea, dehydration, hypokalemia and hypoclorhydria. VIPomas are classically slow-growing, and previously reported cases consistently describe chronic diarrhea and a slowly progressing constellation of associated symptoms. We present a case of acute onset of secretory diarrhea secondary to a VIPoma.

CASE DESCRIPTION/METHODS:

The patient is a 62 y/o F with PMHx of HTN who presented to the ED w/complaints of abdominal pain, diarrhea, nausea and vomiting for approximately 3 days. Patient reported she was having 5-6 episodes of large volume, pale colored diarrhea. She denied any weight loss, change in diet, recent travel, blood in the stool, foul smell or bulky stool. She was initially found to be hypotensive BP 85/45, MAP 58, HR 88. Labs revealed K+ 3.1 meq/L, HCO3 was 16 meq/L, she had an AGMA measured at 15, and AKI with BUN: Cr 52:3.60 mg/dl respectively. On exam of the stool she was noted to have a stool osmolar gap of -14. Given no obvious underlying cause for these findings she underwent CT A/P which revealed a 7.8 × 6 cm mass contiguous w/both body/tail of the pancreas and posterior wall of the stomach, with no other sites of metastasis. EUS/FNA was done and pathology returned as NET type 1. VIP levels were subsequently sent and were elevated at 1385.8 pg/mL. She was started on octreotide 50 mcg TID with significant improvement in her diarrhea. She underwent surgery with distal pancreatectomy and splenectomy. Pathology confirmed the presence of a grade 2, stage T3 well differentiated NET. She had an uneventful recovery and was discharged home. She continues to be asymptomatic several weeks after surgery.

DISCUSSION:

Pancreatic VIPoma was first described in 1958 by Verner and Morrison in a patient with chronic refractory diarrhea and hypokalemia. VIPoma is very rare with an estimated incidence of 0.05-0.2 cases per million people. Acute diarrhea resulting from a VIPoma is rare event in an already rare malignancy. Our patient presented with acute secretory diarrhea proven by a stool osmolar gap less than 50, which resulted in acute kidney injury. Her diarrhea, secondary to VIPoma responded well to octreotide. VIPomas are classically rare tumors, but our specific case presents an even more rare presentation.