bluuebunny/crossref_metadata_2025 huggingface dataset:
2975 Factors Predicting Hepatitis C Therapy Success at a Diverse Urban Setting
Authors: Modi Krishna , Mansour Jonathan , Jafri Syed-Mohammed
Published: October 2019

INTRODUCTION:

Several antiviral treatments are available for chronic hepatitis C with the regimen chosen by reviewing viral genotype, history of prior treatments and insurance. We present outcomes of patients being treated with the different regimens, and factors associated with greater success rate.

METHODS:

The retrospective study was conducted at a single center, urban institution. Inclusion criterion was patients must start treatment between October 2014 and January 2018. Patients were excluded if they failed to follow up. Statistical analysis was performed to evaluate the response to treatment measured as sustained virologic response (SVR) with different treatment regimens, and additional patient history, and viral genotype.

RESULTS:

This study included 1,680 patients of whom 33.5% had previous therapies and 36.9% known cirrhosis. There was also a group of 138 patients (8.2%) who underwent liver transplantation. Overall the comprehensive SVR rate was 95.6%. The antiviral treatments groups studied were ledipasvir/sofosbuvir (8.3%), sofosbuvir/velpatasvir (78.9%), elbasvir/grazoprevir (7.1%), glecaprevir/pibrentasvir (3.9%), sofosbuvir/velpatasvir/voxilaprevir (1.5%), ombitasvir/paritaprevir/ritonavir (0.2%) and ombitasvir/paritaprevir/ritonavir/dasabuvir (0.1%). These were either given alone or in combination with ribavirin. There was no statistical difference in SVR rate between the treatment groups, but there was greater failure in patients given ribavirin with sofosbuvir/velpatasvir or elbasvir/grazoprevir. The largest treatment group, ledipasvir/sofosbuvir, showed genotype 4/5/6 had the highest SVR failure rate (12.5%), and genotype 2 the lowest (2.0%). This treatment group also showed a higher SVR failure in patients with cirrhosis (6.8%) versus those without (2.9%).

CONCLUSION:

There is no statistical difference in achieving SVR rate based on the treatment chosen but patients receiving ribavirin were noted to have SVR failure more frequently. This may be representative of the clinical scenarios in which ribavirin is given, has a higher predictor of treatment failure than ribavirin itself. Patients were also noted to have a higher SVR failure rate if they had cirrhosis, or if their viral genotype was 4, 5, or 6.
2998 Hyperemesis Gravidarum Syndrome Mimicking Recurrent Pancreatitis
Authors: Poola Shiva , Jampala Nannaya , Rives Charles , Ali Eslam
Published: October 2019

INTRODUCTION:

Nausea and vomiting are common complaints of pregnant patients. Hyperemesis gravidarum (HG) is a condition characterized by severe nausea, vomiting, weight loss, and dehydration associated with electrolyte imbalances and nutritional deficiencies. Some patients with HG have a complicated picture in the setting of elevated laboratory findings including liver enzymes and lipase. Although rare, pancreatitis has been demonstrated in a pregnancy. This case highlights a patient with HG which mimicked recurrent pancreatitis.

CASE DESCRIPTION/METHODS:

A 35 year old Hispanic female presented at 12 weeks of intrauterine pregnancy for persistent nausea and vomiting. Her medical history was significant for obesity and fatty liver disease. Baseline LFTs demonstrated AST of 85 U/L, ALT of 188 U/L, lipase of 45 U/L, and t.bili 1.3 mg/dL. The patient improved after hydration and antiemetics. The patient was readmitted four times during her pregnancy for worsening abdominal pain, nausea, and vomiting. Ultrasound and MRI were negative. Viral work up was negative for CMV, Hep C, Hep B, Hep A, HSV, ANA, anti-sm ab and VZV. On her last admission her LFTs peaked to an AST of 645, ALT of 1240, t bili of 2.2, ALP of 142, and lipase of 192. Each admission improved with hydration. The patient was lost to follow up and repeat liver function testing was not repeated after delivery.

DISCUSSION:

The patient in this case had clinical findings and history concerning for HG. HG affects 1% of pregnant women. There are reports of elevated lipase among patients with HG without a diagnosis of pancreatitis. The patient had an elevation of LFTs including AST, ALT and total bilirubin which initially was thought to be due to hepatic steatosis in the setting of her obesity and pregnancy. Throughout each hospitalization the patient had elevation of her LFTs which peaked to an AST of 645 U/L and ALT of 1240 U/L. Although HG has been associated with elevations of LFTs with ALT up to 200 U/L, this patient had a significant increase of LFTs above the expected range. The diagnosis of pancreatitis in pregnancy includes characteristic symptoms and laboratory and radiographic findings. This patient had nausea/vomiting and an elevation of lipase and LFTs however acute pancreatitis was not diagnosed. Radiographic findings were negative. This case speculates whether patients with HG need a different diagnostic criterion for pancreatitis. Overall further research should be done to define the relationship of HG with liver and biliary pathologies.
3003 A Curious Case of Metastatic Pancreatobiliary Adenocarcinoma With Normal Serological Markers
Authors: Brehm Tyler , Hornak Joseph P. , Clement Cecilia , Chatila Ahmed , Sonstein Lindsay , Parupudi Sreeram
Published: October 2019

INTRODUCTION:

Liver function tests (LFTs) are used to screen for, exclude, characterize, and monitor hepatopancreatobiliary (HPB) pathologies. However, the utility of LFTs vary widely based on context, and reliance on laboratory tests in place of clinical judgement is a common pitfall for physicians. Here, we describe a case of significant HPB pathology without LFT abnormalities, and use it as a lens to reexamine the utilization of LFTs in clinical practice.

CASE DESCRIPTION/METHODS:

A 72 year old male with a history of hypertension and hyperlipidemia was admitted to the hospital for two weeks of right upper quadrant (RUQ) abdominal pain without associated factors. Physical exam was notable for a soft, mildly tender, palpable mass in the RUQ extending lateral to the umbilicus. Initial laboratory evaluation—including LFTs, CBC, BMP, and lipase—was normal. However, contrast-enhanced, abdominal CT demonstrated gallbladder distension (17 cm) with dilatation of the intrahepatic, extrahepatic, and pancreatic ducts. MRCP revealed widespread nodularities concerning for metastasis; follow-up ERCP revealed copious bile in the stomach and duodenum but cannulation attempts failed due to scarring in the major papilla area leaving no obvious papillary orifice. The patient was presumed to have a biliary-small bowel fistula allowing for bile drainage. The porta hepatis region contained several malignant-appearing lymph nodes which were biopsied via fine needle aspiration, revealing metastatic adenocarcinoma favoring pancreatobiliary origin. Due to the presumed fistula, he did not need further decompression, and was discharged with oncology follow up.

DISCUSSION:

This patient's case presents an opportunity to examine the use of LFTs in clinical practice and why they may fail to identify relevant pathology. Two hypotheses provide explanations, the first based on Courvoisier's law which states that a non-tender, palpably enlarged gallbladder is unlikely to be due to gallstones. Unlike the acute nature of choledocholithiasis, slowly progressive malignant obstructions can gradually increase biliary pressures, allowing for the pliable gallbladder to distend without precipitating liver failure or elevating LFTs. Secondly, the fistula may have provided partial decompression, keeping biliary pressures high enough to cause gallbladder distension without elevating LFTs. Thus, distal biliary obstruction should be suspected in patients with palpable gallbladder distension, and LFTs may be normal even with significant HPB pathology.
3017 Cholangiocarcinoma: A Formidable Diagnosis
Authors: Master Vidisha , Niec Rachel , Martin Tracey , Wan David
Published: October 2019

INTRODUCTION:

Cholangiocarcinoma is a malignant epithelial cancer of the biliary tract. The disease is difficult to diagnose and is usually fatal due to its late clinical presentation, lack of effective non-operative therapy, and rapid turnover. The typical age at presentation is the seventh decade. We describe a case of unanticipated cholangiocarcinoma in a 32 year old male.

CASE DESCRIPTION/METHODS:

A 32 year old male, with history of childhood Wilm's tumor status post resection, presented with left lower quadrant abdominal pain and 20 pound weight loss over one month. The pain was described as LLQ pressure radiating to the midline and across the abdomen. In addition he reported nausea without emesis, significant abdominal distention causing dyspnea, three episodes of possible GI bleeding (including two episodes of melena and one of hematochezia), light stools and dark urine. CT revealed metastatic disease with diffuse nodal involvement and biopsy showed adenocarcinoma of unknown origin. The diagnosis was originally considered a recurrence of Wilm's tumor but repeat biopsy with IHC revealed primary cholangiocarcinoma. The patient underwent paracentesis and was started on Gemcitabine and Oxaliplatin chemotherapy. Restaging CT showed progression of disease with extensive tumor thrombus extending from the hepatic vein into the IVC and right heart, bilateral pleural effusions, innumerable pulmonary nodules and vertebral metastasis. Due to poor functional status he was not a candidate for further chemotherapy or immunotherapy. Symptomatic treatment was initiated but his condition rapidly declined and he eventually succumbed.

DISCUSSION:

Cholangiocarcinoma is the second most common primary malignant tumor in the liver. It can be intrahepatic or extrahepatic. Patients with extrahepatic tumors usually present with painless jaundice from biliary obstruction, whereas intrahepatic tumors usually present with pain. Common complaints include pruritus, abdominal pain, weight loss, fever, and symptoms of biliary obstruction such as clay-colored stools and dark urine. Contrast CT is sensitive for detecting intrahepatic tumors, the level of biliary obstruction, and also permits visualization of the pertinent nodal basins. Cholangiocarcinoma presents a formidable diagnostic and treatment challenge. The majority of patients present with unresectable disease and have a survival of less than 12 months following diagnosis.
3032 Acute Presentation of Undiagnosed Pancreatic Cancer With Fatal Prognosis
Authors: Mehmood Faisal , Shah Yash , Korsten Mark
Published: October 2019

INTRODUCTION:

Most common presentation of pancreatic cancer are abdominal pain, weight loss and jaundice. However, these symptoms manifest mostly with advance disease and are non-specific making the early diagnosis difficult. Consequences of missing diagnosis can be fatal leading to metastatic disease and decease life expectancy. We came across similar case with obstructive jaundice and had pancreatic mass with life span of 2 months after diagnosis.

CASE DESCRIPTION/METHODS:

69 years old male was admitted for a mechanical fall. His past medical history included CAD, chronic pancreatitis, and diabetes mellitus. He reported 6 days history of pale stools and dark urine which resolved 2 days prior to presentation but had some associated chronic abdominal pain with 50 lb unexplained weight loss over past 6 months. On examination, he was found to have scleral icterus and jaundiced skin. On blood work, he was noted to have AST 242, ALT 477, ALP 508, and bilirubin 13.0 and direct bilirubin of 10.4. All values were normal one month prior to current admission. Abdominal ultrasound showed dilated CBD to 15 mm, intrahepatic ducts and a distended gallbladder without stones. He underwent MRCP and was found to have dilated CBD with 13 mm diameter, intrahepatic biliary ducts, and distended gall bladder with abrupt cut off of the distal CBD. There is also dilatation of pancreatic duct measuring up to 11 mm with a cut off of the proximal pancreatic duct by a large amorphous mass. ERCP was done, but wire passage in CBD was restricted by possible tumor which lead to limitations like lack of biopsy and stent placement. PET CT showed fullness in pancreatic head with increased FDG uptake. He underwent cholecysto-gastrostomy for internal biliary decompression and was noted to have distended gallbladder, and fibrotic pancreas with no pancreatic mass. Bilirubin dropped the surgery. Patient refused invasive procedures afterwards for tissue diagnosis of cancer. He died 2 months after surgery.

DISCUSSION:

Pancreatic cancer is fourth leading cause of cancer related deaths in United States. Incidence increases after the age of 45 with more male to female ratio 1.3:1. USPSTF found no evidence of improved mortality with screening in asymptomatic patients. Surgical resection is only curative with less role among patients with late presentation emphasizing the importance of early diagnosis. Physician should have high suspicion among patients with risk factors to avoid deadly complications.
3051 A Case of a Rapidly Developing, Near-Obstructing Rectal Mass
Authors: Wadehra Anshu , Tama Maher , Ehrinpreis Murray N.
Published: October 2019

INTRODUCTION:

The vast majority of colorectal tumors comprise of adenocarcinomas. However, tumors can also be a result of cancer metastases or benign neoplasms. Rapidly growing colorectal tumors pose a special clinical challenge if recent imaging or endoscopy was done and was unrevealing. Weighing the risks and the benefits of repeating invasive procedures is not always straight forward. Additionally, the time to develop a clinically significant rectal mass depends on the type of growing tissue and has not been well cited in the literature. Moreover, tissue acquisition via mucosal biopsy is not always diagnostic. Our case demonstrates a patient who developed a near obstructing rectal mass within 4 months, with undetermined pathology.

CASE DESCRIPTION/METHODS:

A 73-year-old woman with a history of Stage IV Breast Cancer, HTN, and CKD IV presented with complaints of bright red blood per rectum. She had also noted small caliber stools for one month, with alternating diarrhea and constipation. She had a routine colonoscopy 4 months prior to her presentation which revealed no abnormalities of the colon or rectum. In addition, the patient had a barium enema and PET scan 3 months prior to presentation, which revealed no significant findings. Upon reviewing records from a hospitalization at an outside hospital a month prior to her visit, we found that the patient underwent a flexible sigmoidoscopy showing an atypical rectal mass. Biopsies were significant for hyperplastic colonic mucosa. A repeat flexible sigmoidoscopy deemed appropriate and was performed, which revealed a large, near-obstructing rectal mass approximately 5 cm from the anal verge. A total of 10 biopsies were taken of the mass, which yielded only hyperplastic colonic mucosa. The patient had no further tissue biopsies and was managed with a rectal stent for symptomatic purposes.

DISCUSSION:

Rapidly growing colorectal tumor are unusual and can pose both a clinical and diagnostic challenge. In our case, the patient formed a clinically significant rectal mass within 3-4 months. While the final pathologic diagnosis could not be achieved in this patient, we are suspecting it to have been related to a rapidly growing metastatic breast disease or primary rectal malignancy. In conclusion, a rapidly growing colorectal mass should be suspected in cases when there are new gastrointestinal symptoms despite recent negative work up. A repeat colonoscopy, when appropriate, plays a key role in early diagnosis and management in this group of patients.
3055 Solitary Rectal Ulcer Syndrome: A Rare Cause of Hematochezia
Authors: Then Eric O. , Chishti Umair Shafiq , Ofosu Andrew , Maddika Srikanth , Culliford Andrea , Gaduputi Vinaya
Published: October 2019

INTRODUCTION:

Solitary rectal ulcer syndrome (SRUS) is an uncommon rectal disorder that may result in severe rectal bleeding. The term solitary rectal ulcer syndrome is a misnomer. Endoscopic findings in patients with SRUS can range from mucosal erythema alone to single or multiple ulcers and polypoid mass lesions. Here, we present a rare case of severe hematochezia occurring secondary to a solitary rectal ulcer.

CASE DESCRIPTION/METHODS:

The patient is a 37 year-old male with a medical history of alcohol abuse who presented to our emergency department complaining of three episodes of hematochezia accompanied by dizziness and lightheadedness that began the night prior. Notable workup in the emergency department included a complete blood count (CBC) showing a hemoglobin of 12.5 gm/dL. A fecal occult blood test was also done which returned positive. This was followed by a repeat CBC showing an acute drop in the hemoglobin to 9.8 gm/dL. The gastroenterology service was then consulted and performed a colonoscopy. This was done and showed a large cratered ulcer about two centimeters in size and a non-bleeding visible vessel noted approximately five centimeters from the anal verge (Figure 1). These were treated with BiCAP cautery and the three hemostatic clips. Biopsies were not taken given the high risk of bleeding and emergent nature of the procedure. After the procedure the patient remained hemodynamically stable with no further drops in hemoglobin. He was then discharged with follow up appointments for repeat colonoscopy.

DISCUSSION:

SRUS is an oftentimes-misdiagnosed condition. The prevalence of SRUS is not clear, but has an estimated incidence of 1 in 100,000 people per year. Its diagnosis can usually be accomplished through a combination of symptomatology, endoscopy, sigmoidoscopy, and the histologic finding of fibromuscular obliteration of the lamina propria. The pathogenesis if SRUS is not well known, but various factors contribute to its development. This includes straining, self-induced trauma, paradoxical contraction of puborectalis muscle and rectal prolapse, and intussusception. Treatment of SRUS is based on the symptoms and severity. Asymptomatic patient treatment options include dietary modification, patient education, and behavioral modification. Endoscopic treatment can be applied to control bleeding and allows the clinician to obtain a biopsy specimen. Surgical treatment is recommended for those who have full thickness and rectal prolapse.
3078 Primary Adenocarcinoma of the Cecum Masquerading as Crohn's Disease
Authors: Tayel Hesham , Mehta Sagar V. , Tayel Hussam , Kim Brian , Bahirwani Janak , Chaput Kimberly J.
Published: October 2019

INTRODUCTION:

Abdominal pain and diarrhea are common presenting symptoms in both colorectal cancer and Crohn's disease. Despite that the conditions can usually differentiated from each other based on characteristic abnormalities seen with laboratory tests, imaging, and endoscopy. This case illustrates a 49-year-old male whose clinical symptoms, imaging, and endoscopy strongly suggested Crohn's disease; however, he was ultimately found to have metastatic adenocarcinoma of the cecum.

CASE DESCRIPTION/METHODS:

A 49-year-old male with no significant past medical history presented with generalized abdominal pain and diarrhea for several months. Initial CT scan revealed focal bowel wall thickening of the cecum. Follow up colonoscopy revealed severe terminal ileitis with linear ulcerations concerning for possible Crohn's disease. He was discharged on oral prednisone and mesalamine. His biopsy later revealed nonspecific inflammation but could not rule out malignancy. His symptoms initially improved but several weeks later his abdominal pain reoccurred with newly associated nausea and vomiting. CT scan performed revealed small bowel wall thickening, small bowel obstruction and a 5 cm retroperitoneal mass just anterior to the psoas muscle. Biopsy of the retroperitoneal mass showed adenocarcinoma. He underwent right hemicolectomy with resection of part of the terminal ileum. Tissue biopsy of the cecum later confirmed it be the primary site of the adenocarcinoma.

DISCUSSION:

The incidence rate of colorectal cancer from 2000 to 2013 has declined by 32% in people 50 years and older, however the incidence rate has increased by 22% in those younger than 50 during that same time period. Adenocarcinoma of the colon may mimic Crohn's disease and it should be firmly excluded in younger patients, particularly those patients with suspected Crohn's disease whose symptoms don't respond well to appropriate medical management. Endoscopic and radiological appearances can be deceiving as obstructing tumors may lead to inflammation and ulceration of the terminal ileum and cecum, which may be incorrectly attributed to Crohn's disease.
3079 Another Skeleton in the Hospital Closet
Authors: Patel Pratik , Phan Ethan , Matarese Laura , Powell James
Published: October 2019

INTRODUCTION:

Nutrition is vital for the care of critically ill patients in the hospital. Malnutrition in the hospital setting was first introduced in 1974, illustrating that 50% of patients in urban hospitals are malnourished. Despite this historical finding and advance in medicine, there remains a delay in screening for malnutrition and providing adequate care for this population. We present a case of a young female where severe depression led to diagnostic delay of multiple nutritional deficiencies, eventually leading to her demise.

CASE DESCRIPTION/METHODS:

44 year-old female with a past medical history of Lynch Syndrome s/p right hemicolectomy and severe depression who initially presented to an outside facility after involuntary commitment by her family for failure to thrive. She became severely depressed after diagnosis and lost approximately 100 lbs. At presentation, she was hypotensive and tachycardic requiring pressor support. Abdominal CT scan revealed new cirrhosis and left ureteral calculus with hydronephrosis so she underwent ureteral stent placement. She was also noted to have purpura and severe skin fragility, concerning for nutritional deficiency. Echo revealed new onset heart failure. She remained hypotensive and was transferred to our ICU for further management. Nutritional labs showed severe deficiencies in Vitamins B1, B3, B6, C, D, zinc, copper, and selenium. Despite aggressive repletion and antibiotic therapy, she remained ill. She later developed Candida peritonitis and was initiated on antifungals. Abdominal pain persisted and repeat CT Abdomen revealed pneumatosis at the site of the ileocolonic anastomosis along with loculated ascites. Exploratory laparotomy was performed but she was never able to fully recover. Her condition declined and family opted for hospice care where she eventually passed away.

DISCUSSION:

Despite advances in medicine and nutritional therapy, barriers remain in providing adequate care for the malnourished. Prompt recognition of patients that are at high risk for developing nutritional deficiencies and depression can prove to be life saving. Depression leading to poor nutritional intake can result in vitamin deficiencies, which themselves have been linked to depression, resulting in a vicious cycle that is difficult to escape. Supplementing diet with vitamins for one year has been shown to improve mood. Healthcare providers should understand and promptly screen for malnutrition to prevent morbidity and mortality as in the case of our patient.
3081 Four Severe Adverse Events Within One Week in a Patient With Ulcerative Colitis in the Setting of Prolonged High-Dose Steroid Use
Authors: Campos Marilia , Torrealba Mauricio , de Groen Piet
Published: October 2019

INTRODUCTION:

Prolonged high-dose steroids are known to predispose patients to opportunistic infections and bowel perforation. Here we present a unique case with Inflammatory Bowel Disease (IBD) who within 6 weeks developed four high-dose prednisone-related complications, including clostridium difficile (C. Diff) and cytomegalovirus (CMV) colitis, herpes simplex virus esophagitis and lastly colonic perforation. This case highlights the challenges of steroid refractory ulcerative colitis and the importance of alternative medications like biologics when patients don't have an adequate response to intravenous steroids in order to prevent iatrogenic immunosuppression-related adverse events.

CASE DESCRIPTION/METHODS:

A 73-year-old male had a past medical history of pan-UC presented to his primary care provider with diarrhea; tests for infectious causes, including C. Diff and CMV, were negative and colonoscopy with biopsy specimens supported a diagnosis of severe UC. Patient was started on prednisone and mesalamine but presented to the ED 2 weeks later due to ongoing symptoms. C. Diff was again ruled out and he was discharge on same dose of prednisone and mesalamine. 2 weeks later he was hospitalized for worsening abdominal pain, diarrhea and weight loss. Stool testing for C. Diff was positive so he was switched to intravenous methylprednisolone and oral vancomycin. During this time he was also found to have biopsy proven CMV colitis and HSV esophagitis. Despite treating him with ganciclovir, the patient remained symptomatic; CT was obtained which revealed free air due to a sigmoid perforation. The patient underwent a total abdominal colectomy with ileostomy. His post-operative course was unremarkable is currently off all immunosuppressive therapy, h as an ileostomy and overall is doing well.

DISCUSSION:

UC refractory to high dose steroid treatment is evident within one week after initiation of treatment. At that time, a change in treatment needs to be made and biologics should be considered in patients not responding to steroids. Our patient initially had negative serum (CMV) and stool (C. Diff) tests which led to ongoing steroid use. CMV typically develops after four or more weeks of severe immunosuppression. Herpes can flare up in anybody who is deeply immunosuppressed and colonic perforation – if associated with high-dose steroids – typically occurs also after four or more weeks of treatment. Our case illustrates that high-dose steroids can cause many complications within a short duration in a single patient.
3086 “Knot” Your Average Nasogastric Tube
Authors: Bernica Jessica , Deng Nanfu , Cole Rhonda A. , Ketwaroo Gyanprakash Avinash , Hair Clark
Published: October 2019

INTRODUCTION:

A nasogastric tube (NGT) is commonly used for gastric decompression or enteral nutrition. Placement is usually safely performed blindly with positioning confirmed on plain x-rays. NGT self-knotting is a rare complication that requires awareness as management may necessitate urgent endoscopy.

CASE DESCRIPTION/METHODS:

An 88-year-old man presented with nausea and vomiting, and was found to have a small bowel obstruction. He was managed conservatively with NGT placement for decompression. Due to low output, the tube required manipulation and repositioning. Upper GI series with small bowel follow was obtained for further evaluation with fluoroscopy images revealing a knotted NGT with the tip in the mid esophagus. Attempts were made at removal, but it could not be withdrawn or advanced due to patient discomfort. The patient underwent EGD which confirmed that the knotted NGT was lodged at the upper esophageal sphincter. The NGT was advanced under direct visualization to the stomach where the knotted end was snared. After cutting the proximal end exiting the nare, the knotted NGT was withdrawn endoscopically via the mouth. The patient eventually had resolution of his small bowel obstruction and was discharged.

DISCUSSION:

Though generally considered safe, NGTs are associated with a variety of complications occurring at a rate of 0.3% to 8%. These include aspiration, pneumothorax, tracheal misplacement, esophageal perforation, epistaxis, mediastinitis, and sinusitis. NGT function may be compromised by kinking, malpositioning, and occlusion of the tube. With the literature limited to few case reports and series, the true incidence of NGT self-knotting is unknown. NGT knotting increases risk for further complications such as respiratory difficulty and trauma to the nasopharynx, larynx, and esophagus, including tracheoesophageal perforation or fistulization. NGT knotting may occur from faulty insertion, altered anatomy, repetitive manipulation, narrow bore design, excessive length of tubing in the stomach, prolonged duration of placement, violent peristalsis, and softening of the tube at body temperature. NGT knotting should be considered in patients with any resistance upon attempts at removal. Plain radiographs or fluoroscopy can detect knotting. Various methods for removal of knotted NGTs have been described, generally involving cutting and removing the knotted part through the mouth with the help of direct laryngoscopy or EGD, as illustrated by this case.

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3157 Sweet's Syndrome: A Rare Cutaneous Manifestation of IBD
Authors: Huda Syed A. , Alam Syed Hammad , Chandravanka Chaitanya S
Published: October 2019

INTRODUCTION:

Sweet's syndrome (SS) is one of the rare cutaneous presentations associated with Crohn's disease. SS is characterized by a sudden onset of painful, edematous, and erythematous papules, plaques or nodules on the skin along with fever and neutrophilia. Here we present a case of SS in a patient with Crohn's disease.

CASE DESCRIPTION/METHODS:

A 29-year-old gentleman with a past medical history of Crohn's disease that was well controlled on mesalamine and infliximab infusions presented with a one week history of numerous erythematous papules on the chest and back and a few pustules around hair follicles on the upper torso. At the time of presentation, he was febrile and had elevated WBCs with a neutrophilic predominance. ESR was 63 and CRP was 11.2. Based on the presentation, he was diagnosed with Varicella infection and treated with Valacyclovir. However, he continued to be febrile with worsening new eruptions. Labs including VZV & HSV PCR, viral cultures, fungal cultures, hepatitis panel, HIV and RPR were negative so the patient underwent a skin biopsy to investigate the etiology of the rash. Biopsy showed diffuse infiltration of the epidermis and dermis by a neutrophil-rich inflammatory cell infiltrate without any signs of leukocytoclastic vasculitis. This was consistent with the histopathological findings seen in Sweet's Syndrome. His antivirals were discontinued and he was started on a high dose prednisone taper with a resultant dramatic improvement in signs and symptoms. Over the next 7 days his rash resolved with normalization of white count and inflammatory markers.

DISCUSSION:

SS can be clinically classified into malignancy associated SS, drug induced SS or classic (idiopathic) SS most commonly associated with infections, inflammatory diseases or pregnancy. Classic SS usually appears in the active phase of inflammatory bowel disease. Our patient had uncontrolled CD for two years, but he had not had any extraintestinal manifestations during this time. Moreover, Infliximab has been used to treat steroid non-responsive SS. Our patient developed the syndrome even though he was on infliximab. Sweet's Syndrome should be one of the differentials when a patient with IBD presents with painful pustular rash and fever.
3159 A Case of Takayasu's Arteritis in a Patient With Crohn's Disease
Authors: Sadiq Bitaal , Fourment Chris , Smith Jeffrey
Published: October 2019

INTRODUCTION:

Takayasu's Arteritis is a rare, chronic inflammation of the large vessels, particularly the aorta and its primary branches. Though etiology is largely unknown, the pathogenesis is thought to be due in part to inflammation in vascular tissue. The vast majority of cases worldwide have been in females from 10-40 years of age. Cases of Takayatsu's Arteritis have been reported in patients with Inflammatory Bowel Disease.

CASE DESCRIPTION/METHODS:

We present the case of a 41 y/o Caucasian female, with long standing Crohn's Disease (2006) who reports to our clinic for evaluation in 2010. At the time of presentation, Crohn's symptoms were mild. Over the next four years the patient had multiple flares and was treated with multiple agents. In 2017 she underwent a laparoscopic hemicolectomy after colonoscopy revealed a marked stricture proximal to her terminal ileum.

DISCUSSION:

Pathology from the surgery revealed a neuroendocrine tumor. Subsequent Osteoscan was negative but a CT revealed circumferential thickening of the proximal thoracic aorta at the origin of the left subclavian artery, indicative of aortitis. The findings were consistent with a diagnosis of Takayatsu's Arteritis.
3161 A Rare Cause of Duodenal Perforation From Migrated Biliary Stent Managed Endoscopically
Authors: Barlass Usman , Amin Jaimin , Singh Ajaypal
Published: October 2019

INTRODUCTION:

Biliary stent migration is not uncommon (6-10%). A resultant duodenal perforation is however a rare complication (<1%) often associated with significant morbidity and can require surgery. Here we present a rare case of a duodenal perforation from plastic stent migration which was successfully managed endoscopically with through-the-scope (TTS) clips.

CASE DESCRIPTION/METHODS:

A 75 years old lady with history of painless obstructive jaundice, CT imaging with a hilar soft tissue mass and intrahepatic biliary dilation underwent endoscopic ultrasound (EUS) and endoscopic retrograde cholangiography (ERCP). A 7 Fr × 15 cm plastic biliary stent was placed into the right system after sphincterotomy and stricture dilation. The left system could not be accessed. Post procedure liver chemistries improved and she was discharged on antibiotics with close follow up. Patient developed lower abdominal pain and presented to the emergency department approximately 48 hours after ERCP. CT abdomen revealed biliary stent migration with concern for duodenal perforation and extraluminal air with heterogenous free fluid. Emergent upper endoscopy (EGD) showed migration of plastic biliary stent with distal tip protruding through the lateral wall of the second portion of the duodenum. The stent was removed using rat-tooth forceps revealing a 3 mm mucosal defect which was closed with TTS clips. Hospital course was complicated by fevers and repeat imaging showed increasing size of air and fluid collection. Repeat EGD showed a visible area of leakage on one edge of the previously repaired perforation. This was closed with hemostatic clips. Small bowel follow through studies at day 3 and 7 post procedure confirmed no contrast extravasation to suggest a persistent duodenal leak. Her diet was advanced and she was discharged with clinic follow up.

DISCUSSION:

Duodenal perforation from biliary stent migration is rare and limited case reports present the use of TTS clips in endoscopic management. In our patient the plastic biliary stent was endoscopically visualized protruding through the opposite wall of the duodenum while the proximal end was still in the biliary tree, likely creating enough force to cause a perforation. Although the initial attempted closure with TTS clips revealed no leakage immediately post procedurally, there was persistent leakage requiring repeat endoscopy and further clips for closure. A high morbidity surgical procedure can be avoided by this endoscopic approach even if there is a recurrence of leakage.
3174 Carcinoid Metastasis With Unknown Primary Tumor Origin
Authors: Wieckowska Joanna , Patel Kruti , Minaudo Mark
Published: October 2019

INTRODUCTION:

Carcinoid tumors are rare, slow-growing neuroendocrine tumors found throughout the gastrointestinal system. However, in 3% of cases, the primary tumor is never found. Because establishing the diagnosis and primary tumor location can be challenging, we present the case of an incidentally found metastatic carcinoid tumor to the liver without an identifiable primary.

CASE DESCRIPTION/METHODS:

A 60-year-old male presented to the Emergency Department with nausea, vomiting, vague abdominal pain, and profuse, cyclic diarrhea. RUQ US showed gallstones, hence he underwent cholecystectomy for presumed symptomatic cholelithiasis. During the procedure, a right focally hemorrhagic hepatic nodule lateral to the gallbladder was noted and completely resected. Pathology revealed a well-differentiated neuroendocrine tumor concerning for carcinoid metastasis. Subsequent CT Abdomen/Pelvis with Contrast was unremarkable except for ascending sigmoid colitis and diverticulosis. OctreoScan revealed two questionable foci in the right hepatic lobe and focal uptake in the proximal duodenum. This was concerning for possible origin, and the patient underwent an EGD, which did not reveal anything suspicious. Concomitant biopsies were also negative. In light of his ongoing vague abdominal pain and diarrhea, he underwent a colonoscopy that noted no obvious colonic carcinoid. Biopsies were consistent with chronic colitis. He was prescribed Lialda with improvement in diarrhea. At follow-up, his Chromogranin A was elevated at 1030 ng/mL; ESR and CRP were elevated at 37 mm and 0.8 mg/dL, respectively. Next, he underwent PET DOTATATE, which found hyperactivity in the right and left hepatic lobes and a focus in the mid-sternum compatible with osseous metastasis. Further investigation with MR Enterography revealed extensive, chronic diverticulitis with a colovesical fistula, an intramural sigmoid abscess, and two sites highly suspicious for liver metastasis. Despite these diagnostic modalities, primary tumor location has still not been found. As the patient remained asymptomatic, observation without medical intervention was recommended.

DISCUSSION:

Metastatic carcinoid tumors of unknown origin are ultimately diagnoses of exclusion after an extensive workup. Early diagnosis is imperative to survival. Therefore, familiarity with the clinical signs, symptoms, and diagnostic modalities of carcinoid syndrome may expedite early detection and diagnosis and improve overall prognosis.
3175 Gynecological Intervention Leading to Multiple Gastrointestinal Events
Authors: Sonpal Niket , Olaosebikan Kikelomo
Published: October 2019

INTRODUCTION:

This study follows a case of a right ovarian cystectomy gone wrong. Ninety studies published between 1972-2014, representing 474,063 gynecologic laparoscopies. Six hundred and four bowel injuries were reported for an incidence of 1 in 769. The rate of bowel injuries was dependent on the type of procedure. The small bowel happens to be the most frequently injured in the gastrointestinal tract, with about 166 of 354 (45%) of the cases. The majority of these injuries were due to veres needle or trocar placement with about 201 of 366 (55%) (Llarena N.C et al 2015). This review is to evaluate the gastrointestinal complications that accompanied a trocar induced injury during a gynecological procedure.

CASE DESCRIPTION/METHODS:

A 28-year-old female presented to the ED with septic shock. History obtained from relative stated the patient had a right ovarian cystectomy performed a week before ED visit. Post-op, the patient had increasing abdominal pain which worsened until EMS was called. An abdominal ultrasound showed central vowel dilation predominantly in the small bowel in correlation with ileus. CT abdomen showed free air throughout the abdomen large amount of fluid including the edge of the liver with infarcts in the Liver and spleen. Comprehensive Metabolic Panel showed AST- 5974, ALT- 2472, LDH- 1195 Total bilirubin- 1.5, direct bilirubin- 1.91, Amylase- 155. Complete Blood Count with WBC- 20.70. Coagulation with INR- 2.39, Fibrin > 700. The above test after consultation with specialists indicated Ischemic hepatitis “shock liver” with very strong indications due to hepatic infarction as a result of hemodynamic instability (Friedman L.S et al 2018). Other complications included small bowel ileus, peritonitis due to perforation and systemic involvement as a result of shock.

DISCUSSION:

In conclusion, gastrointestinal complications are rare after a laparoscopic procedure. Irrespective of their frequency can result in mortality. The best approach lies in the surgical technique and experience. Early recognition is the best way to avoid further complications as a delay could result in sepsis and untimely death. In an event of a suspected gastrointestinal injury, general surgical consultation should be sought, and a management strategy implemented. (Karadag M.A et al 2015).
3182 Spontaneous Bacterial Peritonitis in Cardiac Ascites: A Rare but Deadly Occurrence
Authors: Canakis Justin , Canakis Andrew , Ostrander Thomas
Published: October 2019

INTRODUCTION:

Spontaneous bacterial peritonitis (SBP) is frequently described in cirrhotic patients who develop infected ascitic fluid. The phenomenon of SBP in cardiac ascites is rare. Here we present a unique case of a patient who was admitted for advanced cardiorenal syndrome in the setting of a gastroenteritis that likely promoted a bacterial translocation resulting in SBP.

CASE DESCRIPTION/METHODS:

An 85M presented from a nursing facility with lethargy, confusion and non-bloody diarrhea. Medical history was significant for congestive heart failure (CHF) and chronic kidney disease. No history of alcohol use. Upon arrival to the hospital, he was noted to be confused with a mildly distended abdomen, asterixis and two plus lower extremity pitting edema. The patient was admitted for a CHF exacerbation and metabolic encephalopathy. Initial labs revealed a BNP 3915, WBC 11,500, BUN 89, creatinine 3.5, total bilirubin 2, AST 22, ALT 9, and INR 1.27. An abdominal CT scan showed a moderate amount of intraperitoneal fluid. A diagnostic paracentesis was performed. The aspirated fluid was dark yellow and opaque with a serum ascites albumin gradient of 1.9 g/dL, total fluid protein 3.3 g/dL, 1,115 PMNs cells/mm3, 49% polymorphonuclear leukocytes. To much surprise, these findings demonstrated cardiac ascites resulting in SBP. There was no evidence of cirrhosis. Antibiotic treatment was initiated. Unfortunately, the patient exhibited a rapid decline renal function, and expired shortly afterwards.

DISCUSSION:

Due to the liver's extensive vascular supply it is prone to hemodynamic disturbances which can result in passive hepatic congestion from right sided heart failure. Recent studies have supported the diagnostic utility of serum BNP levels to distinguish ascites from cirrhosis or heart failure. It has been generally well accepted that the low occurrence of SBP in cardiac ascites may be related to the protein rich ascitic fluid that has both opsonic and bactericidal activity. Interestingly, the “gut hypothesis” suggests that intestinal hypoperfusion and congestion can lead to altered gut morphology, permeability, and the growth of microbiota that may ultimately stimulate bacterial translocation and endotoxin release. This case tends to shed light on a few quintessential points for clinicians to be aware of, including the potential intersection between the microbiota and metabolic effects of CHF and the necessity to lower the diagnostic threshold for SBP cardiac ascites in patient's presenting for a CHF exacerbation.
3190 Gender Differences in Acute Hepatotoxicity Associated With Cocaine Use: A Case Report and Brief Literature Review
Authors: Bello Fatimah O. , Rivera Arturo Suplee , Rivas Cynthia , Tijani Aramide , Cantazaro Brandon , Rapoport Grigoriy , Herrera Henry R.
Published: October 2019

INTRODUCTION:

A few cases of cocaine induced hepatotoxicity (CIH) have been reported in humans. Most of these cases were associated with chronic use in males, with only one case reported in females. We present a rare case of CIH associated with a binge in a female Hispanic patient with a chronic history of illicit drugs use.

CASE DESCRIPTION/METHODS:

A 32-year-old Hispanic woman with no known medical history presented to the emergency room (ER) for the evaluation of abdominal pain. Pain was said to have commenced about 10 hours prior, located in the right upper quadrant (RUQ), radiating to the back and epigastric area. Pain was described as sharp and only said to be associated with nausea. She denied the use of any illicit drugs. She was hemodynamically stable and physical examination revealed a woman in moderate painful distress and she was anicteric. Abdomen examination was significant for tenderness to palpation in the RUQ. Initial laboratory investigation was significant for elevated AST- 1236 IU/L (N: 13-39 IU/L), ALT- 955 IU/L (N: 7-52 IU/L), ALP- 127 IU/L (N: 34-104 IU/L), and normal total bilirubin. LDH was also elevated 826 IU/L (N: 140-271 IU/L). An extensive work-up was ordered. Interestingly, urine drug screen returned positive for amphetamine, barbiturates, cocaine and tetrahydrocannabinol. She later admitted using drugs on the day prior to admission. All the other results were not significant. At this point, symptoms had significantly improved with conservative management and she was discharged on the 2nd day of admission.

DISCUSSION:

The pattern of liver enzymes in our patient appears to be characteristic of what has been described in prior case reports of CIH. Worth mentioning that, in mice models, there appears to be a difference in the manifestation and pattern of injury by gender. In a study conducted by Visalli et al, both male and female mice were exposed to the same amount of cocaine, but male mice had significantly more severe disease. Lopez Patino et al also described similar gender differences in zebrafish. It is entirely unclear why these gender differences exist; however, it has been postulated that there is a possibility that males and females metabolize some of the enzymes differently. Our review showed the potential role of gender in cocaine metabolism. In patients presenting to the ER, a high index of suspicion is required to improve overall patients' outcomes and avoid unnecessary procedures. Lastly, there is a need for continued research in the area of CIH.