bluuebunny/crossref_metadata_2025 huggingface dataset:
1380 Delayed Presentation of a Traumatic Complete Pancreatic Duct Disruption Successfully Treated With Endoscopic Cystogastrostomy and Long-Term Plastic Stenting
Authors: Awad Christina , Cho Ryan , Miller Charles
Published: October 2019

INTRODUCTION:

Blunt trauma injuries to the pancreas are rare but carry a significant mortality and high complication rate. Motor vehicle collisions are the leading cause for blunt pancreatic trauma in adults. Patients with pancreatic trauma typically present with features of acute pancreatitis, which is often difficult to diagnose due to other intra-abdominal injuries. The Organ Injury Scale is the most widely accepted grading system for pancreatic trauma. The higher the grade of injury, the more likely surgical intervention is required. Pancreatic duct (PD) disruption has traditionally required surgery if PD stenting during ERCP was not feasible. We report a case of delayed complete PD disruption following blunt trauma that was successfully treated endoscopically.

CASE DESCRIPTION/METHODS:

A 58 year-old female with no prior history of pancreatitis presented with intermittent abdominal pain four months after a motor vehicle collision. CT showed a 6.7 × 8 cm pancreatic body cyst. ED evaluation at the time of the MVC had not included abdominal imaging and a CBC and CMP were normal. EUS revealed a 7.5 × 6.7 cm pancreatic body cyst without septation or mural nodule. FNA with a 19 Ga needle fully collapsed the cyst. A pancreatic pseudocyst was confirmed with an amylase of 7500 U/L and CEA of 0.4 ng/mL. Patient reported alleviation of her pain following cyst aspiration, however MRCP 4 days after FNA revealed complete re-accumulation of cyst fluid (Figure1). ERCP with pancreatogram confirmed complete PD disruption (Figure2). Following surgical consultation, the patient opted for EUS-guided intervention for long-term cyst stenting. EUS with cystogastrostomy was successfully performed with a 15 × 10 mm Axios lumen-apposing metal stent (LAMS) and 7 Fr × 7 cm double pigtail stent. At planned LAMS removal, the pigtail stent had migrated making repeat pigtail stenting challenging, but successful. Three month follow-up imaging showed the pigtail stent in the prior cyst cavity with plan to leave the stent indefinitely (Figure 3).

DISCUSSION:

This is a rare case of PD disruption presenting 4 months after blunt trauma and without preceding pancreatitis. While PD disruption has traditionally required surgical intervention, endoscopic cystogastrostomy with long-term plastic stenting is a novel option to avoid surgery. Given difficulty placing the plastic pigtail at the time of LAMS removal and to avoid a second procedure, it is worth considering placement of plastic pigtail stents rather than a LAMS during the initial procedure.
1382 A Case of Candidal Infection of Large Biloma After CT-Guided Liver Biopsy
Authors: Kolli Sindhura , Long Kathleen , Shahnazarian Vahe , Reddy Madhavi , Gurram Krishna C.
Published: October 2019

INTRODUCTION:

Bilomas are collections of bile, either intra- or extrahepatic, with or without a capsule. They typically occur due to disruptions or injuries within the biliary. Complications include peritonitis and sepsis due to secondary infections. Clinical symptoms range from abdominal fullness, dull right upper quadrant pain to nausea, vomiting, and fever. Therapy includes drainage and if persistent, then possibly even surgery. This case describes an atypical presentation of a biloma infected with an uncommon pathogen.

CASE DESCRIPTION/METHODS:

A 64-year-old male with a medical history of alcohol abuse and CT-guided liver biopsy 7 days prior (confirming autoimmune hepatitis) presented to the ED with lethargy, dizziness, anorexia and intermittent diffuse abdominal pain. A CT on admission showed multiple lobulated cystic lesions in the right hepatic lobe communicating with the intrahepatic biliary ducts indicating bilomas. Zosyn was started empirically given his symptoms and leukocytosis. An ERCP was performed, demonstrating a large biloma in segment seven and eight. A 7 Fr × 12 cm stent was placed and the biloma was drained. Culture of the biloma fluid showed candida and numerous neutrophils, prompting the addition of fluconazole. An ERCP was repeated to replace the previous stent with a 10 Fr × 12 cm stent. The patient finished his course of antibiotics and antifungals and signed out against medical advice. He was lost to follow up at our hospital.

DISCUSSION:

Bilomas, while relatively rare, mainly occur due to disruptions of the biliary tree from laparoscopic cholecystectomies, Billroth II procedures, blunt abdominal trauma, radiofrequency ablation or in our case, a liver biopsy. Complications include peritonitis and sepsis as well as secondary infections with gram-negative bacteria. While our patient's biloma was infected, he had a candidal infection, making his case even more unusual. The gold standards for diagnosis are either hepatobiliary cholescintigraphy with Tc-99m-iminodiacetic acid chelate complex as a tracer or an ERCP which can simultaneously identify and treat bilomas. Treatment involves drainage, either endoscopically or percutaneously. The approach is dependent on the patient's clinical status and if he or she can tolerate an endoscopy. Post-procedure imaging is necessary to confirm drainage of the biloma. If it persists, then further drainage or surgical resection of the biloma are options once the patient is no longer septic.
1383 Making It Work With the Tools at Hand: Use of a Biliary Stent to Repair a Pancreatic Leak
Authors: Ludvik Nicholas , Kumar Manoj , Fahmawi Yazan , Mizrahi Meir
Published: October 2019

INTRODUCTION:

Pancreatic duct leaks (PDL) are primarily managed by advanced endoscopist, interventional radiologists, and sometimes by pancreatic surgeons. The mainstay of endotherapy for PDL is trans-papillary pancreatic duct stent placement bridging the PDL. Fully covered biliary metal stents are widely accepted in biliary leaks due to its radial force but there is no conventional fully covered metal stent (FCMS) in US for pancreatic duct for refractory PDL. We describe a patient with refractory PDL where biliary SEMS was used to successfully treat PDL.

CASE DESCRIPTION/METHODS:

Case Presentation A 43-year-old African American male presented to our hospital one month after admission for hemorrhagic pancreatitis attributed to dyslipidemia. Course was complicated by loculated retroperitoneal abscess tracking from pancreas to scrotum. Patient underwent exploratory laparotomy with pancreatic necrosectomy along with broad-spectrum antibiotics resulting in mild improvement in condition. Magnetic resonance cholangiopancreatography revealed PD injury confirmed on abdominal CT with contrast. ERCP confirmed PDL. A 5 F × 8 cm single pigtail plastic pancreatic stent (PPS) was placed. Unfortunately, PPS failed to maintain drainage and prevent leak as observed on contrasted abdominal CT 6 days later. PDL was confirmed again on repeat ERCP and an 8 mm × 6 cm biliary fully covered SEMS was placed in PD. Post stent placement, occlusion pancreatogram (OP) showed no leak. Four days later, repeat CT showed improving fluid collections without leak. After 4 weeks, third ERCP was performed, SEMS was removed with rat tooth forceps without complications, ERCP showed no PDL and a 7 F × 7 cm PPS was placed. Six weeks later, PPS was removed, ERCP showed no PDL and a 7 F × 4 cm PPS was placed. At this time, patient has continued to follow on outpatient basis without further incident.

DISCUSSION:

Discussion Endoscopic treatments for PDL have replaced surgical interventions in number of situations. Biflanged fully covered metal stents for PDL are only available outside US. In the meantime, cases like this emphasize the importance of considering alternative approaches in the treatment of PDL.
1384 Expanding the Horizons of Endoscopy: Cholangioscopy and Radiofrequency Ablation via Percutaneous Transhepatic Biliary Drainage
Authors: Bolanos Gabriel , Kumar Manoj , Fahmawi Yazan , Mizrahi Meir
Published: October 2019

INTRODUCTION:

A variety of transhepatic percutaneous biliary interventions are applicable for the management of biliary system pathologies, including: percutaneous transhepatic cholangiogram (PTC), percutaneous transhepatic biliary drainage (PTBD), and percutaneous transhepatic cholangioscopy (PTCS). These methods are useful to visualize the biliary system for diagnostic and/or therapeutic purposes; however they are generally reserved when endoscopic retrograde cholangiopancreatogram (ERCP) or peroral cholangioscopy is unsuccessful or not feasible. We present a novel approach in the management of malignant hilar biliary obstruction (MHBO).

CASE DESCRIPTION/METHODS:

A 63-year-old male with history of decompensated HCV/EtOH cirrhosis presented with painless jaundice, weight loss, and CT/MRI findings suggested hepatic mass with biliary duct dilation, concerning for hilar cholangiocarcinoma. Interventional Radiology (IR) performed PTC and then PTBD to decompress the biliary tree and placed external bilateral biliary drains. Our Role: With assistance from IR, PTCS was performed with evidence of malignant hilar biliary obstruction however, cytology and biopsies were negative for malignancy. CT guided percutaneous hepatic mass biopsy was reported as poorly differentiated adenocarcinoma. PTCS was again performed with evidence of right-sided malignant stricture and subsequently RFA (RFA catheter with 8 F bipolar probe (soft mode effect of 8-10 watts) and two ring electrodes (8 mm long and 6 mm apart) with ablation length of 25 mm ± 3 mm) of right and left hepatic biliary duct was performed under fluoroscopy guidance (3 cycles). Biliary drains were removed and bilateral biliary stents were placed. Post ablation PTCS showed excellent ablation of malignant tissue and patent ducts on PTC. Excellent toleration and no post-procedural symptoms were reported.

DISCUSSION:

Malignant biliary tumors are often unresectable. Biliary RFA using the bipolar radiofrequency catheter is a new endoscopic therapy for malignant or benign tissue in the pancreatic and biliary tract. This novel approach for PTC/RFA via PTBD provides an alternative for the management of biliary tract obstruction whenever ERCP and peroral cholangioscopy guided treatments are not feasible.
1385 Fire in the Hole! Role of Radiofrequency Ablation for Biliary Stent Occlusion: Prolonging the Stent Patency
Authors: Ludvik Nicholas , Kumar Manoj , Fahmawi Yazan , Mizrahi Meir
Published: October 2019

INTRODUCTION:

Management of malignant biliary obstruction (MBO) is largely palliative yet critical to maximizing patients' quality of life. Uncovered Self-expanding metal stents (SEMS) are widely used in that context. However, the uncovered nature of these stents allows tissue ingrowth and intraluminal obstruction requiring frequent endoscopic retrograde cholangiopancreatography (ERCP), mechanical cleaning with a balloon or a second stent insertion in stent-in-stent fashion. Radiofrequency ablation (RFA) is a new intraductal procedure to ablate the tissue ingrowth and improve the patency of biliary stents. Here we are discussing one such case.

CASE DESCRIPTION/METHODS:

Case A 54-year-old male with pancreatic adenocarcinoma with numerous metastases status post ERCP with uncovered metal stent placement. He was referred with hyperbilirubinemia and concern for stent occlusion. Endoscopy reveled a severely narrowed and distorted duodenum. ERCP was planned. Due to heavy tissue ingrowth and sludge, guidewire had to be placed under cholangioscopic guidance. A RFA catheter with 8 F bipolar probe and two ring electrodes (8 mm long and 6 mm apart) with ablation length of 25 mm ± 3 mm was advanced over guidewire under fluoroscopy. Intraductal RFA of the tissue ingrowth with in the stent was delivered with bipolar soft mode effect of 8-10 watts over 3 cycles. Post-ablation balloon sweeps produced large amounts of debris. A stricture noticed prior to RFA was seen again but with improved caliber. A fully covered 10 mm × 80 mm SEMS was placed across stricture. No procedure related complication was reported and patient continued with his chemotherapy.

DISCUSSION:

Use of RFA in conjunction with SEMS placement appears promising. RFA appears to delay tumor ingrowth, thereby decreasing need for repeat intervention. Furthermore, a recent clinical trial demonstrated that this can prolong not only stent patency but also improves survival. This case emphasizes the increased applicability of RFA not only in gastrointestinal tract but also in biliary disease.
1392 Transjugular Liver Biopsy Causing Hemobilia and the Rarely Reported Hemocholecystitis
Authors: Gollol Raju Narasimha Swamy , Jayananda Sriraksha , Regan Kara , Rosenblatt Mark , Khalid Hamza
Published: October 2019

INTRODUCTION:

Transjugular liver biopsy is a safe and effective tool in liver disease patients in whom percutaneous liver biopsy is contraindicated. Serious complications from transjugular liver biopsy are uncommon. Liver biopsy related hemobilia occurs in less than 1% of cases and hemobilia related hemocholecystitis is very rare.

CASE DESCRIPTION/METHODS:

A 56-year old Asian male with ESRD presented with abdominal pain and melena. 3 days prior to presentation he had undergone a transjugular liver biopsy for evaluation of abnormal LFTs and cirrhotic appearing liver on imaging. Vital signs were normal. Exam was significant for epigastric tenderness. Labs with Hb 10.4 gm/dL, Bili 1.1 mg/dL, ALP 307 U/L, AST 131 U/L, ALT 64 U/L, INR 1, and lipase 5069 U/L. CT abdomen showed a distended gallbladder with ovoid debris within (Figure 1). EGD was with no obvious luminal blood. MRCP showed distended gallbladder with a large sludge ball within, normal CBD, and mild pancreatic head edema. Tagged RBC scan was negative. With continued worsening of LFTs and ongoing gradual decline in Hb, patient was suspected to have intermittent hemobilia and biliary obstruction. ERCP showed bulging major papilla with a trace of blood at the orifice. Cholangiogram showed no obvious filling defects in the bile duct. Gallbladder was un-opacified denoting cystic duct obstruction (Figure 2). Biliary sphincterotomy was performed and balloon sweep of the biliary tree was unremarkable except for some minimal sludge. A plastic stent was placed in the CBD. Patient continued to have worsening right upper quadrant abdominal pain with clinical suspicion for acute cholecystitis. Patient underwent laparoscopic cholecystectomy revealing an edematous and severely inflamed gallbladder. Gallbladder lumen contained bloody bile and blood clots. Microscopic examination of gallbladder revealed extensive wall necrosis and acute inflammation (Figure 3). Patient had an uneventful post-operative course.

DISCUSSION:

Hemobilia after liver biopsy is rare and occurs in less than 1% cases. Acute cholecystitis from hemobilia (hemocholecystitis) is extremely rare and is due to thrombus obstructing the cystic duct. Diagnosing hemocholecystitis is challenging and clinicians need a high index of suspicion in making this diagnosis and thus prevent delay of much needed definitive treatment. Ultrasound and HIDA scan can be useful in making diagnosis. Risk of gallbladder perforation in these cases is 2-15% from gangrenous cholecystitis. Treatment of hemocholecystitis is early cholecystectomy.
1394 An Uncommon Cause of Hematochezia—A Case Report
Authors: Ishtiaq Rizwan , Wilhelm Darlene M. , Gaduputi Vinaya , Hamdani Uzair
Published: October 2019

INTRODUCTION:

Pancreatic cancer is the leading cause of cancer-related mortality in developed countries. In the United States, 3% of the cancer-related mortalities are caused by pancreatic cancer. Pancreatic cancer commonly metastasizes to lungs, lymph nodes, liver, and peritoneum. Metastasis of pancreatic cancer to the colon is very rare, and few cases have been reported in the literature so far.

CASE DESCRIPTION/METHODS:

In this case report, we describe a case of a mass in the colonic site which was initially thought to be primary colon cancer. However, on further radiological and histological examination, the mass was confirmed to be a metastatic tumor from a primary pancreatic cancer (Figure 1 shows cancer in the tail of the pancreas). Immunohistochemical markers were used to differentiate between primary pancreatic and primary colon cancer (Figure 2).

DISCUSSION:

In consideration of this interesting finding, the importance of immunohistochemical markers in the differentiation between primary and metastatic colon cancers based on their expression is emphasized. We emphasize that the pattern of immunohistochemical markers especially the combination of CK7 and CK20 is a useful tool to differentiate between metastasis in the colonic sites and primary colon cancer. We have also described an interesting relation between the side of colonic metastasis and the involved segment of the pancreas which has not been described in the literature before. In this manuscript, we have also compared and analyzed ten previous cases in medical literature with similar presentation of colonic metastasis from pancreatic cancer.
1399 DLBCL Mimicking a Cholangiocarcinoma: Earlier Diagnosis, Better Outcome?
Authors: Khadilkar Arjun , Mateja Candice , Thomas Sarah
Published: October 2019

INTRODUCTION:

Diffuse Large B-Cell Lymphoma (DLBCL) is the most common subtype (∼25%) of Non-Hodgkin's Lymphoma. In 40% of cases, disease arises in extra-nodal, extra-medullary tissues, primarily in the stomach or GI tract. This is a rare case presentation of DLBCL mimicking cholangiocarcinoma.

CASE DESCRIPTION/METHODS:

56-year old male with no significant past medical history presented to the ER with progressive abdominal pain for the past three months. Patient had early satiety and unintentional weight loss of sixty pounds over the past year. Labs on admission were significant for WBC: 13.55 (93% Neutrophils), Hemoglobin: 7.3, AST: 158, ALT: 150, Total Bilirubin: 17.7, Alkaline Phosphatase: 846, Albumin: 2.1, and LDH: 442. HIV was negative. Physical exam was notable for cachexia, scleral jaundice, and diffuse abdominal pain. CT of abdomen showed 2.6 × 3.4 cm mass encasing the common bile duct, intra and extra-hepatic biliary ductal dilation, retroperitoneal lymphadenopathy, suspicious liver metastases, significant ascites, and main portal, superior mesenteric, and splenic vein thrombosis, all concerning for cholangiocarcinoma. Patient was started on heparin drip for the vein thromboses. Gastroenterology attempted an ERCP, but was unable to cannulate the biliary tree. Analysis of ascitic fluid was negative for malignant cells. EGD showed large varices in lower third of esophagus and two non-bleeding gastric ulcers. Both ulcers were biopsied for histology. Gastric biopsy from EGD demonstrated diffuse large B-cell lymphoma with neoplastic cells, strongly CD20+ and weak BCL 6. Bone marrow biopsy showed no marrow involvement. Hematology Oncology recommended chemotherapy with R-CHOP. Few days later, the patient developed a GI bleed and transferred to MICU. Repeat EGD showed esophageal varices with blood clot covering fundus and body. The next day the patient was made comfort measures and passed.

DISCUSSION:

DLBCL has an incidence of approximately 7 cases per 100,000 persons per year. Per case report by Zakaria et al, there have been 28 reported cases of NHL to arise in the extra-hepatic bile ducts between 1982 and 2012. Diagnosis is best made by excisional lymph node biopsy or immunophenotyping. Treatment options primarily include surgery and chemotherapy. Prognosis varies among reported cases of DLBCL involving the GI tract from death within 32 days to survival greater than 72 months. DLBCL with biliary tract causing obstructive jaundice is a rare presentation, but it should among the differential diagnoses.
1412 A Rare Case of Post-ERCP Panniculitis
Authors: Shipley Lindsey C. , McGraw Timothy A. , Parrish Charles A. , Harrison Devin S. , Mitchell Rachel E. , Wilcox Charles M. , Ahmed Ali M.
Published: October 2019

INTRODUCTION:

Pancreatic panniculitis affects 0.3-3% of patients with a wide variety of pancreatic disorders. It is characterized by subcutaneous fat necrosis following the release of pancreatic enzymes into the circulation. Endoscopic retrograde cholangiopancreatography (ERCP) is a rare cause of panniculitis. Based on our literature review, this is the fourth case report of post-ERCP panniculitis.

CASE DESCRIPTION/METHODS:

An 80-year-old female with a history of choledocholithiasis with biliary stent placement presented for elective ERCP. The procedure demonstrated a moderate, inflammatory distal biliary stricture, a migrated biliary stent and choledocholithiasis. A biliary sphincterotomy, cholangioscopy and laser lithotripsy and stent exchange was performed with approximately 80% of stone removal. Post- procedure the patient noted tender erythematous raised nodules on her legs. Skin biopsy was performed with findings consistent with pancreatic pannicultitis. Follow-up ERCP was normal with trace sludge and removal of the biliary stent. At follow-up she was improved without abdominal pain and reported healing of the lower extremity cutaneous lesions.

DISCUSSION:

Pancreatic panniculitis is a rare skin finding that is independent of disease severity and can occur at any point during the disease process. Post-ERCP panniculitis is rare and only reported in three other cases. Pancreatic panniculitis is typically tender, ill-defined, red-brown nodules located in the lower extremities. The gold standard for diagnosis is biopsy with histopathology significant for a mostly lobular panniculitis without vasculitis with the presence of the typical ghost cells, necrotic and calcified adipocytes. Treatment is aimed at addressing the underlying pancreatic disease and the lesions typically resolve with improvement in pancreatic inflammation.
1415 A Rare Presentation of Diffuse Large B-Cell Lymphoma as a Pancreatic Mass
Authors: Seifers Cole , Pottebaum Benjamin , Siniakowicz Karolina , Ruzkowski Charles
Published: October 2019

INTRODUCTION:

Diffuse Large B-Cell Lymphoma (DLBCL) of Pancreas is a fast-growing Non-Hodgkin lymphoma (NHL), which accounts for only 0.5% of all pancreatic tumors. In most cases, it presents as a single, metastatic mass or diffuse nodules in the pancreas. DLBCL should be considered in patients with a pancreatic mass, especially if: personal history of lymphoma, presence of an immunodeficiency syndrome, or prior infection with EBV.

CASE DESCRIPTION/METHODS:

A 60-year-old type II diabetic male presented to the ED with nausea, vomiting, diarrhea and 40 lb weight loss. Patient's mother had known pancreatic adenocarcinoma. Social history revealed multiple sexual partners of both sexes. On exam patient had epigastric tenderness, and a 1 cm non-tender supraclavicular lymph node. A CT abdomen/pelvis with contrast revealed a 4.8 × 7.5 × 4 cm mass in the head of the pancreas and retroperitoneal metastatic adenopathy. Endoscopic ultrasound characterized a “U” shaped parenchymal mass extending from the head to the tail of the pancreas encircling the splenic artery. Fine needle aspiration and biopsy both revealed DLBCL. Bone marrow biopsy and imaging studies were unremarkable, therefore the pancreas was determined to be the primary site. Additional testing found the patient to be HIV positive with a CD4 count of 119 and thus diagnosed with AIDS. He was started on antiretroviral therapy prior to initiation of R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisone). Following his first chemotherapy dose, he was readmitted to the hospital with fever and weakness. Patient continued to decompensate and expired 23 days from his initial diagnosis.

DISCUSSION:

Most common sites of extranodal involvement of NHL are the gastrointestinal tract, liver, lung, bone marrow, and the central nervous system. DLBCL can present with extra-nodal involvement in about 50% of cases, but only 0.2-2% involve the pancreas. Clinically, most cases of Primary Pancreatic Lymphoma (PPL) are misdiagnosed as pancreatic adenocarcinoma. PPL generally carries a better prognosis once treatment is initiated in an immunocompetent individual. In this rare case, the patient was concurrently diagnosed with AIDS and Stage IV DLBCL of the pancreas. This case highlights an unusual presentation of a primary pancreatic malignancy that typically presents as a metastatic lesion. Furthermore, this case shows the utility of endoscopic ultrasound to better identify and characterize pancreatic masses when compared to other diagnostic modalities.
1418 A Troublesome Remnant
Authors: Zackria Rasiq
Published: October 2019

INTRODUCTION:

Postcholecystectomy syndrome (PCS) is the persistence of symptoms of biliary colic after cholecystectomy. Although PCS is relatively common with multiple etiologies, a remnant cystic duct is a rare etiology accounting for only 2.5% of cases. Mirizzi's syndrome is a rare cause of PCS due to a remnant cystic duct stone.

CASE DESCRIPTION/METHODS:

A 34-year-old female with a history of choledocholithiasis status-post cholecystectomy 6 years prior presented with severe, constant, sharp right upper quadrant pain with nausea and vomiting for 1 day. She had abdominal tenderness with a negative Murphy sign. She was found to have elevated liver chemistries. Patient had two hospitalizations within the past year with similar presentations with the finding of choledocholithiasis requiring endoscopic retrograde cholangiopancreatography (ERCP) on both occasions. Magnetic retrograde cholangiopancreatography (MRCP) showed a dilated, remnant cystic duct with filling defect indicative of obstruction caused by the stone. ERCP was done with removal of one stone followed by surgical resection of the remnant cystic duct with an endoluminal stone.

DISCUSSION:

The cystic duct typically measures 2-4 cm in length, and formation of stone in the structure leads to symptoms of dyspepsia, nausea, vomiting, and possibly jaundice. Cholecystectomy provides symptom relief to 85% of patients. After cholecystectomy, an incomplete surgery can leave a residual duct of greater than 1 cm in length, defined as a cystic duct or gallbladder remnant. Formation of calculi in this structure can lead to PCS. PCS can present as continuation of symptoms after the operation or after an interval of 2 days to 25 years after disease free period. PCS has been reported in 5 to 40% of patients post-cholecystectomy. Most common causes are extrabiliary, however, biliary etiologies are not uncommon. The incidence of PCS due to remnant cystic duct has been reported to be less than 2.5%. Identifying and promptly treating the underlying etiology are important to minimize morbidity. Cystic duct remnant stones may predispose a patient to postcholecystectomy Mirizzi's syndrome. While difficult to diagnose with different imaging studies, this can be effectively diagnosed with MRCP and treated with ERCP. One study showed that ERCP/MRCP failed to identify 2 out of 3 patients with a remnant cystic duct. While endoscopic therapy is an effective and safe alternative to surgery for postcholecystectomy Mirizzi's syndrome, surgical intervention is a definite treatment.
1421 Pancreaticocolonic Fistula: A Rare Cause of Recurrent Infective Endocarditis
Authors: Samo Salih , Giles Karen , Mulki Ramzi , Taborda Cesar , Cassani Lisa S. , Goebel Stephan U. , Raja Shreya M.
Published: October 2019

INTRODUCTION:

Pancreatic fistulas to adjacent organs may develop as a result of severe pancreatitis and pancreatic cystic lesions, which can lead to infectious complications. The aim of this case is to recognize pancreaticocolonic fistula (PCF) as an unusual cause of persistent infection such as infective endocarditis (IE).

CASE DESCRIPTION/METHODS:

59-year-old male with a history of chronic alcoholic pancreatitis, recurrent mitral valve IE (Proteus, Morganella and Enterococcus species), end stage renal disease, and heart failure (HF) was admitted after a fall. Initial labs showed almost 2 g drop in baseline hemoglobin (9.8 to 8.1 g/dL). Non-contrasted computed tomography (CT) of abdomen to assess for retroperitoneal bleed revealed a 1.3 × 1.6 cm air-filled cavity at the pancreatic tail communicating with the colonic splenic flexure in addition to moderate ascites. Contrasted CT showed similar findings (Figure 1), suggestive of a PCF. Ascites fluid analysis was consistent with a transudative process (attributed to HF) with amylase <10. An endoscopic ultrasound with fine needle aspiration for a pancreatic tail cyst two years prior revealed a hemorrhagic cyst. A colonoscopy two years ago showed 13 polyps up to 1 cm in size with histology consistent with tubular adenomas and tubulovillous adenomas. Given concern for colonic pathology as a nidus of the PCF, a colonoscopy was pursued. This revealed a small fistulous opening (Figure 2) 45 cm from the anal verge, which was closed with a clip. There was no evidence of malignancy. The PCF was thought to be the sequela of recurrent pancreatitis with cyst formation eroding into the colonic wall, resulting in recurrent polymicrobial bacteremia and IE. Endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic sphincterotomy and pancreatic stent placement is planned. Repeat culture data on broad-spectrum antibiotics has remained negative.

DISCUSSION:

PCF is a rare complication of severe acute necrotizing pancreatitis with a high mortality rate. Surgery is the main treatment modality, but conservative and endoscopic management are alternative options in non-surgical candidates. Our patient was deemed high surgical risk. Conservative management includes nutritional support (preferably enteral), electrolyte repletion, broad-spectrum antibiotics, somatostatin analogues, and percutaneous drainage. Endoscopic treatment with ERCP and subsequent pancreatic sphincterotomy and pancreatic duct stenting lead to fistula closure in many cases.
1423 Primary B-Cell Pancreatic Lymphoma Presenting as Acute Pancreatitis
Authors: Tikue Alay M. , Suchartlikitwong Sakolwan , Medrano Rita , Arevalo Meily , Zitun Mohamed , Khandewal Nuvneet , Thein Kyaw , Swarup Sriman , Nugent Kenneth , D'Cunha Nicholas
Published: October 2019

INTRODUCTION:

Primary pancreatic lymphoma (PLL) is a very rare type of pancreatic malignancy and accounts for less than 1% of all pancreatic masses. Presenting symptoms are non-specific and may lead to delay in diagnosis.

CASE DESCRIPTION/METHODS:

A 71-year-old man with diabetes mellitus and hypertension presented to hospital with epigastric pain, nausea, and vomiting for 3 days. He had loss of appetite and weight loss for 2 months. On physical examination, his vital signs were normal, and he had tenderness on palpation at epigastric area without signs of peritonitis. Complete blood counts were within normal limits. He had transaminitis and elevated total bilirubin and alkaline phosphatase. Serum amylase and lipase were 123 IU/L (normal: 13-53) and 864 IU/L (normal: 13-60), respectively. Tumor markers, including CA 19.9 and CEA, were normal. Magnetic resonance imaging (MRI) of the pancreas showed a large mass at the pancreatic head measuring 8.3 × 7.6 cm in maximum diameter with peripancreatic and retroperitoneal adenopathy (Figure 1). Endoscopic ultrasound demonstrated the mass in the pancreatic head and malignant-appearing peripancreatic lymph nodes. Computer tomography (CT) guided biopsy of the pancreatic mass was performed. Pathology revealed a high grade B-Cell Lymphoma. Bone marrow biopsy did not show atypical cells. Staging CT scans revealed a 9 mm sized mediastinal node. He was diagnosed with stage III high grade B-Cell primary pancreatic lymphoma. An International Prognostic Index was 2 which predicts a 5-year survival of 51%. He received R-CHOP regimen for treatment and currently on cycle 5 with a good response.

DISCUSSION:

Primary pancreatic lymphoma is a rare malignancy accounting for 0.7% of all pancreatic malignancies and 1% of extranodal lymphomas. The disease is male predominant about 7 times more frequent than in females.2 Non-specific gastrointestinal symptoms are the most common presentations, including abdominal pain, obstructive jaundice, or acute pancreatitis. Imaging of the pancreas by MRI or CT scan may help to distinguish PPL from the more common pancreatic adenocarcinoma. However, cytohistology of the mass is required for diagnosis and to guide definitive treatment. Surgery has a limited role in management, and chemotherapy is the main treatment.
1425 A Stent Long-Forgotten: Obstructive Jaundice and Acute Cholangitis Due to Migrated Biliary Stent
Authors: Jacob Bobby , Das Kanak , Wankhade Charudatta , Stavropoulos Stavros , Rizvon Kaleem
Published: October 2019

INTRODUCTION:

Long-term biliary stenting may be beneficial in high risk elderly patients or patients with multiple comorbidities with irretrievable CBD stones. However, the rate of complications increases with the longer duration that the stent has been placed and replacement or removal of biliary stents are recommended after 3-6 months. Little information exists on consequence of long-term biliary stents and management of its complications.

CASE DESCRIPTION/METHODS:

A 73-year-old Pakistani female with chief complaint of worsening right upper quadrant pain for 3 days, jaundice and intermittent fevers. Patient had a complex medical and surgical history of necrotizing gallstone pancreatitis complicated by bowel perforation status post partial pancreatectomy, common biliary duct stent placement and right-sided colectomy in 2009. Computed tomography revealed a dilated gallbladder with cholecystocutaneous fistula and dilated common bile duct and prior CBD stent which was migrated in the distal CBD. External drainage was performed by Interventional Radiology, followed by ERCP with the cholangiogram revealing choledocholithiasis and the migrated CBD stent lodged in common bile duct and common hepatic duct. Significant opacity was also noted suggesting that the stent was enclosed and cemented within the biliary duct. A few biliary sweeps with inflated balloon catheter to retrieve the migrated stent was attempted without success. Patient was then subsequently transferred to a tertiary facility for advanced endoscopic intervention with successful retrieval of the migrated biliary stent and various advanced endoscopic techniques with placement of metallic stent and nasobiliary drainage.

DISCUSSION:

Endoscopic management should be the primary management option prior to surgery, especially in those patients with significant comorbidities unfit for surgery. In our patient the ERCP was technically difficult and complex due to a large amount of stone burden in the setting of an up-migrated lodged stent placed 10 years ago within the bile duct. Multiple tools and interventions including biopsy forceps, adult and pediatric raptor forceps, web baskets, extraction balloons, cholangioscope, and electrohydraulic lithotripsy, metal stent placement and nasobiliary drainage. This specific case adds to current literature the various advanced endoscopic techniques that can be used in management of complications which can occur with biliary stenting.
1427 Minimally Invasive Treatment for Severe Acute Pancreatitis With Colonic Stenosis
Authors: Cen Dong , Shen Bo , Wang Yanting , Wan Zhe , Cai Xiujun
Published: October 2019

INTRODUCTION:

Colonic stenosis is a rare complication of acute pancreatitis (AP). It may be the consequence of inflammation and necrosis caused by AP. Early intervention is necessary, since the progression of colonic stenosis in AP leads to high mortality. We present a case of stenosis of right colic flexure in AP with total minimally invasive treatment.

CASE DESCRIPTION/METHODS:

A 73-year-old male patient with severe AP due to biliary lithiasis was transferred to our hospital because of recurrent infection and fever at the local hospital. The patient had upper and right lower quadrant abdominal pain at admission. Computed tomography (CT) revealed enveloping necrosis around pancreatic head and exudation of the ascending mesenteric side. CT-guided percutaneous catheter drainage was performed to relieve abdominal and peripancreatic abscess. One week after admission, the patient experienced acute onset severe dull pain in the lower right abdomen. CT showed closed loop ileus from ascending colon to transverse colon (Figure 1a). The colonoscopy revealed the stenosis of right colic flexure and adjacent part of transverse colon and the narrow section was 6 cm (Figure 2a). A fully covered intestinal stent (2 cm × 10 cm) was implanted under colonoscopy (Figure 2b, c). Postoperative CT revealed intestinal stent was in place (Figure 1b). The symptom was quickly controlled after implantation. Meanwhile, pancreatic duct stent was implanted to control the pancreatic fistula. The patient recovered smoothly with the supportive treatment and irrigation tubes were removed before discharge. After 2 months of discharge, CT presented a little necrosis around pancreas and colonic stenosis disappeared (Figure 1c). It was found that the stent had been extruded and right colonic flexure was slightly narrow by colonoscopy (Figure 2d).

DISCUSSION:

Colonic stenosis secondary to AP is uncommon. It may result from diffusion of inflammation by pancreatic enzymes and pancreatic necrosis. The anatomic relationship of the pancreas and large bowel is an important factor. In this case, stenosis of right colonic flexure is related with necrosis around pancreatic head. Colonic stenosis in AP can progress to colonic ischemia, necrosis and perforation, leading to very poor prognosis It needs operation and resection. Therefore, timely treatment is important. Here, we used total minimally invasive techniques, including implantation of pancreatic duct stent and colonic stent, to prevent detrimental consequence. The prognosis of the patient is good.
1430 Spontaneous Perforation of an Acalculous Hydropic Gallbladder in a Diabetic Patient With Neuropathy: An Under-Diagnosed Entity
Authors: Amarnath Shivantha , Polavarapu Abhishek , Gumaste Vivek
Published: October 2019

INTRODUCTION:

Gallbladder hydrops (HGB), a gradual increase in volume of the gallbladder in the absence of inflammation or abnormalities of the biliary tract, is under-reported due to various diagnostic criteria used worldwide. The primary cause is cholelithiasis, and initial management is often conservative as they are mostly clinically silent. Surgery is considered for complications of HGB. The universal rise in prevalence of diabetes mellitus (DM) has led to a concomitant increase in the incidence of gallbladder diseases. We report a case of a diabetic patient who presented with viral gastroenteritis and was found to have non-traumatic spontaneous rupture of a HGB.

CASE DESCRIPTION/METHODS:

78-year-old male with a complicated cardiac history including heart failure with placement of an automated implanted cardioverter, and non-insulin dependent DM with neuropathy exhibited one-day history of crampy, epigastric abdominal pain with non-bilious, non-bloody vomiting and watery diarrhea. Recently, his grandson was diagnosed with viral gastroenteritis. Patient was afebrile with unremarkable laboratory findings. CT of the abdomen with contrast highlighted a 6.7 cm × 11 cm HGB without cholecystitis or biliary ductal dilatation. Gallbladder ultrasound demonstrated sludge without evidence of wall thickening, gallstones, or pericholecystic fluid. Surgery recommended medical optimization and outpatient cholecystectomy due to his high risk (ASA III). He was admitted for viral gastroenteritis and began IV hydration. Hours later, patient endorsed worsening epigastric pain radiating to the right flank. HIDA scan revealed patency of the cystic duct with evidence of free biliary leak within the right peritoneal cavity. IV antibiotics were initiated followed by emergent cholecystectomy which uncovered a spontaneously perforated gallbladder with ruptured biliary contents into the peritoneum. Later, he developed septic shock, multi-organ failure, and expired on day 6.

DISCUSSION:

HGB, although rare, is frequent in the DM population and can present with serious complications. Our literature review uncovered that diabetics can develop HGB even in the absence of gallstones. Autonomic dysfunction affecting gallbladder contractility and reduced sensitivity of the gallbladder wall to cholecystokinin are key mechanisms. A sonogram may be used to screen for gallbladder dysfunction in diabetics, and if HGB is identified, we propose prophylactic cholecystectomy at an appropriate moment to significantly reduce morbidity and mortality.
1433 A Case of Cocaine-Induced Pancreatitis
Authors: Tian Frances , Strzepka Jessica , Garcia-Bedoya Olga , Yazici Cemal
Published: October 2019

INTRODUCTION:

Cocaine-induced pancreatitis is a rare and likely under-reported entity. Physicians must maintain a index suspicion when treating patients with cocaine use who present with abdominal pain especially if they are also on other concomitant medications that increase the risk of acute pancreatitis.

CASE DESCRIPTION/METHODS:

A 61-year-old male with cocaine abuse and heart failure with reduced ejection fraction (HFrEF) presented with 3 days of epigastric abdominal pain, nausea, and vomiting. His last intranasal use of cocaine was a few days prior to onset of symptoms. Lipase was 2300 (U/L) and computed tomography of the abdomen (CT) demonstrated an edematous and homogeneously enhancing pancreas with a small amount of peripancreatic fluid. Abdominal ultrasound was negative for cholelithiasis. Patient had a remote history of alcohol use but denied recent alcohol abuse. Toxicology was positive for cocaine on day of admission. An ethanol level was not obtained. Triglyceride, IgG4, and calcium levels were within normal limits. Notably, the patient was also hospitalized two months prior to present presentation for new onset left cerebellar stroke. Upon further evaluation, the patient was found to have a left ventricular ejection fraction of 30-35%, consistent with new diagnosis of HFrEF. The patient was started on metoprolol prior to discharge. Based on lack of other identifiable causative factors, patient's pancreatitis was attributed to concurrent cocaine and beta-blocker use.

DISCUSSION:

Pancreatitis is the most common gastrointestinal diagnosis resulting in admission, costing 2.6 billion dollars annually. The most common etiologies are gallstones and alcohol. Few cases of cocaine-induced pancreatitis have been reported in the literature. Cardiovascular and central nervous system (CNS) toxicities of cocaine such as acute coronary syndromes, chest pain, agitation, and strokes are well documented. Acute gastrointestinal complications of cocaine use are less common however usually include ischemic bowel and related perforation. There are only 5 reported cases of cocaine-induced pancreatitis. The mechanism of action of cocaine is inhibition of noradrenaline re-uptake, which produces vasoconstriction and thrombosis of mesenteric vessels. The pathophysiology of cocaine-induced pancreatitis is postulated to be related to vasoconstriction and thrombotic microangiopathy. In this patient, prior heavy alcohol may have led to underlying parenchymal disease and concomitant use of a beta-blocker were likely additive.
1434 A Rare Case of Multiple Myeloma Presenting as Pancreatic Plasmacytoma Causing Obstructive Jaundice
Authors: Achufusi Ted George
Published: October 2019

INTRODUCTION:

Extramedullary plasmacytomas represent a rare type of plasma cell tumors which can present outside of the bone marrow. Although extremely uncommon, they should be considered in the differential diagnosis when it comes to obstructive jaundice and pancreatic malignancy. Here, I present a case of obstructive jaundice caused by extramedullary plasmacytoma mimicking an adenocarcinoma, diagnosed by endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA).

CASE DESCRIPTION/METHODS:

A 72-year-old Caucasian male patient presented to our hospital with complaints of fatigue and painless jaundice. On admission, his liver biochemistries were abnormal with ALT 417, AST 414, ALP 1309, T bili 15.9, D bili 13.4, with normal lipase, amylase and WBC. CT abdomen was significant for a large mass adjacent to the pancreatic head along with multiple retroperitoneal and intra-abdominal nodules. Subsequently, patient underwent EUS with FNA of the pancreatic lesion. Tissue biopsy was positive for plasmacytoma. Follow up ERCP was unsuccessful as CBD could not be cannulated due to bulging papilla. As such, IR guided biliary drainage was placed with successful decompression of the biliary tree and corresponding improvement in liver biochemistries. Further workup showed evidence of widespread plasmacytomas including involvement of heart and bone.

DISCUSSION:

Pancreatic plasmacytomas remain a rare entity, with only five percent of all plasma cell tumors occurring outside of the bone marrow. This case documents a rare occurrence of visceral involvement of multiple myeloma, brought to clinical attention by atypical involvement of pancreatic head and body. Gastrointestinal plasmacytomas are usually limited to the liver and stomach, with only a limited amount of cases describing pancreatic involvement. Most reported cases describe microscopic plasma cell infiltration of the pancreas, making this presentation of a well-formed mass unusual. Availability of EUS and FNA sampling has made it easier for clinicians to diagnose plasmacytomas, as radiological differentiation of these tumors from other pancreatic malignancy is difficult. Furthermore, it is imperative to make the correct tissue diagnosis as prognosis and management differs from other pancreatic malignancy. This case highlights the importance of keeping a broad differential when suspecting a pancreatic malignancy in a patient with obstructive jaundice and those with history of plasma cell disorders.
1435 Pancreaticoenteric Fistula: A Very Unique Complication of Acute Pancreatitis
Authors: Rodriguez Ramos Roberto J. , Amill Reinaldo Ramirez
Published: October 2019

INTRODUCTION:

Pancreaticoenteric fistulas are a rare complication of acute pancreatitis. Spontaneous fistulation has been described in the literature in cases where acute pancreatitis is complicated with infection or necrosis. As a direct consequence to the fistula formation, direct vascular injury may occur, resulting in blood loss and rapid clinical deterioration.

CASE DESCRIPTION/METHODS:

A 77-year-old male with past medical history of essential hypertension, type 2 diabetes mellitus and coronary artery disease status post coronary artery bypass grafting in 2017 was brought to Emergency Room due to sudden onset right leg pain. He was admitted due to subacute limb ischemia and started on antiplatelet and anticoagulation medical therapy. Hospital course complicated with abdominal pain and four episodes of large volume port wine stools per rectum and significant drop in hemoglobin levels. After initial resuscitation measures, which include intravenous hydration and supportive blood products transfusions, patient was consulted to Gastroenterology service for evaluation and recommendations. Esophagoduodenoscopy revealed large clean base ulcerated lesion with an associated fistulous process in the first portion of the duodenum. No active bleeding nor blood remnants were noted. Abdominopelvic CT scan was immediately done and showed extensive devitalization of the pancreas along with large peripancreatic fluid collection with abundant internal gas suggestive of a contained perforation of duodenum. Interventional radiology and General surgery was consult.

DISCUSSION:

Spontaneous pancreaticoenteric fistula in the setting of pseudocysts formation secondary to necrotizing pancreatitis is a very rare and unique complication. Typical management is conservative, with medical therapy resulting in closure of the vast majority of fistulas. The infrequency with which pancreaticoenteric fistulas are encountered makes them a formidable diagnostic and treatment challenge. Even though it has been described in the literature, there still much to investigate regarding upper gastrointestinal fistulas and its associated vascular complications after acute pancreatitis.