bluuebunny/crossref_metadata_2025 huggingface dataset:
1307 A Rare Case of Metastatic Adenocarcinoma to the Pancreas Secondary to a Primary Lung Malignancy
Authors: Vangimalla Shiva , Mirza Muhammad U. , Agostini Tandy , Patel Mitesh R.
Published: October 2019

INTRODUCTION:

Metastatic pancreatic tumors are an infrequent occurrence. Pancreatic metastasis from non-small-cell lung cancer (NSCLC) is rare and might present with few symptoms when the tumor is small. Here, we report such an occurrence of metastatic pancreatic adenocarcinoma secondary to primary lung malignancy.

CASE DESCRIPTION/METHODS:

A 62-year-old male presented with cough, shortness of breath, early satiety and abdominal pain for a few days. His medical history was notable for hypertension, congestive heart failure, emphysema, and heavy cigarette use. He was hemodynamically stable on presentation. Initial labs were pertinent for NT-proBNP 969 pg/ml, low white blood cells 3.5 K/uL, low hemoglobin 11.7 gm/dL, elevated lipase 566 units/L, and elevated INR 3.2. Chest X-ray showed left basilar consolidation with pleural effusion. CT chest/abdomen/pelvis revealed 3 cm × 4 cm × 5 cm lower lobe consolidation in left lung (Figure 1), 2 cm × 2 cm × 2 cm low-attenuation lesion in pancreatic head, and multiple sclerotic lesions of thoracolumbar spine. Preliminary infectious workup was negative. He was started on empiric antibiotics for community-acquired pneumonia. Further testing for malignancy revealed a normal level of CA19-9 22.9 IU/ml, CEA 1.3 ng/ml, and PSA 0.83 ng/ml. He underwent upper endoscopic ultrasound (EUS) which showed 28 mm × 25 mm hypoechoic mass in the pancreatic head (Figure 2). The preliminary diagnosis was consistent with “adenocarcinoma”. Further immunostaining analysis of pancreatic mass was positive for TTF1 (Figure 3) and PD-L1, negative for p63 and CK5/6 compatible with primary lung adenocarcinoma. The lung mass was not biopsied in view of the presumptive diagnosis - primary lung adenocarcinoma with secondary metastasis to pancreas. After discharge, he was due to follow up in the Oncology clinic for more definitive treatment.

DISCUSSION:

There have been only a few reported cases of pancreatic metastases in the setting of primary lung malignancy. Among the subtypes of lung malignancy, pancreatic involvement is more common in small cell carcinoma whereas it is much less common in adenocarcinoma. Clinical presentation may range from asymptomatic to acute pancreatitis. EUS guided FNA and immunostaining studies tend to be the diagnostic tool of choice to differentiate between primary and secondary tumors. Identification of pancreatic metastases is important as it confers poorer prognosis and worse survival.
1308 An Extraordinary Case of Delayed and Isolated Recurrence of Renal Cell Carcinoma in the Pancreas
Authors: Palmer Quinton D. , Khan Salman Ali , Perisetti Abhilash , Khan Nazish , Johnson Kemmian D. , Inamdar Sumant
Published: October 2019

INTRODUCTION:

Renal cell carcinoma (RCC) is the most common malignancy of the kidney. RCC is curative with nephrectomy followed with post-operative surveillance with computed tomography (CT) or magnetic resonance imaging (MRI). RCC recurrence rarely occurs beyond 5 years. We present a 57-year-old woman 8 years post left nephrectomy due to RCC, who presented with an incidental pancreatic head mass on MRI subsequently confirmed as RCC.

CASE DESCRIPTION/METHODS:

A 57- year old Caucasian woman with a past medical history of recently diagnosed T1a N0M0 colorectal carcinoma (CRC) status post right hemicolectomy and Grade 2 RCC status post left nephrectomy 8 years prior to presentation, underwent post-surgical surveillance for CRC two months post hemicolectomy. She reported no clinical symptoms. Incidental findings on outside hospital MRI of the abdomen and pelvis with contrast demonstrated a 2.5 cm hypodense mass at the pancreatic head (Figure 1). Metastatic work up for CRC including whole body positron emission tomography was negative. She was referred to our institution for endoscopic ultrasonography with find needle aspiration (EUS-FNA) of the pancreatic mass. Blood test showed normal liver function test and CA 19-9. The EUS showed a 2 cm × 2 cm ill-defined hypoechoic and heterogenous in echotexture mass in the head and neck of the pancreas (Figure 2). A 22-gauge needle with a stylet was used to perform FNA. Immunostains showed neoplastic cells positive for PAX-8 and RCC; immunophenotype consistent with clear cell RCC (Figure 3). She underwent successful central pancreatomy with pancreato-gastrostomy without complications.

DISCUSSION:

This case is extraordinary as RCC recurred after 8 years following nephrectomy as an isolated pancreatic mass following 5-year surveillance without evidence of recurrence. Up to 93% of recurrence occurs within 5 years post nephrectomy and current guidelines recommend RCC surveillance up to 5 years post nephrectomy. EUS-FNA provided a minimally invasive method of accurately diagnosing metastatic RCC and is an excellent tool for evaluating pancreatic lesions. Reporting such a case should raise the awareness among physicians for delayed recurrence of RCC in sites such as the pancreas and further longitudinal studies should be sought to assess the prolonged surveillance strategies to identify such recurrences.
1317 Case of an Unusual Complication of a Biliary Stent
Authors: Goyal Abhinav , Sher Daniel J.
Published: October 2019

INTRODUCTION:

Biliary stent complications are not rare but we present a very rare complication of biliary stent.

CASE DESCRIPTION/METHODS:

64 year old male with hypertension, diabetes mellitus, coronary artery disease, chronic thrombocytopenia, and orthotopic liver transplant six months prior to presentation for alcoholic cirrhosis was transferred to our center from an outside hospital. He was admitted with fever, nausea, and shortness of breath for 4 days. On arrival, his heart rate was 105/min, and blood pressure 141/88 mm Hg, oral temperature 36.8°C. Physical exam was unremarkable. Total and direct bilirubin were newly elevated to 2.7 and 2.0 mg/dL respectively from 1 and 0.5 mg/dL 10 days ago. WBC was 6.4 × 103/mcL. Gram negative rods were detected in cultures drawn at outside hospital. Due to these findings abdominal ultrasound was done which showed a well positioned pediatric feeding tube inside the bile duct placed at time of transplant to maintain anastomotic patency. There was lack of pneumobilia and progressive extrahepatic biliary ductal dilation. Due to a concern for cholangitis from blocked biliary tube an ERCP was recommended. During ERCP, feeding tube was visualized at ampulla and removed. Biliary cannulation was achieved with wire and sphincterotomy performed. A 1.5 cm anastomotic stricture was seen with ductal dilation proximal and distal to it. A 7 French and 9 cm plastic biliary stent was placed across the stricture. Patient improved symptomatically and bilirubin trended down over next 3 days. On fourth day, he developed sudden onset diffuse abdominal pain which was exacerbated by minimal movement. No rebound tenderness or rigidity was noted. He was tachycardic to 112 beats/min. Due to this a stat CT of abdomen/pelvis was done without contrast. Biliary stent was seen to be extending through the contralateral wall of the duodenum, terminating into peritoneal fat with increase in intra-abdominal free fluid. No free air was seen. He was immediately taken to OR for an omental patch repair of the duodenum and peritoneal washout revealed bilious fluid in the peritoneum. Pt had a slow recovery and was discharged to skilled nursing facility fourteen days after the surgery.

DISCUSSION:

We present a rare but important early complication of biliary stent placement that needs to be recognized promptly to reduce morbidity and mortality. There are very few cases described in literature and most stent related perforation occured between 5 days and 2 weeks post placement.
1325 Isolated Thrombosis of the Superior Mesenteric Vein
Authors: Essrani Rajesh , Mehershahi Shehriyar , Essrani Rajesh , Kirshan Ravi Shri Jai , Mehmood Asif
Published: October 2019

INTRODUCTION:

Acute pancreatitis can result in many vascular problems such as splanchnic vein thrombosis (splenic, portal, and/or superior mesenteric veins) and pseudoaneurysm. Thrombosis of the superior mesenteric vein (SMV) without simultaneous thrombosis of the splenic or portal vein is very rare.

CASE DESCRIPTION/METHODS:

A 40-year-old man with a past medical history of tobacco abuse admitted with complaints of sudden onset of epigastric pain with radiation to back associated with nausea and vomiting since last two days. On exam, blood pressure 156/76, respiratory rate 13, saturation 91% on room air, and pulse 101. The abdomen was soft but tender in the epigastric area, no right upper quadrant tenderness, and bowel sounds decreased in all quadrant. Blood work showed hemoglobin 15.1 g/dL, hematocrit 45.2%, WBC 17.04 K/uL (80% neutrophils), platelets 600 K/uL, AST 24 U/L, ALT 22 U/L, alkaline phosphatase 144 U/L, lactate 1.2 mmol/L, triglyceride level 86 mg/dL, LDL 160 mg/dL, calcium 9.1 mg/dL, BUN 30 mg/dL, creatinine 1.3 mg/dL, sodium 139 mmol/L, and lipase 600 U/L. CT abdomen/pelvis showed pancreatitis, normal biliary duct, and an absence of opacification of the SMV. He denied any personal or family history of coagulopathy and denied alcohol intake. He was treated with pain medications and lactated Ringer's solution at 5 mL/kg per hour. Hematology recommended low-molecular-weight heparin 1 mg/kg twice a day and Coumadin. His conditions improved in 3 days, and he was discharged home with Coumadin to complete three months of treatment.

DISCUSSION:

Mesenteric venous thrombosis (MVT) is usually caused by a local intra-abdominal inflammatory process (e.g., pancreatitis), local trauma (e.g., splenectomy), heritable, and acquired thrombophilia. Most cases of pancreatitis are mild and self-limiting, but some cases may develop complications such as MVT which is an emergent condition. It is rare to find an isolated SMV thrombosis without involving splenic or portal vein in acute pancreatitis as thrombosis usually develops due to vascular stasis in the setting of local infection. SMV thrombosis can present acutely, subacutely, or more chronically. CT of the abdomen is used for the diagnosis. The treatment of SMV thrombosis (acute and subacute) is predominantly conservative, consisting of systemic anticoagulation, bowel rest, and serial observation for any signs of clinical deterioration. Surgical exploration is limited to those patients with definite signs of bowel infarction.
1326 Over the Counter Drug Causing Acute Pancreatitis
Authors: Essrani Rajesh , Mehershahi Shehriyar , Essrani Rajesh , Parvataneni Swetha , Lohana Ajeet Kumar , Mehmood Asif
Published: October 2019

INTRODUCTION:

Acute pancreatitis is caused by alcohol, gall stone disease, drugs, trauma, infections, and metabolic causes like hypercalcemia and hyperlipidemia. Hypercalcemia induced acute pancreatitis has been well documented but rarely due to over the counter calcium carbonate. We present the case of over the counter calcium carbonate-induced pancreatitis.

CASE DESCRIPTION/METHODS:

A 35-year-old male admitted for epigastric pain with radiation to back associated with nausea and vomiting. He was complaining of fatigue, poor appetite, and increased urination. He had a history of gastroesophageal reflux disease and was taking over the counter (OTC) drug for it. Vitals signs were stable. On Exam, he appeared slightly confused with dry skin and generalized abdominal tenderness. Blood work: WBC 16.4 K/uL, sodium 139 mmol/L, BUN 23 mg/dL, creatinine 2.6 mg/dL, AST 34 U/L, ALT 26 U/L, bicarbonate 34 mmol/L, alkaline phosphatase 114 U/L, calcium 15.1 mg/dL, triglyceride level 79 mg/dL, LDL 110 mg/dL, lipase 560 U/L and negative ethanol level. CT abdomen/pelvis showed pancreatitis with normal biliary tract. He was treated with pain medications and ringer lactate fluid. Further investigation showed low PTH, low Vitamin D (25), normal PTHrP, vitamin D (1,25), SPEP, UPEP and free light chain. Patient admitted that he was taking 7-8 tablets of calcium carbonate since last 3 weeks for acid reflux. His symptoms and calcium level improved gradually with ringer lactate and he was discharged after 6 days. He was educated on side effects of excessive use of the OTC drugs.

DISCUSSION:

The milk-alkali syndrome consists of hypercalcemia, renal failure, and metabolic alkalosis secondary to the consumption of excessive calcium and alkali. Excessive calcium intake is usually considered as more than 4-5 g of calcium carbonate per day. Excessive self-medication with over-the-counter drugs is very common and leads to life-threatening illnesses. Medications should be reconciled on every encounter with patients, including over the counter medications, and patients should be educated about the side effects of excessive use. Acute pancreatitis secondary to antacid-induced milk-alkali syndrome has been rarely reported in the literature.
1328 Intrauterine Pregnancy Complicated by a Distal Common Bile Duct Mass: An Unlikely Diagnosis of Extrahepatic Cholangiocarcinoma With Intrahepatic Metastasis
Authors: Collins Kelsey , Dong Ray , Rozenshteyn Frederick , Lung Edward
Published: October 2019

INTRODUCTION:

Cholangiocarcioma (CCA), a malignancy that originates from the epithelial cells of the biliary tree, is rare and often portends a poor prognosis with a survival rate of 5-10% at 5 years. CCA is even more infrequent during pregnancy with only a few reported cases.

CASE DESCRIPTION/METHODS:

A 37-year-old, 31-week pregnant female, presented to the ED with worsening epigastric pain for 3 months. She also had jaundice for several days. Her total bilirubin was 6.5, ALP was 631, ALT was 86, and AST was 80. Lipase was normal. CA 19-9 was elevated to 4649. She had an abdominal US that showed gallbladder sludge, 1.0 cm CBD, and coarse hepatic echogenicity. She underwent MRCP, which revealed CBD dilatation to 1.1 cm, leading up to a 1.7 cm segment of obstruction at the distal CBD, where there was an ill-defined heterogeneous soft tissue mass. Distal to the lesion, the CBD was normal in caliber, with slight prominence of the pancreatic duct at the pancreatic body. In addition, there were 2 hepatic lesions. ERCP was then done for further diagnostic workup. The CBD was deeply cannulated and injected with contrast, with brisk flow up to the hepatic ducts. The middle third of the CBD contained a 25 mm area of severe, localized stenosis, and the upper third of the CBD was dilated to 18 mm. Sphincterotomy was done, and a partially covered metal stent was placed in the CBD with good position and good bile flow. She then proceeded to undergo a CT-guided liver biopsy of the largest hepatic lesion, which ultimately showed moderately differentiated adenocarcinoma with extensive tumor necrosis and desmoplasia. Immunohistochemistry was diffuse and strongly positive for cytokeratin 7 and cytokeratin 19. Findings were all consistent with extrahepatic cholangiocarcinoma with intrahepatic metastasis. Oncology was consulted, who recommended starting a course of Abraxane, Gemcitabine, and Cisplatin, which she deferred until after childbirth. She continued to follow up with Oncology outpatient, but ultimately had uncontrollable disease. She passed away in inpatient hospice due to liver failure and polymicrobial bacteremia likely due to bowel leak and pneumobilia.

DISCUSSION:

CCA represents 3% of all gastrointestinal malignancies, and is extremely uncommon during pregnancy. Symptoms and labs can be similar to those seen in HELLP, obstructive cholestasis, and acute fatty liver of pregnancy. A full diagnostic workup is fundamental in pregnant patients presenting with abdominal pain, jaundice, and abnormal liver enzymes.
1330 Recurrent Abdominal Pain in the Elderly: An Interesting Case of SBO and Brittle Diabetes Due to Undiagnosed Annular Pancreas
Authors: Collins Kelsey , Constantino Joseph , Chuang Philip , Dong Ray , Laskova Violetta , McCabe Evin
Published: October 2019

INTRODUCTION:

Annular pancreas, a congenital anomaly caused by a complete or partial ring of pancreatic tissue surrounding the descending duodenum, is uncommon and often presents in childhood with gastric outlet obstruction. Although the incidence is 5-15 per 100,000 patients based on autopsy, the true incidence rate is unknown as many patients are asymptomatic. We present a case of recurrent abdominal pain and associated uncontrolled Diabetes and undiagnosed annular pancreas.

CASE DESCRIPTION/METHODS:

An 83-year-old female with a history of CAD, DM2, HTN, HLD, GERD, and recurrent abdominal pain with labile diabetes presented to the ED with abdominal pain for 2 days. The pain was epigastric and associated with constipation and inability to pass flatus for 1 day. Labs were significant for glucose of 529, ALP of 204, AST of 96, ALT of 108, lactate of 2.6, and HbA1c of 16.6. She underwent CT Abdomen/Pelvis, which showed marked dilatation of the 1st two portions of the duodenum with an abrupt transition point and distended colon with fecal material without evidence of obstruction. An upper GI series was obtained; which was remarkable for obstruction at the 2nd portion of the duodenum. NGT decompression of barium from the stomach was performed and endoscopy showed extrinsic compression between the 1st and 2nd portions of the duodenum. EUS was subsequently performed but could not confirm the stenosis; sonography was suspicious for annular pancreas. MRCP was performed showing glandular parenchymal atrophy of the pancreatic body and tail and partial annular pancreas causing obstruction of the 2nd portion of the duodenum. Over the next few days her insulin regimen was titrated and her symptoms improved with subsequent discharge. On follow-up she and her family ultimately declined surgical or duodenal stent placement due to the patient's multiple comorbidities.

DISCUSSION:

Although most asymptomatic annular pancreas never cause problems, they can still become symptomatic. The patient's annular pancreas likely resulted in partial bstruction which contributed to recurrent misdiagnosed pancreatitis. This resulted in impairment of her pancreatic function, worsening her DM thus potentiating her labile diabetes. Additionally, years of fibrosis and scarring from inflammation of her annular pancreas likely lead to her eventual duodenal narrowing, further exacerbating symptoms.
1332 Diarrhea, Heartburn, and Recurrent Pancreatitis: An Interesting Presentation of Zollinger-Ellison Syndrome
Authors: Penrice Daniel , Janssens Laurens , Halfdanarson Thorvardur
Published: October 2019

INTRODUCTION:

Zollinger-Ellison syndrome (ZES) is a condition characterized by severe diarrhea and peptic ulcer disease caused by the secretion of gastrin by a neuroendocrine tumor located in the duodenum or pancreas. The most common presenting finding is peptic ulcer disease, followed by heartburn, diarrhea, and weight loss.

CASE DESCRIPTION/METHODS:

A 40-year-old man presented with watery diarrhea and heartburn for 2 years. In addition, he endorsed history of recurrent pancreatitis beginning 15 years prior to presentation. Esophagogastroduodenoscopy (EGD) revealed reflux esophagitis and enlarged gastric folds with erythematous duodenopathy, mucosal biopsies were negative for malignancy. Patient was started on oral proton pump inhibitor with only mild improvement in heartburn and diarrhea. Upper endoscopic ultrasound revealed a 4 × 6 cm mass in the region of the pancreatic head and biopsies were consistent with neuroendocrine tumor. Abdominal computed tomography with intravenous contrast revealed an uncinate process mass. Gastrin level at the time of evaluation was significantly elevated 971 pg/mL (normal <100) and glucagon level was normal. Gallium-68 dotatate positron emission tomography (PET) scan was performed to fully stage the tumor and was notable for a large mass in the uncinate process as well as nodal metastases localizing around the right kidney in the portocaval region. Patient was referred to surgery and underwent Whipple procedure with excision of infrarenal lymph nodes without complication. Stools returned to normal in the month after surgery and proton pump inhibitor was tapered without recurrence of symptoms.

DISCUSSION:

In patients with the constellation of refractory peptic ulcers, diarrhea, heartburn, or abdominal pain, ZES should be suspected. Only approximately 25 percent of gastrinomas arise in the pancreas, with the majority being found in the first portion of the duodenum. Elevated level of gastrin (especially in the absence of PPI therapy) in the presence of low gastric pH is suggestive of ZES. Initial steps in localizing the tumor involve upper endoscopy and abdominal imaging. Gallium-68 dotatate PET imaging (PET/CT or PET/MRI) is increasingly preferred over other imaging modalities for identifying somatostatin receptor-positive neuroendocrine tumors due to high sensitivity in identifying these tumors. Conventional imaging was unable to capture the extent of disease in this patient, but advanced imaging was able to localize portocaval nodal metastasis.
1335 Unchewed Food: The Enemy of Lumen-Apposing Metal Stent Placement in EUS-Gallbladder Drainage
Authors: Iriana Sentia , McVay Tyler , Adler Douglas G. , Sossenheimer Michael
Published: October 2019

INTRODUCTION:

Lumen-apposing metal stents (LAMS) represent a novel therapeutic endoscopic tool for the treatment of acute cholecystitis in high-risk surgical patients via transluminal EUS guided gallbladder (GB) drainage with reported 92-98% success rates. We describe a patient's successful EUS guided drainage and subsequent clinical deterioration after food related LAMS occlusion.

CASE DESCRIPTION/METHODS:

A 63-year-old man with extensive cardiopulmonary disease, GB hydrops, chronic cholecystitis and prior course of decompression with percutaneous cholecystostomy tube (PTC), was re-evaluated for worsening post-prandial abdominal pain. A CT showed a hydropic GB with layering stones and sludge, concerning for cholecystitis. Semi-urgent decompression with IR cholecystostomy tube vs. EUS-GB drainage was suggested because of his poor surgical candidacy. The patient declined PTC due to reduced quality of life and lack of symptomatic relief in the past. A linear EUS evaluation showed a distended, thick walled GB (12 cm in size) with sludge and debris. A cholecystoenterostomy via doppler EUS was created, followed by deployment of a 15 mm LAMS stent with immediate drainage of copious purulent bile. A 7 Fr × 7 cm double pigtail stent was placed across the LAMS. Despite a technically successful procedure, the patient did not experience clinical improvement. A follow up CT demonstrated decreased GB distention, appropriate LAMS position and related intraluminal GB gas; yet increased GB wall thickening, pericholecystic fluid, and fat stranding in the perihepatic region were consistent with worsening acute cholecystitis. A repeat EGD was performed to ensure proper LAMS location and patency. Large unchewed food pieces in the duodenal bulb and an at least partially occluded LAMS, due to food-debris, were discovered. The LAMS and GB lumen were cleared of food debris using a combination of forceps and water irrigation. The patient was placed on a full liquid diet and subsequently demonstrated clinical improvement.

DISCUSSION:

EUS-guided GB drainage with LAMS placement is a viable alternative to cholecystectomy for high risk surgical candidates when performed in clinical centers of expertise. Procedural success is high, yet lack of clinical improvement may require further evaluation for possible LAMS occlusion. We describe a case of lack of improvement due to documented occlusion of the LAMS related to poorly chewed food. Dietary counseling for patients post LAMS placement may be beneficial.
1337 Persistent Diarrhea in a Patient With a Pancreatic Tail Mass: VIPoma Diagnosed With Endoscopic Ultrasound-Guided Fine-Needle Biopsy
Authors: Shah Ruchit N. , West Sara , Zhang Bin , Confer Bradley
Published: October 2019

INTRODUCTION:

Vasoactive intestinal peptide-secreting tumors (VIPoma) are extremely rare with a worldwide incidence of 1 in 10 million per year. Approximately 56-80% of VIPomas metastasize before a diagnosis can be established. We present a case of a VIPoma localized to the pancreatic tail diagnosed with endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) and treated successfully with octreotide and surgery.

CASE DESCRIPTION/METHODS:

A 64-year-old male presented with a 10-month history of gradually worsening diarrhea, muscle cramps, and a 30-lbs weight loss. He was tachycardic but hemodynamically stable. His abdomen was mildly distended and tympanic, but the remainder of his exam was unremarkable. Sodium was 125 mmol/L (ref: 135-146 mmol/L), potassium 1.6 mmol/L (ref: 3.5-5.1 mmol/L), bicarbonate 16 mmol/L (ref: 22-32 mmol/L), and chloride 87 mmol/L (ref: 98-107 mmol/L). Computed tomography showed a 4 cm lobulated, heterogeneously enhancing mass abutting the antero-inferior pancreatic tail with calcifications and pancreatic duct measuring 4.5 mm. Patient subsequently underwent EUS-FNB of the mass (Figure 1) with a 25-gauge fork-tip biopsy needle (Medtronic, Minneapolis, MN). Cytology revealed plasmacytoid cells with pleomorphic nuclei, abundant cytoplasm, and frequent naked nuclei indicative of neuroendocrine tumor (NET), grade II (Figure 2). Two consecutive vasoactive intestinal peptide (VIP) levels of 1170 pg/ml and 600 pg/ml (ref <75 pg/ml) along with an octreotide scintigraphy scan showing the presence of a radiotracer avid pancreatic tail mass, confirmed the diagnosis of VIPoma (Figure 3). Patient was started on octreotide and underwent laparoscopic distal pancreatectomy and splenectomy with resolution of symptoms.

DISCUSSION:

Pancreatic NETs are very rare and constitute only 1-2% of all pancreatic solid-mass tumors. VIPoma is one such NET and is intrapancreatic in 95% of cases. Approximately 56-80% of patients present with metastatic disease before a diagnosis is made. Also known as pancreatic cholera, VIPoma syndrome is characterized by a low osmotic gap secretory diarrhea, hypokalemia, hypochlorhydria, and acidosis. Infections, being more common, can delay diagnosis and treatment. Diagnosis is made by EUS-FNB and octreotide scan, as seen in our case. Treatment includes complete resection in rare cases where metastasis has not occurred. In patients presenting with secretory diarrhea and metabolic derangements in the setting of a pancreatic mass, EUS-FNB can be utilized to diagnose and stage the tumor.
1339 Gastro-Colic Fistula: A Delayed Complication of Whipple's Procedure for Tropical Pancreatitis
Authors: Tageldin Omar , Itani Wafic , Mansoor Muhammad Sohail , Parsa Nour
Published: October 2019

INTRODUCTION:

Gastrointestinal (GI) fistula is a serious condition that can lead to electrolyte disturbance, severe debility and even death. It occurs as a complication of gastrointestinal surgery mostly involving malignancies. We present a case of a gastro-colic fistula (GCF) occurring six years after Whipple's procedure.

CASE DESCRIPTION/METHODS:

A 58 years old Guyanese male with current alcohol abuse was admitted for 2 months of diarrhea. He reported more than 2 dozen watery bowel movements a day including nocturnal episodes, fecal incontinence, chills and a 15 lbs weight loss. Lab work showed significant hypoalbuminemia, hypokalemia and normal anion gap metabolic acidosis. He reported a history of tropical pancreatitis complicated by acute necrotizing pancreatitis followed by Whipple's procedure 6 years ago. Patient underwent CT abdomen which showed diffuse wall thickening of the ascending colon while colonoscopy revealed circumferential ulcerated mucosa in the same area. The colonoscope was not advanced further due to high risk of perforation. Biopsies from ulcer base and margin showed benign colonic mucosa with regenerative changes. An EGD was performed that revealed a 3 cm peri-anastomotic gastric ulcer and a large GCF in ulcer base. Fecal material was found in stomach and fistula was easily traversed with gastroscope. Patient was put on TPN and underwent exploratory laparotomy with partial greater omentectomy, distal gastrectomy with Roux-en-Y gastrojejunostomy, transverse colectomy with end colostomy, long Hartmann's pouch and a partial small bowel resection. Post-procedure he was slowly advanced to a regular diet with resolution of his diarrhea.

DISCUSSION:

GCF happens most commonly in surgeries involving GI malignancies. Imaging of choice is barium enema with barium seen in the stomach via a pressure gradient created from the colon to the stomach. GCF can be diagnosed endoscopically but may be missed if the fistula opening is small or obscured by adjacent mucosal changes as we encountered during colonoscopy in this case. Risk factors for developing GCF after Whipple's procedure include infection, sepsis, breakdown of intestinal anastomosis due to ischemia, tension in anastomotic tissue, distal obstruction hypoproteinemia, radiation injury and underlying IBD. Controlling fistula output by keeping patient NPO, proton pump inhibitors and maintaining adequate nutrition are key factors in healing GCF. Endoscopic or surgical approaches for fistula closure should be considered on individual basis.
1344 Sump Syndrome With Massive Choledocholithiasis Requiring Electrohydraulic Lithotripsy
Authors: Duarte-Chavez Rodrigo , Matin Ayaz , Martinez-Tapia Ana , Tayel Hussam , Tayel Hesham , Bahirwani Janak , Geme Berhanu
Published: October 2019

INTRODUCTION:

Cholelithiasis is highly prevalent and affects 10-15% of the United States population. About 10-20% of the patients with symptomatic cholelithiasis have also choledocholithiasis; this is treated with ERCP and subsequent cholecystectomy. Recurrent CBD stones after ERCP occur in 4-24% and are caused mainly by bile stasis.

CASE DESCRIPTION/METHODS:

A 76-year-old female presented to our practice 3 years ago with cholangitis, requiring ERCP with removal of multiple stones and sludge. Balloon dilation with plastic stent placement was also performed due to distal CBD stenosis. She had a history of cholecystectomy and ERCP 25 years ago, complicated with bowel perforation. We performed 9 ERCPs subsequent to her first visit with us due to recurrent cholangitis. Because of the CBD stenosis and recurrent choledocholithiasis, biliary bypass with side-to-side choledochoduodenostomy (CDD) was performed. Six months after the CDD she had another episode of cholangitis. ERCP was performed but there was massive lithiasis in the CBD and stones could not be removed (Figures 1 and 2). Electrohydraulic lithotripsy (EHL) had to be used under direct visualization through the CDD and stones were removed using a combination of snare, balloon and basket (Figure 3). The CBD was completely cleared and a double-pigtail stent was placed at the CDD. Two days after the procedure the patient was discharged home and her LFTs were normal during follow up.

DISCUSSION:

CDD is a procedure performed to improve biliary drainage but its use has dramatically decreased after ERCP. Sump or “cul-de-sac” syndrome (SS) is a complication of CDD that results from bile stasis and the accumulation of debris in the segment of CBD between the anastomosis and the ampulla of Vater, facilitating bacterial proliferation and stone formation. The prevalence of SS after CDD is estimated to be between 0-9.6%. The current treatment for SS is decompression of the CBD distally with sphincterotomy and CBD clearance with basket and balloon. With our patient, we decided to avoid sphincterotomy since there was a long segment of distal CBD stenosis and the CDD opening was also wide enough to allow access to the CBD. The massive lithiasis in this patient might have been caused by the reflux of duodenal content into the CBD trough the CDD, but she also had recurrent choledocholithiasis even prior to the CDD and other factors were perpetuating the stone formation in the CBD. We present a unique case of SS with massive CBD lithiasis that required use of EHL through the CDD.
1345 Pancreatic Pseudocyst Leading to Gastric Outlet Obstruction: A Hard Diagnosis to Swallow
Authors: Falde Sam , Kamboj Amrit K. , Dines Virginia
Published: October 2019

INTRODUCTION:

Recurrent pancreatitis with pseudocyst can present with gastric outlet obstruction. Endoscopic evaluation should be utilized in certain contexts, especially to exclude more sinister causes of this presentation.

CASE DESCRIPTION/METHODS:

A 43-year-old woman with a history of alcohol use disorder presented with a gastric outlet obstruction. This was felt secondary to a pancreatic pseudocyst given multiple episodes of recurrent pancreatitis, the last being 1 week prior to her current admission. On presentation, physical exam was significant for ascites and epigastric tenderness. Labs were notable for AST 214 U/L, ALT 99 U/L, alkaline phosphatase 147 U/L, lipase of 203 U/L, and negatives serum alcohol. Notably, Ca 19-9 was elevated to 154 IU/mL during admission 2 weeks prior. Computed tomography chest and abdomen revealed bilateral pleural effusions, pseudocyst, and abdominal ascites. A thoracentesis and paracentesis were performed with cytology for both peritoneal fluid and pleural fluid confirming metastatic adenocarcinoma. Given her refractory symptoms, an esophagogastroduodenoscopy (EGD) was performed which showed an obstructing tumor at the gastric outlet with biopsies revealing poorly differentiated gastric adenocarcinoma. A gastric stent was placed; however, she had continued nausea and vomiting. Repeat EGD showed gastric stent failure and subsequent endoscopic gastrojejunostomy with Axios stent was placed. The patient's functional status declined rapidly as a result of her advanced malignancy and on hospital day 8 she suffered a cardiac arrest, passing shortly after being transitioned to comfort cares.

DISCUSSION:

The patient's prior history of alcohol use disorder, recurrent pancreatitis, and imaging consistent with pancreatic pseudocyst made this case prone to numerous cognitive errors initially obscuring the etiology of her gastric outlet obstruction and pancreatitis. By reframing the presentation, we were able to question pancreatic pseudocyst as the sole source of the gastric outlet obstruction. Traditionally, Ca 19-9 is associated with pancreatic adenocarcinoma. It also can be elevated in the setting of other gastric malignancies and acute pancreatitis. In pancreatitis, absolute value and trends of Ca 19-9 can help differentiate between pancreatitis and malignancy. The diagnostic uncertainty around this patient's presentation with recurrent pancreatitis, pseudocyst, and gastric outlet obstruction required endoscopic evaluation to ultimately diagnose metastatic gastric adenocarcinoma.
1346 CA 19-9: Elevation in Mycobacterium Avium-Intracellulare Infections
Authors: Turse Erica , Chuang Keng-Yu
Published: October 2019

INTRODUCTION:

Carbohydrate antigen 19-9 is usually associated with pancreatic malignancy. However, other causes as bronchiectasis can cause lab elevation. Here we present a case of an elevated CA 19-9 with pulmonary mycobacterium avium-intracellulare.

CASE DESCRIPTION/METHODS:

66 year old HIV negative female with MAI (Figure 1) on Ethambutol, Rifampin, Azithromycin (started 4/2017, stopped 10/2017, restarted 1/2018) presented to clinic with complaints of epigastric pain with unintentional weight loss. She was started on proton pump inhibitor and H2 blocker therapy and underwent EGD and colonoscopy with biopsies positive for Helicobacter pylori. She received quadruple therapy with eradication on stool antigen. She complained of a mass in her supra-pubic region and given this with her weight loss and normal endoscopies, a CT Abdomen and Pelvis was performed which showed no hepato-biliary abnormalities but significant bladder distention (Figure 2). This resolved on its own prior to her seeing urology or coming in for follow up. A CA 19-9 remained elevated at 105, 94, and 111 during this time frame.

DISCUSSION:

Mycobacterium is a masquerader causing hydronephrosis to bronchiectasis, both seen in our patient, with the mechanism of CA 19-9 elevation unknown. Shin et al presented a patient with MAI and elevated CA 19-9 levels, which improved with treatment.
1
Studies have shown an elevated CA 19-9 may be from MAI infection or other causes of bronchiectasis, such as Chang et al in 2013.
2
Yamazaki et al compared CA 19-9 in patients with deteriorated (96.9) vs non-deteriorated (19.2) disease.
3
Hong and colleagues in their analysis showed that CA 19-9 could be elevated in patients with MAI and improved with treatment.
4
Here, we highlight the importance of a differential diagnosis of non-pancreatic etiologies for elevated CA 19-9 levels.
1348 The Ketamine Connection: Ulcerative Cystitis and Biliary Dilatation in the Setting of Chronic Ketamine Abuse
Authors: Tarzi Davood , Pradhananga Jyoti
Published: October 2019

INTRODUCTION:

Recreational ketamine abuse can present with a unique constellation of symptoms, and limited literature on this topic makes this case a rare learning opportunity.

CASE DESCRIPTION/METHODS:

A 37-year-old male with diffuse psoriasis and a one-year-history of ketamine inhalation presented to the ER complaining of recurrent episodes of epigastric pain. The pain was described as colicky, non-radiating, and 10/10 in intensity; he related the pain acutely worsened in the 3 days prior to admission. He also had a remote history of cocaine and marijuana abuse. He denied vomiting, diarrhea, melena, dysphagia, odynophagia, fevers, or chills. Physical exam findings were negative for a Murphy's sign. Laboratory studies were significant for eosinophilia and an elevated lipase. A CT of the abdomen revealed hypodensities in the liver parenchyma and dilatation of the intrahepatic biliary ducts, common bile duct, gallbladder, and pancreatic duct. These findings suggested an obstructing stone or mass lesion at the ampulla. Furthermore, a pelvic CT also revealed an asymmetric, markedly thickened anterior urinary bladder wall and bladder dome; these findings were concerning for underlying malignancy of the bladder. A urinalysis revealed elevated white blood cells and red blood cells, but cytology was negative. A re-evaluation of the patient revealed symptoms of difficulty urinating, with sensation of having to push to void and dysuria at the end of micturition. Of note, the patient denied any history of freshwater swimming or exposure to factory chemicals. The patient underwent an EUS, which revealed a dilated common bile duct without stones, an acalculous gallbladder, and a deformed ampulla. A bedside cystoscopy was performed, revealing no tumors or strictures, but revealed a high-riding median lobe of the prostate at the bladder neck. Additionally, the posterior dome showed a thickened, erythematous area, and another rounded area consistent with ulcerative cystitis. Urology scheduled the patient for a repeat cystoscopy with biopsy, but unfortunately he left against medical advice as his pain and other symptoms had resolved.

DISCUSSION:

Ketamine, known for its hallucinogenic effects, is used recreationally among various populations. Hepatic-dominant metabolization, with urinary (90%) and biliary (10%) excretion leave these organs exposed to ketamine metabolites and their effects. This case emphasizes the importance of drug history in patients presenting with biliary colic and urinary symptomatology.
1350 Small Pancreatic Cyst Progressed to Metastatic Pancreatic Neuroendocrine Tumor in Three Months
Authors: Jin-Dominguez Fangyuan , Ahmad Dina , Faulx Ashley , Chak Amitabh
Published: October 2019

INTRODUCTION:

We report a case of an incidentally found asymptomatic pancreatic tail cyst that rapidly grew from 1 cm to 3.4 cm in a 3-month period. The final diagnosis is metastatic pancreatic neuroendocrine tumor (NET).

CASE DESCRIPTION/METHODS:

A 72-year-old male was referred for EUS to evaluate an incidental 13 mm pancreatic tail cyst found on CT chest. He was asymptomatic and had no prior history of pancreatitis or family history of pancreatic cancer. EUS showed a 10 mm microcystic lesion in the pancreatic tail with a central echogenic area suggestive of a serous cystadenoma (Figure 1a). CT performed three months later for follow up on lung nodules demonstrated interval enlargement of the pancreatic lesion to 3.4 cm. The lesion appeared isodense and solid. EUS confirmed the rapid increase of size from 1 to 3 cm (Figure 1b). FNA was performed and cytology was interpreted as malignant cells derived from adenocarcinoma. Serum CA 19-9 was 1.88 U/ml. Pancreatic protocol CT (Figure 2) found a new 4 cm low-attenuation liver lesion within segment IV B. Biopsy of the liver lesion was negative for neoplasm. Patient was referred to surgery and the plan was to perform laparoscopy, excisional wedge liver biopsy, followed by distal pancreatectomy and splenectomy if the wedge biopsy did not show metastatic adenocarcinoma. Intraoperatively, a very small subcapsular lesion was excised from the liver and sent for frozen section to pathology. By the time pathology came back reporting a 2.5 mm lesion with evidence of poorly differentiated carcinoma, the surgeon has already transected the splenic artery. Therefore, distal pancreatectomy and splenectomy were completed. Final pathology reported grade 3 well differentiated NET of distal pancreas with metastasis involving 1/13 LNs and liver, negative margins achieved. Ki-67 labeling index was 75% (Figure 3). Patient has had no sign of cancer progression six months after the initial diagnosis.

DISCUSSION:

Our interesting case raises many important points to consider; Pancreatic NET can uncommonly have a cystic component. Additionally, pancreatic NET can mimic pancreatic adenocarcinoma and cytology alone cannot reliably differentiate between high grade neuroendocrine tumors and adenocarcinoma. This patient could have been erroneously treated for metastatic adenocarcinoma. Endosonographers should be alert to this possibility when a presentation is not typical for adenocarcinoma and/or the lesion has cystic components with a smooth border.
1353 Beware of When a Pancreatic Cyst Is Not a Cyst: Endoscopic Ultrasound Guided FNB of Neuroendocrine Tumor in the Pancreas
Authors: Sharma Neil , Kota Sharwani , Krishnakurup Jay
Published: October 2019

INTRODUCTION:

We present a case of pancreatic NET was assessed by EUS guided FNB at our institution during 2018 presenting initially as an incidental cyst on cross sectional imaging. Further evaluation was performed via EUS after patient sought a second opinion. EUS imaging characteristics favored a solid mass rather than a cyst. FNB of a 9.0 mm × 10.5 mm in the head of the pancreas was performed.

CASE DESCRIPTION/METHODS:

A 73 year old female was referred after having an incidental finding on recent CT and MRI indicating abnormal cyst in the head of the pancreas. Her symptoms included dyspepsia, fatigue, and dizziness. She has a past medical history of hypothyroidism, hypertension, hypercholesterolemia, gout, and neuropathy. Initial CT scan done showed an incidental cystic mass in the head of the pancreas which was “benign cyst versus cystic neoplasm,” and an MRI was recommended. Further evaluated through an MRI to be a “cystic neoplasm – possible IMPN.” We performed a history and physical exam in the office and then proceeded with an EGD which showed esophageal candida confirmed by cold forceps biopsy that showed PAS and GMS stained positive for invasive fungi Candida esophagitis. We then proceeded with an EUS which revealed a hypoechoic, heterogeneous solid mass in the neck of the pancreas measuring 9.0 mm × 10.5 mm in size and in the head of the pancreas adjacent to the pancreatic duct (Figure 1). The mass was not cystic. The remainder of the pancreatic parenchyma without ductal dilation, normal biliary system, gallbladder, and liver. We performed EUS guided FNB rather than aspiration in order to obtain a large core of histologic tissue. Pathological analysis of the mass reveals a diagnosis of well-differentiated neuroendocrine tumor, grade 1 at a rate of less than 2 mitoses/2 mm2. T1N0M0, grade 1 neuroendocrine tumor was confirmed at tumor board review.

DISCUSSION:

In conclusion, PNETS are increasing in incidence due to increased use of EUS and cross sectional imaging. Pancreatic cysts have also become a common incidental finding. The complexity arises in determining which cysts seen on cross sectional imaging require further evaluation. Some “cysts” or hypodense pancreatic structures on imaging may not be cystic in nature. EUS provides a greater sensitivity and specificity than high resolution CT scans, and allows for tissue sampling. The shift from EUS-FNA to EUS-FNB has allowed for improved tissue acquisition and true histology via EUS and disgnosis of even subcentimeter lesions.
1355 Accessory Spleen: An Unusual Pancreatic Mass Posing a Diagnostic Dilemma
Authors: Dellatore Peter , Schwartz Mark , Zhang Lanjing , Skole Kevin , Katz Kristina , Saumoy Monica
Published: October 2019

INTRODUCTION:

There are two main causes of accessory spleen; failure of fusion of the splenic anlage during the fifth week of fetal life and following autotransplantation after a splenectomy. They are structurally identical to the spleen and are most commonly found in the splenic hilum or pancreatic tail. Although rarely noted on radiograph due to low spatial resolution, their detection is increasing with more advanced modalities. This can result in the finding of a pancreatic mass that poses a diagnostic dilemma.

CASE DESCRIPTION/METHODS:

The patient is a 62-year-old man with a history of hepatitis B infection. On routine surveillance he had ultrasound findings of a liver calcification with inability to determine the presence of cirrhosis and a mildly elevated alpha-fetoprotein level. He was sent for an MRI, which revealed a 2.3 × 1.9 cm mass in the pancreatic tail showing mild hyperintense T2 signal and hypointense T1 signal. A CT from 2011 showed a slight contour bulge to the pancreatic tail in the same region, without appreciation of a discrete lesion. He underwent EGD with endoscopic ultrasound (EUS). A 21.4 × 13.7 mm well-circumscribed, homogeneous lesion was found in the pancreatic tail and biopsied. The pathology shows an immunohistochemical-staining pattern consistent with splenic tissue, confirming the diagnosis of an intrapancreatic accessory spleen (IPAS). No further intervention was needed and the patient was sent home.

DISCUSSION:

Pancreatic cancer has a 5-year survival rate of 9%, therefore it is imperative that all pancreatic masses are investigated thoroughly and promptly. In cases of an IPAS, its differentiation from a pancreatic mass is difficult as splenic tissue can mimic pancreatic tumors, especially on MRI. It is essential to differentiate between the two as IPAS are only clinical relevant when there is torsion, rupture, hemorrhage, or the patient carries a diagnosis of idiopathic thrombocytopenic purpura requiring the removal of all splenic tissue. Imaging modalities such as ultrasound, CT, MRI, and scintigraphy can aid in the diagnosis of IPAS. However, these have limitations and have not shown to provide a definitive diagnosis. EUS with fine needle aspiration is being increasingly used to characterize pancreatic lesions. In this case, it enabled adequate tissue sampling while avoiding unnecessary procedures. This case illustrates another use for EUS in an otherwise difficult diagnostic scenario.