bluuebunny/crossref_metadata_2025_split huggingface dataset:
1420 No Stone Left Unturned: Use of a Novel Device for Pancreatic Calculi Extraction
Authors: Schwarzbaum David , Kim Sang 
Published: October 2019

INTRODUCTION:
Pancreatic calculi are found in up to 60% of patients with chronic pancreatitis and can cause pancreatic ductal obstruction and chronic pain. Previous endoscopic methods for pancreatic stone removal include blind mechanical lithotripsy with a balloon or basket, or directly visualized laser or electrohydraulic lithotripsy (EHL). However, these techniques have variable success rates with significant complications. Here we present the first use of the SpyGlass™ Retrieval Basket for extraction of pancreatic duct stones.

CASE DESCRIPTION/METHODS:
A 65-year-old male with compensated alcoholic cirrhosis and chronic recurrent pancreatitis was referred for evaluation of a diffusely dilated pancreatic duct (PD) seen on MRI. The patient underwent an endoscopic ultrasound (EUS) which showed a tortuous main PD dilated to 8.6 mm. Two hyperechoic foci up to 10 mm were found in the main PD suggestive of calculi. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP). Pancreatogram revealed a dilated and beaded main PD with stones in the head and neck portion of the main PD. A pancreatic sphincterotomy was performed; and the main PD was dilated and swept with a Hurricane balloon removing one stone and debris. Complete ductal clearance could not be achieved using mechanical lithotripsy with a balloon, so the patient returned for a subsequent ERCP. We then used SpyGlass™ for direct pancreatoscopy, which revealed multiple large calculi in the genu of the main PD. The SpyGlass™ Retrieval Basket was advanced through the SpyScope™ and used to manipulate, dislodge and remove the PD stones. Six stones were extracted from the duct. The patient had mild post-ERCP pain, which was treated with oral medications.

DISCUSSION:
The Spyglass™ Retrieval Basket is a device developed for directly visualized stone extraction through the SpyGlass™ system. In contrast to EHL or laser lithotripsy it does not require fragmentation of stones, which may reduce the risk of post-procedural pancreatitis and perforation. This is the first use of the SpyGlass™ Retrieval Basket to extract stones from the pancreatic duct.
1432 Pancreatic Acinar Cell Carcinoma With Lipase Hypersecretion Syndrome
Authors: Edwards Marcellus , Ayoola Rotimi , Hassan Muhammad Masood , Naab Tammey , Laiyemo Adeyinka 
Published: October 2019

INTRODUCTION:
Pancreatic acinar cell carcinoma (PACC) is a rare, highly aggressive, malignant, exocrine-functioning neoplasm. Acinar cells are the most common cells (82%) in the pancreas but accounts for only 1-2% of primary pancreatic neoplasms. In 10-15% of these cases patients can develop lipase hypersecretion paraneoplastic syndrome (LHS) characterized by subcutaneous fat necrosis, polyarthralgia and peripheral eosinophilia.

CASE DESCRIPTION/METHODS:
A 69-year-old man with history of hepatitis C virus, hypertension, gout, peripheral artery disease and prostate cancer presented with a 1-month history of painful nodules on his bilateral lower extremities (LE). He described progressively worsening joint pain, bilateral LE swelling and purulent drainage from the right LE nodule. Examination revealed hepatomegaly, a 3 × 3 cm nodule on the anteromedial surface of the right LE with purulent drainage, and multiple small, hyperpigmented nodules on bilateral LE. Labs were significant for a white blood cell count of 17.3, hemoglobin of 8.7, normal eosinophil count, albumin of 2.9 g/dL, lipase 5444 IU/L, CA 19-9 44 U/mL and an AFP of 1.8 ng/mL. Computerized tomography revealed an 8.7 × 6.2 × 5.7 cm pancreatic mass encroaching on the 2nd part of the duodenum. Multiple hypoattenuated lesions were seen within the liver largest measuring 4.7 × 5.6 × 7.2 cm with metastatic invasion into the portal vein and superior mesenteric vein. Patient underwent wound debridement. An esophagoduodenoscopy revealed a 5 cm duodenal mass with ulceration extending from the duodenal bulb towards the 2nd portion of the duodenum. Lastly, he underwent an interventional radiology guided liver biopsy. Biopsy of the liver and duodenum both were consistent with PACC. Biopsies from the right leg revealed pancreatic panniculitis. Multi-drug resistant sepsis and recurrent upper gastrointestinal bleeding requiring arterial embolization complicated the hospital course. The patient was placed on comfort care and passed.

DISCUSSION:
LHS typically presents in advanced disease and is considered a negative prognostic factor. In LHS, PACC overproduces zymogen granules containing lipase, which cause inflammatory and fat necrosis in peripheral tissue through hematogenous spread. Immunochemistry staining is usually positive for trypsin, chymotrypsin and lipase. No standard therapy for PACC has been made but 5-fluorouracil is considered to be effective, and surgical intervention is recommended if possible.
1438 A Starry Sky Liver: Klebsiella Pneumoniae Septic Shock Caused by Infected Multiple Biliary Hamartomas
Authors: Neubert Zachary , Mirhosseni Nader , Lawson Robert D. 
Published: October 2019

INTRODUCTION:
Biliary hamartomas or von Meyenburg complexes are an exceedingly rare benign cystic disease of the liver. They are diagnosed radiographically due to a distinct appearance. We present an unusual case of a patient presenting with septic shock from multiple infected biliary hamartoma cysts.

CASE DESCRIPTION/METHODS:
A 52-y/o caucasian female presented to the emergency department with 20 pounds of unintentional weight loss over 3 months, painless jaundice, rigors and worsening altered mental status. Medical history included: Down's syndrome with progressive dementia, depression, and hypothyroidism. Physical exam notable for hypotension, fever, and tachycardia. Laboratory evaluation illustrated a leukocytosis of 10.9, total bilirubin of 7.6, direct bilirubin 6.1, alkaline phosphatase 926, ALT 44, AST 71, INR 2.3. An abdominal ultrasound revealed numerous hepatic cysts without cholelithiasis. MRCP confirmed innumerable uniform hepatic cysts without connection to the biliary tree consistent with multiple biliary hamartomas. The hepatic cysts lacked mural nodules. She was treated for presumed septic shock from ascending cholangitis with empiric IV antibiotics and vasopressors. With continued supportive care, her liver enzymes and coagulopathy normalized. Blood cultures grew Klebsiella pneumoniae. Her septic shock resulted from cholangitis due to infected biliary hamartomas. She discharged after 7 days in healthy condition.

DISCUSSION:
Multiple biliary hamartomas (MBH) are rare, benign lesions of the liver. They occur roughly 0.6-2.8% of the general population. Multiple biliary hamartomas are thought to arise from ductal plate malformations involving the small interlobular bile ducts. The cysts are typically uniform in size and most are asymptomatic found incidentally on imaging. MBH are associated with autosomal polycystic kidney disease, hepatic fibrosis, and polycystic liver disease. Gold standard for diagnosis of MBH is MRCP. It depicts striking stereotypical multiple T2 hyper-intense cystic lesions distributed homogeneously within the liver without communication to the bile ducts. Differential diagnosis for this imaging appearance includes metastasis, simple liver cysts, liver cancer, biliary adenomas, and Caroli's disease. Albeit unclear, MBH may be a risk factor for cholangiocarcinoma. This case highlights a peculiar case of biliary septic shock caused by infected liver biliary hamartomas.
1442 Acute Pancreatitis Induced by a Migrated Percutaneous Endoscopic Gastrostomy Tube: A Case Report
Authors: Hawa Fadi , Marii Anas , Al-Sous Ola 
Published: October 2019

INTRODUCTION:
Percutaneous Endoscopic Gastrostomy (PEG) tube placement is a widely used and effective method to provide enteral feeding in critically ill patients. However, it could cause major complications leading to significant morbidity. This case reports a rare late complication of a migrated PEG-tube to the duodenum causing obstruction of the biliary tree and resulting in acute pancreatitis.

CASE DESCRIPTION/METHODS:
A 50-year-old male with complicated tonsillar squamous cell carcinoma requiring tracheostomy and PEG-tube placement, suffered a traumatic brain injury resulting in paraplegia. Two months later, while at an in-patient rehabilitation unit, patient developed sudden onset epigastric abdominal pain. Physical examination was significant for diffuse abdominal tenderness. PEG-tube was noted in place. Laboratory studies showed elevated lipase (781 U/L) but otherwise normal liver enzymes without a cholestatic pattern. Abdominal Computed Tomography (CT) scan showed acute pancreatitis with a portion of the PEG tube in the duodenum abutting the Ampulla of Vater, and causing biliary obstruction. Patient was started on conservative management, and his PEG-tube was exchanged at the bedside. Subsequently, patient had rapid improvement of his symptoms and his lipase levels normalized within two days.

DISCUSSION:
The exact incidence of PEG-tube migration to the duodenum remains unclear; there are thirteen case reports of PEG tube migration induced acute pancreatitis reported in the literature. It is hypothesized that tube migration to the duodenum is caused by the peristaltic movement of the intestines. This results in disruption of the biliary flow and serves as a predisposing factor to acute pancreatitis. The increasing number of cases reporting this adverse event suggests that acute pancreatitis might be one of the late complications of PEG tube placement that carries significant morbidity. Despite inability to prove causality, the rapid improvement in patient's clinical status and laboratory findings after PEG tube exchange, supports the aforementioned hypothesis. Awareness of such complication and its possible consequences including acute pancreatitis can ensure early recognition and timely treatment of such adverse event.
1444 Spontaneous Asymptomatic Intraperitoneal Rupture of a Pancreatic Pseudocyst Prior to Attempted Endoscopic Drainage
Authors: Sadowski Brett , Tritsch Adam , Young Patrick 
Published: October 2019

INTRODUCTION:
Pancreatic pseudocysts are inflammatory fluid collections occurring after an episode of acute pancreatitis. Drainage of large pseudocysts is indicated in symptomatic patients at least 4 weeks after an acute episode in order for encapsulation. Prior to stent placement, some advocate for contrast-enhanced imaging to evaluate for a pseudoaneurysm formation. We present a case of symptomatic patient who was scheduled for cystgastrostomy but was found to have had spontaneous intraperitoneal rupture of her pseudocyst, leaving her symptom free.

CASE DESCRIPTION/METHODS:
A 63-year-old female smoker with a history of ileal Crohn's disease in clinical remission, chronic pancreatitis as well as cholelithiasis was admitted of progressive epigastric and right upper quadrant pain, early satiety, nausea and weight loss three months following an episode of acute pancreatitis. CT performed during hospitalization demonstrated a 15 × 10 × 9 cm pseudocyst in the tail of the pancreas leading to gastric compression, having grown from 4.9 × 5.1 × 2.8 cm within a week of her index presentation. The patient was discharged with close follow up and was evaluated with physical exam within 5 days, at which time endoscopic cystgastrostomy was scheduled for early in the next week. She completed an abdominal CT scan the morning of her procedure noting that over the weekend, her symptoms had substantially improved. Her CT demonstrated a 95% reduction in cyst volume with new perihepatic ascites but she remained clinical asymptomatic. Her procedure was canceled and she was subsequently underwent a cholecystectomy.

DISCUSSION:
Size alone does not mandate drainage, though larger cysts are more likely to be symptomatic, making treatment indicated. Though guidelines regarding the management of pseudocysts recommend peri-procedural imaging prior to drainage, there is variability in clinical practice. In our case, given the high pre-test probability for pseudocyst (and not a cystic neoplasm), imaging was obtained to rule out a pseudoaneurysm in an effort to reduce a risk of bleeding. Instead, it showed a spontaneous rupture of the pseudocyst, which occurs in <3% of cases, with theoretical mechanisms including minor abdominal trauma, increased intra-abdominal pressure or cyst wall digestion by proteolytic enzymes. Case reports of spontaneous rupture into the stomach and portal vein have been reported. Unlike prior cases of intraperitoneal rupture, our patient remained asymptomatic without evidence of peritonitis.
1445 Spontaneous Isolated Celiac Artery Dissection: A Rare Cause for Acute Pancreatitis
Authors: Cheung Maggie , Marella Dean , Dhar Kalyani , Patel Manish S. 
Published: October 2019

INTRODUCTION:
Spontaneous celiac artery dissection is a rare event. Due to similar presenting symptoms of abdominal pain, diagnosis of celiac artery dissection as a cause of acute pancreatitis can be easily missed.

CASE DESCRIPTION/METHODS:
A 51-year-old man with a history of cholecystectomy presented with severe epigastric pain radiating to bilateral upper quadrants. He denied nausea, vomiting, diarrhea and fevers. Physical exam was notable for epigastric, LUQ, and RUQ tenderness. Labs revealed lipase 35 U/L. CT A/P showed peripancreatic inflammatory changes with hyperdense peripancreatic fluid, concerning for hemorrhagic pancreatitis. Typical etiologies for acute pancreatitis were absent, including alcohol and gallstones, and IgG4 was negative, suggesting this was not autoimmune pancreatitis. MRCP was performed and identified a dissection of the celiac axis extending to the splenic artery. CT angiography confirmed celiac artery dissection and re-demonstrated peripancreatic fat stranding. Patient received aggressive IV fluids for the first 24 hours with improvement in pain. Vascular surgery recommended starting aspirin 81 mg daily without any surgical intervention and the patient was discharged home with close follow-up.

DISCUSSION:
Though our patient had a normal lipase, he had severe epigastric pain and peripancreatic stranding on imaging, satisfying 2 of the 3 criteria for acute pancreatitis. In the absence of other causes, imaging identified celiac artery dissection as the etiology of his pancreatitis. Of the visceral artery dissections, celiac artery dissection represent only 4% of cases, and only 5 reported cases have identified spontaneous celiac artery dissection as a cause of pancreatitis. In the setting of a dissection, the pancreas likely experienced an ischemia-reperfusion injury, where there was transient hypoperfusion from the celiac trunk, followed by reperfusion from collaterals from the superior mesenteric artery, resulting in exposure to oxygen-free radicals and cellular processes leading to inflammation. There is no standardized treatment, but conservative management with antiplatelet and/or anti-coagulation is pursued in mild cases of pancreatitis. Surgery is reserved for severe cases involving bowel ischemia, vessel rupture, or continued abdominal pain. This case highlights a rare presentation of acute pancreatitis secondary to a spontaneous isolated celiac artery dissection.
1452 Unusual Complication Following Screening Colonoscopy
Authors: Dirweesh Ahmed , Shamsi Nabiha , Freeman Martin , Trikudanathan Guru 
Published: October 2019

INTRODUCTION:
Colonoscopy in general can be a challenging procedure as the colon is often quite mobile and tortuous. While abdominal pain is relatively common during and after the procedure, evaluation is always required to rule out serious causes such as colonic perforation and organ injury.

CASE DESCRIPTION/METHODS:
A 62-year-old female with a history of a left nephrectomy (23 years ago) underwent a screening colonoscopy (performed with good bowel preparation, under conscious sedation, and the whole colon was described as significantly redundant, tortuous and endoscopically normal) at the referring facility. She developed worsening left sided abdominal pain, nausea and vomiting three days after the procedure (managed at several occasions with bowel rest and antibiotics for presumed enteritis/diverticulitis). CT scan, 3 months following colonoscopy showed a complex irregular collection involving pancreatic tail and splenic flexure with adjacent partially rim-enhancing fluid collection abutting the greater curvature of the stomach. A CT guided percutaneous aspiration of fluid collection showed a markedly elevated lipase and amylase. This was concerning for pancreatic duct (PD) leak. She underwent an ERCP and placement of 3 Fr by 13 cm single pigtailed Advantix stent and 5 Fr by 3 cm Geenen stent for a confirmed PD leak. Although no definite fistulous communication to colon was seen on the fluoroscopic images, an immediate post ERCP non-contrast CT scan revealed contrast in the left colon concerning for a colo-pancreatic fistula. Her clinical symptoms resolved immediately following procedure. A follow up ERCP after 4 weeks confirmed no further PD leak.

DISCUSSION:
This patient's presentation is most consistent with chronic PD leak. The likely explanatory mechanisms include traction on fibrous surgical adhesions between the splenic flexure and distal pancreas, direct blunt trauma by passage of the colonoscope through the splenic flexure, and external abdominal pressure around the left colon. This case illustrates that it is possible for a patient with pre-existing risk factors to develop a significant pancreatic injury following colonoscopy. Careful review of patient's surgical history at time of informed consent is essential to identify those at risk and to take preventive measures including avoiding and reducing endoscope looping, avoiding excessive force and minimizing air insufflation.
1460 An Unusual Histopathology of Colonic Polyps
Authors: Vohra Ishaan , Almoghrabi Anas , Katiyar Vatsala , Randhawa Tejinder , Palacios Pedro , Kotwal Vikram , Attar Bashar M. 
Published: October 2019

INTRODUCTION:
Sarcoidosis is a multi-system disorder most commonly known to involve lungs, eyes, skin and joints. Colonic involvement either in isolation or as a part of systemic disease has been reported in less than 20 cases. Here, we describe a patient who presented with abdominal pain, constipation, and weight loss and was found to have colonic sarcoidosis.

CASE DESCRIPTION/METHODS:
A 38-year-old woman presented with chronic left lower quadrant abdominal pain, constipation, and unintentional weight loss for a few months. Her past medical history significant for treated latent tuberculosis and uterine fibroids. She denied fever, diarrhea, melena or hematochezia. Physical exam revealed tenderness in the left lower quadrant and periumbilical region. Laboratory work up showed hemoglobin of 9.6 (11.7-14.9 g/dL). Her ACE levels were elevated at 120 (8-52 U/L). Chest xray showed scattered pulmonary nodules and bilateral hilar lymphadenopathy. CT scan demonstrated extensive porta hepatis, mesenteric, portocaval, retroperitoneal, and inguinal lymphadenopathy. Biopsy of inguinal lymph node showed granulomatous lymphadenitis but no malignancy. Acid fast bacilli and fungal stains were both negative. Further, colonoscopy revealed multiple sessile polyps in descending colon ranging between 2-8 mm (Figure 1), removed with excisional biopsy. Biopsy from the colon polyps revealed numerous non-caseating granulomas (Figure 2). She was diagnosed with multi-system symptomatic sarcoidosis and was started on prednisone with improvement of her symptoms.

DISCUSSION:
Gastrointestinal tract involvement by sarcoidosis is seen in less than 1% of cases, with stomach being the most commonly affected organ. Colonic sarcoidosis is extremely rare and has variable clinical presentation but abdominal pain is most commonly described. Endoscopic appearance is very nonspecific and includes polyps, mass like lesions, erosions, ulcers and focal nodularity. Diagnosis requires demonstration of non necrotizing granulomas in the involved organ, evidence of sarcoidosis in at least one other organ system and exclusion of other granulomatous disorders such as tuberculosis, fungal infections, inflammatory bowel disease and malignancy. While no therapy is warranted for inactive disease, steroids are the initial treatment of choice in symptomatic patients.
1470 Pylephlebitis: An Unusual Presentation of Metastatic Colon Cancer
Authors: Madhani Kamraan , Aamar Ali 
Published: October 2019

INTRODUCTION:
Pylephlebitis occurs in the setting of abdominal inflammatory processes and commonly begins with thrombophlebitis of mesenteric veins draining areas of infection. If unrecognized, it can carry a 30-day mortality as high as 32%.
1
Common etiologies include pancreatitis and diverticulitis, whereas no cases associated with metastatic colon cancer had been reported.
2,3
Thus, a high index of suspicion is necessary to make a timely diagnosis of a rare condition.

CASE DESCRIPTION/METHODS:
A 64-year-old man presented with 3-week history of constipation and fever of 103° F. Physical exam revealed scleral icterus, and tenderness to palpation of the abdomen. Lab studies were significant for leukocytosis of 21,000 cells/mL. Blood cultures remained negative. Abdominal CT revealed widespread tumor in the liver and thrombosis of the superior mesenteric vein (SMV) extending into the portal vein, causing edema in the colonic mesentery (Figure 1). Presence of gas within the clot in the SMV was noted. Core biopsy of a liver mass revealed adenocarcinoma. Colonoscopy revealed a cecal mass, confirmed to be colonic adenocarcinoma (Figures 2 and 3). The patient was started on antibiotics for suspected pylephlebitis, later transitioned to oral Ciprofloxacin and Metronidazole, for 4 weeks. Intravenous heparin was changed to Enoxaparin.

DISCUSSION:
Without the development pylephlebitis, our patient's colon cancer likely would have spread beyond the liver. While bacteremia was not detected, it is not reported with 100% frequency.
1
The presence of gas within the clot along with fever and leukocytosis raised suspicion for infection of the venous clot. Therapy includes antibiotics for up to 6 weeks with consideration for anticoagulation. While the routine use of anticoagulation for pylephlebitis remains controversial, given the risk of thrombus extension causing mesenteric ischemia, the benefits outweighed the risks. Pylephlebitis due to metastatic colon cancer is a rare etiology, and should be considered in patients presenting without commonly reported risk factors.