bluuebunny/crossref_metadata_2025_split huggingface dataset:
2488 Severe Dengue Fever With Impending Liver Failure in Thalassemic Patient With Pregnancy: A Diagnostic Challenge
Authors: Rattanachaisit Pakkapon , Komolmit Piyawat 
Published: October 2019

INTRODUCTION:
Dengue infection is a leading fatal arthropod-borne disease in the tropics. Gastrointestinal presentation of dengue fever (DF) includes abdominal pain, vomiting, jaundice, hepatomegaly and liver failure. The presentation in a patient with thalassemia, during pregnancy poses a clinical challenge in differential diagnosis between the severe form of dengue infection and a complication of pregnancy, HELLP syndrome.

CASE DESCRIPTION/METHODS:
A 36 years old female with thalassemia during 34 weeks of pregnancy was admitted due to fever with chills. She later developed dyspnea and uterine contraction on the third day of fever. The physical examination revealed body temperature of 39°C, marked pale conjunctiva, mild icteric sclera and mild hepatosplenomegaly. The initial investigation showed white blood cell count of 34020 × 106/L with lymphocytic predominance, hemoglobin of 9.8 g/dL, platelet count of 62000 × 106/L and INR 2.09. Liver function test revealed total bilirubin 4.4 mg/dL, direct bilirubin 3.4 mg/dL, aspartate aminotransferase (AST) 813 IU/L, alanine aminotransferase (ALT) 350 IU/L, and alkaline phosphatase (ALP) 180 IU/L. She underwent cesarean section due to fetal distress with the diagnosis of HELLP syndrome. After the operation, her fever persisted. The follow-up blood tests showed leukocytosis, worsening thrombocytopenia and high level of transaminase enzymes (AST 3285 IU/L and ALT 1279 IU/L). The following investigation showed hemolytic anemia and coagulopathy. No evidence of microangiopathic hemolysis was detected. The dengue NS1 antigen was positive. She was treated with intensive fluids replacement and intravenous N-acetyl cysteine. Her fever lasted for five days and abnormal blood tests become normal within 2 weeks.

DISCUSSION:
Concurrent DF in a pregnant woman with thalassemia poses difficulty in the diagnosis and might lead to a poor prognosis. Severe dengue infection can cause liver injury with severe thrombocytopenia and hemolytic crisis in thalassemic patients mimicking those occurs in HELLP syndrome. The clinical clues for diagnosis of DF in this situation include fever, thrombocytopenia and acute non-microangiopathic hemolytic anemia. However, awareness of the disease during an outbreak, especially in a rainy season, is probably the most important clue for an early diagnosis. Intensive fluids and hemodynamic management is the key for dengue treatment. Evidence of therapeutic role of N-acetyl cysteine or other liver support systems in DF with liver failure are limited.
2496 Management of Recurrent Ectopic Variceal Bleeding in Ileal Conduit With TIPS
Authors: Chittajallu Vibhu , Romero-Marrero Carlos 
Published: October 2019

INTRODUCTION:
The simplest classification of portosystemic collateral veins classifies all non-esophagogastric varices as ectopic varices. Ileal varices are an example of ectopic varices formed from the ileal veins (tributaries of SMV) and draining into the mesenteric vessels. We present a case of an ileal conduit complicated by recurrent ectopic variceal bleeding amenable to a transjugular intrahepatic portosystemic shunt (TIPS) procedure.

CASE DESCRIPTION/METHODS:
A 45 year-old male with Hepatitis C and alcohol related cirrhosis complicated by portal hypertensive gastropathy and non-bleeding esophageal varices (EV) presented with a one month history of recurrent hematuria via his ileal conduit. He had a history of colon cancer stage IIB status post cystoprostatectomy and sigmoidectomy with ileal conduit in 2013. He had required three hospitalizations for his recurrent bleeding, needing multiple blood transfusions. Previous workup included a CT abdominal angiogram showing porto-systemic collaterals without active extravasation of contrast, an ileal conduit loopogram showing good functionality, and an ileal conduit endoscopy showing no visible ileal varices or active bleeding. On admission to our institution, he was hemodynamically stable and did not required additional blood transfusions. An abdominopelvic CT scan showed a normal ileal loop conduit and again small mesenteric portosystemic collaterals were evident. There was a high suspicion for ectopic varices in the ileal conduit, and a TIPS procedure was performed. A pre-TIPS portogram showed the presence of large ectopic ileal varices filled with contrast with resolution after TIPS placement. TIPS was successful with decrease of hepatic venous pressure gradient from 18 mmHg to 9 mmHg. He was discharged after TIPS procedure and has not required repeat hospitalization for hematuria.

DISCUSSION:
Ectopic varices account for up to 5% of variceal hemorrhage, and there is no consensus for therapeutic management. This patient had ileal conduit varices causing recurrent clinically significant hematuria. TIPS placement successfully controlled his recurrent ectopic variceal hemorrhage.
2497 Hydatid Cyst Masquerading as Appendicitis
Authors: Kumar Anila , Gollapudi Lakshmi Asritha , Lee Kyu-In , Newman Rebecca 
Published: October 2019

INTRODUCTION:
Human echinococcosis (HE) is a zoonosis and can cause life-threatening tissue cysts in the liver. We present a case of an unusual presentation of hepatic echinococcosis diagnosed and treated in the United States (US).

CASE DESCRIPTION/METHODS:
A 23-year-old woman who emigrated from Ecuador to the United States presents to the ED with headaches, fevers and abdominal pain associated with vomiting and rigors. She denied sick contacts and recent travel. She noted 4-5 similar episodes in the past that self-resolved. Her vitals were significant for a fever of 102.3°F and heart rate in 120s. Her labs were significant for a WBC 14.8 k/mm3 but the comprehensive metabolic panel was within normal limits. Exam revealed a supple neck and right lower quadrant tenderness. Due for concerns of appendicitis, she got a CT A/P C+, which was significant for a 4.2 × 2.6 cm and 1.3 cm low-density lesion in the right hepatic lobe. She was started empirically on flagyl and ciprofloxacin and discharged the next day. An outpatient MRI confirmed a cystic neoplasm in segment 5 of the liver with septation. Serum workup included a negative echinococcus antibody and she was referred to a surgical oncologist. She underwent liver segment 4 and 5-6 tumor resections without any complications. Pathology revealed calcified echinococcal cysts with extensive necrosis and abscess formation suggestive of microscopic areas of rupture. She was started on albendazole and is doing well.

DISCUSSION:
Echinococcosis is a zoonotic disease, with a two-host lifecycle and occurs in humans when Echinococcus eggs infect the liver (70%) and lungs (20%). After ingestion of eggs, the embryos escape and penetrate the intestinal mucosa, enter the portal circulation and then are trapped in the liver. Human cystic echinococcosis (CE) is the most common type of HE. The greatest prevalence of HE is in temperate areas such as parts of South America, North Africa, Asia and Australia. Diagnosis is made on imaging by US, CT and MRI. Treatment includes surgical resection, percutaneous drainage and anti-parasitic agents. Although the vast majority of cases occur outside the US, cases within the US exist and are incidentally found. Despite progress in controlling echinococossis, this condition remains a public health problem in endemic countries and a cause of morbidity and mortality. It should be included on the differential of a patient from an endemic area found to have cystic lesions on liver.
2503 Cholestasis in a Patient With HNF-1B Mutation
Authors: Conner Michael , Baddour Nabil , Regenstein Fredric 
Published: October 2019

INTRODUCTION:
Maturity Onset Diabetes of the Young, MODY5, is a syndrome characterized primarily by renal cysts, renal dysfunction and early onset diabetes caused by pancreatic atrophy and hepatic insulin resistance. Hepatocyte nuclear factor 1b (HNF1b) plays a key regulatory role in the organogenesis of tubular epithelia within the renal, pancreatic and biliary systems.

CASE DESCRIPTION/METHODS:
33-year-old woman presented to hepatology clinic with chronically elevated liver chemistries in a mixed hepatocellular/cholestatic pattern (Table 1). Abnormalities were first noted in her teens with symptoms of fatigue and pruritus. No history of liver-toxic medications. Medical history: pre-diabetes, polycystic ovarian syndrome with associated infertility issues, renal cysts. Surgical history: bladder/ureteral surgery as a child. Unremarkable social history. Father with ulcerative colitis. Work up included negative hepatitis panel, anti-smooth muscle ab, anti-mitochondrial ab, and ANA. Normal ceruloplasmin, copper, and ferritin. Sonogram with a 15.6 cm homogenous liver, cholelithiasis (resolved on repeat study), and bilateral renal cysts. Liver biopsy was essentially normal with minimal focal lobular chronic inflammation and mild sinusoidal congestion. Her medical history prompted genetic testing for HNF1B mutation, positive for heterozygous disease. MRI/MRCP revealed normal appearing bile ducts and pancreatic atrophy, consistent with the diagnosis.

DISCUSSION:
HNF1b deficiency compromises the functional integrity of human cholangiocytes by altering the structure of primary cilia. Roelandtet al. were the first to demonstrate aberrant cholangiocytes at the structural level in patients with HNF1b heterozygosity (Figures 1 and 2). The defects do not affect the structure of intra and extrahepatic ducts themselves, so patients may present with normal hepatic and biliary architecture. More overt biliary anomalies have been noted in HNF1b associated MODY5, with many carriers of the mutation demonstrating choledochal cysts. HNF-1b mutations should be considered in patients with cholestasis, late onset diabetes and renal cysts, particularly when standard work up does not reveal a cause for abnormal liver chemistries. While morbidity is associated with pancreatic and renal dysfunction, symptomatic management of cholestasis should be addressed. Further studies are needed to determine if surveillance is necessary to assess the development and potential malignant transformation of choledochal cysts.
2508 A Case of Graves Disease Presenting With Severe Hepatic Dysfunction
Authors: Imam Zaid , Odish Fadi , Hanna Angy , Tahhan Mamon 
Published: October 2019

INTRODUCTION:
Cholestatic hepatitis attributed to thyroid disease is a rare presentation with only a handful cases reported in the literature. Often confused as a potential adverse effect of anti-thyroid therapy, this entity can prove to be elusive to diagnose and challenging to manage.

CASE DESCRIPTION/METHODS:
A 37-year old healthy male presented complaining of jaundice, pruritus, fatigue and significant weight loss over 3 months. His only medication was oxycodone for chronic back pain after a remote accident. Physical examination demonstrated scleral icterus with no hepatosplenomegaly or stigmata of chronic liver disease. Diagnostic evaluation demonstrated (1) Lymphocytic leukocytosis of 14,000 cells/mm3, microcytic anemia, normal platelet count, kidney function, serum albumin and INR, (2) mixed LFT pattern (R factor: 2.6) with marked cholestasis with ALP of 222 IU/L, AST of 132 IU/L, ALT of 192 IU/L, total bilirubin of 17.3 mg/dl with a direct fraction of 9.4 mg/dl (3) negative hepatitis, viral serologies, ANA, and AMA (4) elevated ferritin of 2,938 ng/ml with heterozygous H63D mutation, (5) normal MRCP (6) liver biopsy demonstrating cholestatic changes not compatible with autoimmune hepatitis, minimal iron deposition, and no evidence of fibrosis (7) TSH < 0.01, fT4 (free thyroxine) of 1.5, fT4 (free triiodothyronine) of 4.3 and strongly positive thyroid stimulating immunoglobulins, TSH receptor antibodies, and anti-TPO antibodies. A radioiodine uptake scan (RAI) was consistent with Grave's disease. The patient was started on methimazole, propranolol and underwent subsequent surgical thyroidectomy with complete resolution of his symptoms and near complete resolution of his hepatitis in 3 months duration.

DISCUSSION:
Thyrotoxicosis presenting with severe hepatic dysfunction can prove a challenging entity to treat. Challenges include potential hepatotoxic effects of methimazole, propylthiouracil or radioactive iodine, and the risks of inducing thyroid storm by performing a surgical thyroidectomy without appropriate pre-treatment. The case reported highlights the importance of recognizing liver injury secondary to thyrotoxicosis, and reports successful treatment with surgical thyroidectomy after pre-treatment with methimazole and propanolol.
2509 Role of EUS in Prostate Cancer Recurrence
Authors: Sharma Neil , Gopakumar Harishankar , Krishnakurup Jay 
Published: October 2019

INTRODUCTION:
We describe the first documented case of the use of EUS for evaluation, biopsy, and placement of fiducial markers in the same setting by an advanced interventional endoscopist for recurrent prostate cancer.

CASE DESCRIPTION/METHODS:
A 56 yrs old Caucasian male with history of prostate cancer status post radical robotic prostatectomy in 2008. The pathology revealed moderately differentiated adenocarcinoma with focal mucinous change, Gleason Score 7. Stage T3a N0 M0. The right posterolateral 6 mm superficial to the apex, capsular incision were positive. Zero of the nine lymph nodes removed were positive. His post op PSA remained low till January of 2015. The PSA starts to show an upward trend from May 2017 and rose to 2.07 ng/ml in December 2017. He didn't have any clinical complaints. A PET scan in January 2018 was negative for recurrence. An MRI in February 2018 showed some enhancement of soft tissue in the prostatic bed favoring post-surgical changes (Figure 1). The patient was referred for EUS due to concerns regarding the rising PSA levels. We used a radial EUS to evaluate the prostatic bed, which was difficult due to post prostatectomy echogenic artifact. However we noticed a slightly prominent hypoechoic area in the prostatic bed (Figure 2). We then used a linear EUS scope (Figure 3) and a 22G core needle to biopsy this area, which on touch prep cytology was positive for adenocarcinoma. We then placed fiducial markers in the surgical bed under EUS guidance. Patient then underwent radiotherapy with complete response to treatment.

DISCUSSION:
Any rising PSA levels of any magnitude (biochemical recurrence) should be followed and evaluated further after prostatectomy to ensure complete cure of prostate cancer. Although different imaging modalities are available to tackle these issues, they lack specificity. It's a common practice to place fiducials in a prostate cancer prior to radiation treatment. The role of EUS in the surveillance and diagnosis of patients after prostatectomy has not been validated. Once patient undergo prostatectomy or radiation, the prostatic bed develop significant fibrosis. This is a challenge for future radiological imaging to identify the recurrent disease. A rising PSA level of any is worrisome in a prostatectomy patient and EUS guided FNB of the prostatic bed will be a great tool to issue accusation and, confirming the diagnosis. Furthermore the fiducials can be placed in the same session for stereotactic salvage radiation with limited peripheral injury.
2512  A Rare Late Complication After Roux-en-Y Gastric Bypass: Recurrent Hepatic Abscesses
Authors: Ahmed Zarir , Odufalu Florence-Damilola , Nazzal Mustafa , Prather Charlene 
Published: October 2019

INTRODUCTION:
There are many rare late post-operative complications for Roux-en-Y gastric bypass (RYGB), but hepatic abscesses from enteric fistula formation is a rare complication. Herein we describe a case of recurrent hepatic abscess formation after a revision of a RYGB procedure

CASE DESCRIPTION/METHODS:
A 66 year-old female with a history of obesity status-post a RYGB in 2003 requiring revision with partial gastrectomy with GJ creation in 2017 presented to her PCP with abdominal pain, reduced appetite, fevers, and chills. She had several admissions for recurrent polymicrobial hepatic abscesses requiring prolonged courses of IV antibiotics after her revision. She had a temperature of 101.1 F, blood pressure of 101/55, heart rate 69. Labs revealed ALP of 280, ALT of 83, AST of 208, and WBC of 11.5. CT revealed an 11 cm abscess between the liver and diaphragm (Figure 1). She was started on antibiotics and interventional radiology did CT-guided abscess drain placement revealing green pus. An upper endoscopy revealed Roux-en-Y gastrojejunostomy anatomy with gastrojejunal anastomosis with healthy mucosa. Given her recurrent abscesses, there was concern that this was a biliary or intestinal fistulous tract causing the abscesses. Imaging with CT fistulogram demonstrated a fistulous tract in the bilio-pancreatic limb of the RYGB. She underwent exploratory laparotomy with findings of the gastric remnant which was adherent to the left lobe of the liver (Figure 2). The staple line of gastric remnant along with the fistula were resected and underwent successful repair. She has had no further recurrence of hepatic abscesses.

DISCUSSION:
Late post-operative of RYGB include enteric fistulas, cholelithiasis, marginal ulcers, small bowel obstruction, and nutritional deficiencies. However, hepatic abscesses from enteric fistula formation is a rare complication. Liver abscesses can seed from the biliary tree and liver parenchyma through the hepatic artery or portal venous system. Only 5-15% of infections are accounted from surgical trauma. The etiology of recurrent hepatic abscesses in our patient resulted from fistula formation at the gastric staple line leading to an exposure to enteric secretions. Given RYGB anatomy, accessing the gastric remnant is often difficult and at times never done. This case highlights the need for providers to continue to have a high index of suspicion of pathology occurring in the gastric remnant and to consider fistula formation.
2513 Endoscopic Management With an Over-the-Scope Gastric Clip of a Staple-Line Leak Following Sleeve Gastrectomy
Authors: Tawadros Augustine , Skole Kevin , Chau Wai Y. 
Published: October 2019

INTRODUCTION:
Obesity has become a global epidemic with substantial socioeconomic and healthcare-related costs. Due to the limited utility of diet and behavior modification, there is tremendous interest in surgical weight loss strategies. Among those, sleeve gastrectomy (SG) has become the most commonly performed bariatric procedure. This is due to its efficacy and relative safety compared to other surgical options. However, post-SG leaks do occur. For example, staple-line leak (SLL) occurs in up to 3% of patients, most commonly at the proximal border of the staple line, near the esophagogastric junction. Usually, these leaks present in the early postoperative period, but there are increasing reports of SLL occurring months or even years after the initial surgery. Often, bariatric surgical complications are referred to tertiary centers for management. We present a case of a SLL managed at a community hospital.

CASE DESCRIPTION/METHODS:
A 38 year-old woman, with limited past medical history, presented 6 weeks after SG with a staple-line leak. Her immediate post-op period had been complicated by a peri-splenic abscess, which was managed with IV antibiotics (ABX) and percutaneous drainage (PD). Upper GI series (UGIS) at this time did not reveal a SLL. After clinical and radiographic resolution, the drain was removed. Several days later, the patient presented with nausea, vomiting, and non- bloody watery diarrhea. She was found to be febrile and tachycardic; labs, including a test for Clostridium dificile, were negative. A repeat CT scan confirmed an upper abdominal fluid collection. Subsequent UGIS revealed a SLL in the proximal stomach with a suture line fistula. After several weeks of NPO status, ABX and PD failed to lead to leak closure, the patient underwent endoscopy with successful placement of an Ovesco Over-the-Scope gastric clip (OTSC). Repeat UGIS confirmed fistula closure. After several weeks of additional conservative management, the PD was removed. Several months later, the patient remains stable.

DISCUSSION:
As the use of SG becomes more widespread, complications such as SLL will need to be addressed. Often, patients with SLL are referred to a tertiary center. We present a case successfully managed in a community hospital with the application of an OTSC. Practitioners who follow SG patients should be familiar with the indications and use of the OTSC.
2522 An Unusual Case of a Colo-enteric Fistula
Authors: Roccato Mary Kathryn , El Hage Chehade Nabil , Samarasena Jason , Sowa Piotr , Lee John 
Published: October 2019

INTRODUCTION:
Entero-enteric fistulas are complications seen in patients with active Crohn's disease or history of extensive intra-abdominal surgeries. Presentations can be non-specific and include disease progression, rectal bleeding, or persistent febrile episodes. Upper and lower gastrointestinal endoscopy are used to diagnose entero-enteric fistulas. Contrast injection along with abdominal radiography can visualize and provide further anatomical details. In the following report, we present the case of a patient with pancreatic adenocarcinoma who presented with rectal bleeding. The diagnosis of colo-enteric fistula was made by fluoroscopy with contrast injection and pathology results.

CASE DESCRIPTION/METHODS:
A 62-year-old male with PMH of pancreatic adenocarcinoma treated with chemotherapy and whipple procedure complicated by multiple recurrences of liver metastases treated with radiofrequency ablation and excision of abdominal wall implants, who presented with rectal bleeding. On admission, EGD did not identify the source of bleeding, Colonoscopy showed a 4 cm ulcerated pocket at the hepatic flexure. Contrast injected into the pocket revealed a fistulous tract with an extra-colonic segment. Traversing the tract with the colonoscope revealed small bowel tissue. Biopsies of fistulous opening was consistent with necrotic tissue concerning for metastatic implants.

DISCUSSION:
To the best of our knowledge, most entero-enteric are caused by either active untreated Crohn's disease or as a result of multiple abdominal surgeries. This is a rare case of colo-enteric fistula formation due to metastatic pancreatic cancer. Few case reports show intra-colonic fistula formation due malignancy. Upon literature review, there are case reports of primary lymphoma leading to colo-enteric fistula formation. Diagnosis was difficult to achieve due to non-specific clinical presentation of chronic diarrhea. The fistula was diagnosed by computed tomography enterography (CTE) demonstrated a ileo-ileal fistula and ileo-colonic fistula. Ultrasound (US) showed small intestinal wall thickening and development of a fistula of the sigmoid colon due to malignancy. Although rare, enteric fistula formation due to malignancy should be suspected in patients with GI symptoms and history of metastatic disease.