bluuebunny/crossref_metadata_2025_split huggingface dataset:
3007 Santorinirrhage Due to Hemosuccus Pancreaticus as a Rare Manifestation of Upper Gastrointestinal Bleeding
Authors: Ghavimi Shima , Nasir Umair M. , Panchal Dayna , Patel Neel , Hashemipour Reza , Ahlawat Sushil 
Published: October 2019

INTRODUCTION:
Hemosuccus pancreaticus (HP), bleeding from the pancreatic duct into the gastrointestinal (GI) tract via ampulla of vater, is extremely rare. Some causes include pancreatitis, pseudoaneurysm of the peri-pancreatic vessels, or malignancy. The rarity with which this condition is encountered makes HP difficult to diagnose. We present a case of HP with bleeding from the minor duodenal papilla from a pancreatic pseudocyst.

CASE DESCRIPTION/METHODS:
A 39-year-old male with alcohol use disorder and chronic pancreatitis presented to the hospital with complaints of abdominal pain and melena. Labs showed significant anemia: hemoglobin, 6.90 g/dL. He was admitted for blood transfusions and further investigation. Endoscopic evaluation showed portal hypertension gastropathy, without evidence of gross bleeding. CT abdominal scan showed cystic lesions at the pancreatic tail and within the pancreatic body (Figure 1). Endoscopic ultrasound fine needle aspiration biopsy of the cystic lesion was done. Fluid analysis was consistent with pancreatic pseudocyst with elevated amylase. He was discharged home in stable condition with gastroenterology follow-up. He returned to the hospital with recurrent episodes of melena and transfusion-dependent anemia. He had IR guided transjugular intrahepatic portosystemic shunt from right hepatic vein to right portal vein. He continued to have episodes of melena with new coffee-ground hematemesis. Repeat endoscopy was performed with frank bleeding noted from the minor duodenal papilla (Figure 2). MRI was unable to confirm pancreas divisum due to pancreatic atrophy and poor visualization of the pancreatic duct. CT abdominal scan now showed hemorrhage within the two pancreatic cysts. Mesenteric angiogram was performed which showed pseudoaneurysm off proximal splenic artery and gastroepiploic artery both of which were embolized (Figure 3). His abdominal distension and pain improved significantly after the procedure with no more episodes of melena or hematemesis. He was discharged home without recurrence of symptoms.

DISCUSSION:
Our case illustrates the diagnostic dilemma of obscure upper GI bleeding. HP with bleeding from the duct of Santorini has been reported twice. All hemodynamically stable patients with HP should undergo endoscopic, radiographic, and angiographic evaluation. Therapeutic options consist of selective embolization or surgery. A multidisciplinary team approach with a precise protocol is paramount to drastically reduce the mortality and morbidity of patients.
3009 Importance of Prompt Diagnosing and Treatment of Type 1 Autoimmune Pancreatitis
Authors: Mion-Bet Daniele , Lattanzio Natalia , Kadaba Vikaran , De Urresti Miren 
Published: October 2019

INTRODUCTION:
Type 1 Autoimmune Pancreatitis (AIP) is a rare cause of chronic pancreatitis that accounts for only 2% of chronic pancreatitis cases. Mainly presenting in males between ages of 50-70. This is IgG4 related disease. It commonly presents with abdominal pain, jaundice, and weight loss. AIP is primarily diagnosed clinically and later confirmed through radiological and serological studies. Because pancreatic cancer presents similarly but differentiates in treatment, it is important to distinguish between the two.

CASE DESCRIPTION/METHODS:
A 72-year-old male with a PMH of chronic pancreatitis presented for evaluation of loss of appetite, fatigue and 100 lb weight loss over the course of 7 weeks. He also admitted to two weeks of chills and diaphoresis, and denied abdominal pain, diarrhea or constipation. On admission, there was no jaundice present and vitals were unremarkable, except for a temperature of 102 F. Patient's labs were within normal limits, except for sodium 129, ESR 85, total bilirubin 1.3, AST 101, ALT 79, and ALP 364. CT showed the pancreas heterogeneous, an ill-defined mass, consistent with pancreatic adenocarcinoma. Furthermore it showed hepatomegaly with numerous low-density lesions consistent with hepatic metastases. Biopsy of the pancreatic mass displayed a storiform fibrosis pattern with an elevated IgG4 of 3.8 g/L, suggesting Type 1 AIP. Liver biopsy was negative for malignant cells. Patient was diagnosed with AIP and was discharged on a steroid regimen.

DISCUSSION:
Type 1 AIP is defined as a fibro-inflammatory process that often includes elevated IgG4 levels. Imaging can also reveal irregular narrowing of the pancreatic duct with diffuse or focal enlargement of the pancreas. It is important to distinguish between AIP and pancreatic cancer due to the different treatments and prognosis. A study found AIP to account for 27% of Whipple resections performed for suspected pancreatic adenocarcinoma. AIP has a benign clinical course and is highly responsive to steroids. An elevated IgG4 together with imaging studies are the most sensitive and specific finding; an IgG4 value of >2.8 g/L distinguishes AIP from other inflammatory or malignant conditions. Finally, the prompt diagnosis of AIP is important for appropriate follow up. Studies have demonstrated an increased risk of developing cancer of the stomach, prostate, colon and bile duct post diagnosis of AIP. A retrospective study of 108 patients with AIP, 18 cancers were found in 15 patients in the median follow-up period of 3.3 years.
3013 Fish Mouth Ampulla: Classic Main Duct Intraductal Papillary Mucinous Neoplasm
Authors: Patel Pratik , Jampala Nannaya , Regan Kara , Mudireddy Prashant 
Published: October 2019

INTRODUCTION:
Intraductal Papillary Mucinous Neoplasms (IPMNs) were first identified in 1982 and there have been increasing rates of diagnosis of IPMNs in recent years with the improvement of imaging modalities. Due to the indolent course of IPMNs, many patients may initially remain asymptomatic for many years. IPMNs should be acted on quickly after diagnosis as they can progress to malignancy. We present a case of a patient who presented with symptoms similar to pancreatitis but was found to have a main duct IPMN with the classic fish mouth appearance of the ampulla.

CASE DESCRIPTION/METHODS:
A 62-year-old male presented to an outside hospital with epigastric abdominal pain and nausea. RUQ Ultrasound revealed normal liver and gallbladder with heterogenous echotexture within an enlarged pancreas. Abdominal CT Scan revealed a low density heterogenous, contrast enhancing, possibly multicystic lesion at the uncinate process and near the pancreatic head measuring 3.6 × 3.6 cm with dilation of the pancreatic duct. MRCP revealed a dilated pancreatic duct at 6 mm and a cystic appearing pancreatic mass involving uncinate process and portion of the right pancreatic head concerning for intraductal papillary mucinous neoplasm. He was transferred to our facility for formal Gastroenterology evaluation. EGD was performed and revealed a markedly dilated ampulla with mucinous discharge, with classic “fish mouth” appearance. The pancreatic duct was diffusely dilated from the tail to ampulla, up to 17 mm in the head/neck. A cystic lesion measuring 41 × 35 mm adjacent to the main pancreatic duct extending to the uncinate was noted. FNA was performed and pathology confirmed the diagnosis of main duct IPMN. He successfully underwent a Whipple procedure.

DISCUSSION:
This case illustrates the importance of recognizing a classic endoscopic feature of main duct IPMN: the fish mouth ampulla of Vater. There are three types of IPMNs: main duct, side branch and mixed. MD-IPMNs have the most malignant potential of the three and should be acted on promptly with surgical referral for resection. Approximately 65% of MD-IPMNs are malignant, compared to 20% for side branch IPMNs. Due to the indolent course of IPMNs, many patients will remain asymptomatic for many years. Eventually, patients will present with symptoms similar to pancreatitis. Despite the lack of clear consensus for management of pancreatic cystic lesions between multiple guidelines, all agree that MD-IPMNs should be surgically resected due to the high malignant potential.
3015 Pancreatic Ascites: A Rare Complication of Chronic Pancreatitis
Authors: Abbas Syed , Boroda Konstantin , Shahid Tamoor , Hertan Hilary 
Published: October 2019

INTRODUCTION:
Pancreatic ascites is a rare complication of chronic pancreatitis. We present a case of recurrent pancreatic ascites refractory to medical management.

CASE DESCRIPTION/METHODS:
A 62-year-old man with alcohol related chronic pancreatitis thrombosis initially presented with abdominal pain which was treated as a chronic pancreatitis flare which was managed conservatively. CT showed a pseudocyst and a portal vein thrombus, for which he was started on therapeutic enoxaparin (Figure 1). EUS later showed the pseudocyst, along with calcifications and hypoechoic strands in pancreatic parenchyma (Figure 2). Subsequently, the patient had two more hospitalizations for chronic pancreatitis flares, but with new development of abdominal distention. CT confirmed the presence of a large intraabdominal and pelvic ascites. He underwent a diagnostic paracentesis revealing a SAAG less than 1.1, amylase level of 5954 U/L and a total protein of 3.1 mg/dl. Hence a diagnosis of pancreatic ascites was confirmed and portal hypertension was ruled out. The patient suffered rapid reaccumulation of ascites and required weekly paracentesis. He was treated with subcutaneous Octreotide, without improvement. Because of this, he underwent ERCP which showed leakage of contrast from the pancreatic duct (PD) (Figure 3). A PD stent was placed. After this he still developed ascites, but at a slower rate. Repeat paracentesis showed an amylase level of 291 U/L and subsequently 21 U/L.

DISCUSSION:
Minor PD injuries are common in acute pancreatitis resulting in peripancreatic fluid collections. The fluid collection is often contained and results in pseudocyst formation. Pancreatic fluid collections can also leak into the peritoneum leading to pancreatic ascites. The majority of cases occur in males in the 5th decade of life. Pancreatic ascites is primarily exudative with markedly raised ascitic amylase and protein content greater than 2.5 g/dl. Medical management includes diuretics and somatostatin analogs. If this fails, ERCP with PD stent placement is performed. This decreases intraductal pressure and diverts pancreatic secretion to the small bowel, thereby enhancing healing of the disrupted PD. Surgical therapy is recommended for patients with a lack of response to conservative therapy for 3-4 weeks or failure of endoscopic intervention. Our case report demonstrates the utility of endoscopic PD stent placement in patients with recurrent pancreatic ascites.
3016 Can Primary Biliary Cirrhosis Cause Bradycardia?
Authors: Awad Mohammed T. , Ghazaleh Sami , Reddy Aravind , Ghanim Marcel , Ye Feng , Nehme Christian , Alkhathlan Mujahed , Assaly Ragheb 
Published: October 2019

INTRODUCTION:
Obstructive jaundice is a known cause of sinus bradycardia. It is usually attributed to the effect of bile salts on the electrophysiology of the heart and mainly on the SA node. But can Primary biliary cirrhosis cause bradycardia? Here, we are presenting a case of sinus bradycardia with a junctional rhythm that could be secondary to primary biliary cirrhosis.

CASE DESCRIPTION/METHODS:
A 65-year-old female with a history of primary biliary cirrhosis complicated by esophageal varices and recurrent ascites. The patient presented with a syncopal episode. The patient had a history of episodes of lightheadedness for several days before admission. Upon arrival at the hospital, the patient was bradycardiac with heart rate around 30 and she was hypotensive. She was given several doses of atropine and then she was started on dopamine drip. Initial EKG showed that the patient has a junctional rhythm. After reviewing the patient cardiac history, we found that the patient didn't have any heart issues before and she had a coronary angiogram done one year ago and showed normal coronaries. Medications were reviewed and showed that the patient was on Metoprolol 25 mg twice daily for anxiety and she was on it for more than 10 years and there were no recent changes in the dose. Labs showed that the patient had mild elevation is AST 41 IU/L and ALT 62 IU/L. Total serum bilirubin was 1.7 mg/dl (mildly elevated) and direct bilirubin was 0.7 mg/dl (mildly elevated). After beta-blocker was held, the patient heart rate improved, and dopamine drip was discontinued.

DISCUSSION:
This is a case of primary biliary cirrhosis who presented with symptomatic bradycardia. This patient was on beta-blockers for a long period of time and she didn't have any heart issues given her last coronary angiogram and echocardiogram were normal. We believe that one of the contributors of the patient bradycardia is the primary biliary cirrhosis itself as it can cause bradycardia which is believed to be secondary to bile salts. In conclusion, primary biliary cirrhosis should be considered as a cause of bradycardia and the use of metoprolol in those patients should be closely monitored as Metoprolol is primarily metabolized by the liver and can intensify the bradycardia.
3019 Solid Pseudopapillary Tumor of the Pancreas: A Typical Presentation in an Atypical Patient
Authors: Osho Azeez , Ayoola Rotimi , Ibrahim Mohd Elmugtaba , Cezar Carensa , Taddesse-Heath Lekidelu , Aduli Farshad 
Published: October 2019

INTRODUCTION:
Solid pseudopapillary tumor (SPT) of the pancreas is a rare neoplasm. It accounts for 1% of all tumors of the pancreas. It is a benign tumor with a low malignant potential and a favorable prognosis. It typically presents in young women, and on imaging it can be seen as a large encapsulated mass with solid and cystic components. The female to male predominance is 10:1. The following case shows a typical presentation of SPT in a male patient.

CASE DESCRIPTION/METHODS:
A 25-year-old man from Guatemala with no medical history presented with epigastric pain, nausea, vomiting, weight loss and poor oral intake. The abdominal pain was stabbing, intermittent, and radiating to the back. Family, social and surgical history were negative. Vitals were normal. On physical examination he appeared dehydrated with epigastric tenderness and a palpable left upper quadrant mass. Labs showed normal chemistry, liver function tests, lipase, CA 19-9, CEA and CA 125. Complete blood count showed an elevated white blood cell count of 23,000. Computerized tomography revealed a 7.6 × 10 × 8 cm heterogenous mass in the distal body and tail of the pancreas, with solid, and cystic components and calcifications. The patient underwent esophagogastroduodenoscopy (EGD) and endoscopic ultrasound with fine needle aspiration (FNA) of the mass. EGD showed a small non-bleeding duodenal ulcer. Pathology on the FNA revealed SPT. The patient underwent a distal pancreatectomy and splenectomy with negative margins, and a normal spleen. Lymph nodes were negative for malignancy. The patient did well post operatively with resolution of his symptoms.

DISCUSSION:
SPT is a rare tumor predominately seen in females. In men it tends to occur at an older age with an aggressive behavior. The origin of SPT is not clear. 60% of SPT are found in the body and tail of the pancreas. SPT is primarily benign but about 15% exhibit malignant features such as metastasis or invasion of adjacent structures. The most common sites of metastasis are the liver and peritoneum. Typical presentation is a palpable abdominal mass with symptoms of abdominal pain, nausea, vomiting and early satiety. The histopathology of SPT reveals solid nests of poorly cohesive cells resulting in a pseudopapillary architecture with positive nuclear staining for beta catenin, positive immunostaining for CD10, CD56, vimentin; they are negative for chromogranin. Cystic fluid is often bloody with low CEA and low amylase. Surgical resection is curative. The five-year survival rate is 95%.
3022 Metastatic Colon Adenocarcinoma Presenting as a Hilar Obstructing Lesion Diagnosed With EUS-FNB
Authors: Arroyo-Mercado Fray Martin M. , Likhtshteyn Michelle , Haidary Tahmineh , Vignesh Shivakumar 
Published: October 2019

INTRODUCTION:
Bile duct obstruction from periportal masses has a broad differential diagnosis.1 Cross-sectional abdominal imaging can help to detect periportal masses, but have low sensitivity in the diagnosis of proximal biliary and hilar lesions.2 Endoscopic ultrasound (EUS) allows for evaluation of periportal and biliary lesions and enables tissue diagnosis via fine needle biopsy (FNB). We present a case of a young patient who was presumed to have primary metastatic ovarian cancer; with EUS and ERCP guided sampling we arrived at a specific diagnosis of metastatic adenocarcinoma of colonic origin.

CASE DESCRIPTION/METHODS:
A 41-year-old female with a history of ovarian cancer s/p TAH and BSO and jejunal resection presented with painless jaundice, hematochezia, and high fever. Abdominopelvic CT scan showed a 2 cm mass in the region of the porta hepatis invading the portal vein and diffuse thickening of the rectosigmoid colon (Figure 1). Colonoscopy from a year prior was unremarkable, and subsequent colonoscopy was significant for hemorrhoids and hyperplastic polyps. Due to clinical suspicion for cholangitis, an ERCP was performed primarily for biliary drainage; a common hepatic duct (CHD) stricture and right hepatic duct dilation were found (Figure 2). Two 7 French 12 cm plastic stents were deployed across the common bile duct (CBD) stricture with their proximal end within the dilated right main hepatic duct. EUS showed a 2 cm lesion adjacent to the hilum that was invading the CHD and biliary bifurcation extending 1-2 cm distal and proximal to the bifurcation, portal, and hepatic artery. EUS-FNB demonstrated adenocarcinoma of jejunal origin based on cytokeratin markers (Figure 3).

DISCUSSION:
Specific diagnosis of periportal lesions involving the hilum of the liver is a limitation of cross-sectional imaging. EUS offers better visualization of the periportal region and enables tissue sampling for cytological or histological diagnosis. EUS-FNB has high sensitivity for diagnosis of lesions involving the common hepatic duct. It also enables assessment of vascular invasion and loco-regional staging, which is essential prior to therapy. Our case highlights, how EUS-FNB of a periportal lesion offered a specific diagnosis of metastatic colonic adenocarcinoma to the common hepatic duct. ERCP at the same session enabled biliary drainage that was essential prior to appropriate chemotherapy. The EUS FNB and ERCP with stent placement made a significant impact on the management of our patient.
3028 Glycogenic Hepatopathy Masquerading as Acute Relapsing Hepatitis: A Diagnostic Pitfall
Authors: Gallagher Bridget , El Younis Cherif 
Published: October 2019

INTRODUCTION:
Glycogenic hepatopathy (GH) is a rare conditioned characterized by elevated liver enzymes, hepatomegaly with or without right upper quadrant pain, typically seen in poorly controlled diabetes type 1, rarely in type II. It is related to glycogen accumulation during periods of high blood glucose, and tends to resolve with improvement of glycemic control. The course of liver enzyme abnormalities is transient. We present a case of glycogenic hepatopathy masquerading as biliary stones.

CASE DESCRIPTION/METHODS:
A 54 year old female with no known liver, history of HTN, CVA and poorly controlled type 2 diabetes mellitus (T2DM), complicated by multiple episodes of DKA and hyperosmolar hyperglycemic state, presented to the hospital with abdominal pain, nausea, constipation and high liver enzyme abnormalities. This was preceded by an admission 2 months prior with hyperglycemia above 600, ketones, and similar liver enzyme abnormalities. Work up was initiated including liver US, CT scan, MRCP, viral and autoimmune serologies which were normal or negative (Graph 1). Liver biopsy in progress.

DISCUSSION:
The patient in this case report has risk factors for metabolic syndrome with HTN, BMI of 26, T2DM with poor control, with episodes of hyperglycemia, associated with peaks of liver enzymes that mimic hepatocellular or mixed injury, which resolved slowly with control of hyperglycemia, being completely normal between spikes. This pattern of presentation is typical for GH, a metabolic entity that was linked to poorly controlled diabetes, and is caused by transient accumulation of glycogen within hepatocytes that follows passive influx of glucose into hepatocytes utilizing hepatic glucose transporter-2. Long-term prognosis is unclear and may in recurrent cases progress to fibrosis and cirrhosis, similar to NAFLD. Clinical suspicion for GH is based on correlation between peaks of blood sugar and acute rise in LFTs as well as periods of normalization of LFTs corresponding to resolution of acute hyperglycemia. Recognition of this entity is highly significant, as not only direct the effort to correct the underlying metabolic abnormalities, it also avoids unnecessary and costly work up knowing its transient and self-limited course. Liver biopsy if confirmatory. Glycogenic hepatopathy is an underdiagnosed metabolic hepatopathy in the setting poorly controlled diabetes, completely reversible, and should be considered in patients with T1 or T2DM with risk factors for NAFLD who present with acute and relapsing hepatitis.