bluuebunny/crossref_metadata_2025_split huggingface dataset:
1237 Efficacy and Safety of Nitazoxanide-Based Regimen for the Eradication of Helicobacter pylori Infection: A Systematic Review and Meta-Analysis
Authors: Iqbal Umair , Khara Harshit S. , Khan Muhammad Ali , Haq Khwaja F. , Hu Yirui , Siddiqui Hafiz U. , Bergenstock Marika , Howden Colin W. , Shellenberger Mathew 
Published: October 2019

INTRODUCTION:

Helicobacter pylori (HP) is the most common cause of gastritis worldwide. Clarithromycin-based triple therapy and bismuth-based quadruple therapy are among recommended first-line treatment regimens, but may fail in around 30% of patients. Resistance of HP to clarithromycin and metronidazole is also a growing concern. Therefore, there is a need for newer, reliable eradication regimens for HP. Nitazoxanide (NTZX), a bactericidal thiazolide antibiotic, has been effective in HP infection. We conducted a systematic review and meta-analysis to evaluate the efficacy of NTZX-based regimens for the eradication of HP.

METHODS:
We searched several databases from inception to April 2019 to identify studies that used nitazoxanide as part of an HP treatment regimen. We only included patients who completed the full length of therapy and were tested for eradication on follow up. Our primary outcome was the pooled HP eradication rate. We also performed a subgroup analysis to evaluate NTZX-based regimens in patients who had failed prior treatment. Pooled eradication rates and 95% confidence intervals (CIs) were initially calculated as per protocol analysis from the included studies. Publication bias was evaluated by Egger's test.

RESULTS:
Twelve studies including 978 patients met our inclusion criteria and were included in the meta-analysis. There were 4 randomized controlled trials, 7 prospective cohort studies and 1 retrospective cohort study. 7 studies were of good quality and 5 studies were of fair quality. HP eradication was successful in 826; (pooled eradication rate = 83%; 95% CI 76-90%) without significant heterogeneity (P = 0.17). In a subgroup analysis including 230 patients who had failed other prior regimens, the pooled eradication rate was 80% (95% CI 66-94%) without significant heterogeneity (P = 0.39). No serious adverse events were reported. In a subgroup analysis, the highest eradication rates were with levofloxacin, doxycycline, NTZX and a proton pump inhibitor; pooled eradication rate = 92% (81 -100%). There was no publication bias as evaluated by Egger's test [P = 0.94].

CONCLUSION:
NTZX-based regimens appear safe and effective first-line for HP eradication and are also successful as salvage therapy in patients who had failed prior treatments. Larger randomized controlled trials are required to determine the most effective NTZX-based regimen and the optimum duration of therapy for this increasingly multi drug-resistant infection.
1274 An Unusual Case of Sarcoidosis Involving the Pancreas
Authors: Sannapaneni Shilpa , Desai Amit P. , Feldman Mark 
Published: October 2019

INTRODUCTION:
Sarcoidosis is a multisystem disease primarily involving the lung. Skin, eyes, lymph nodes, spleen, liver, bones, exocrine glands, heart, kidneys, and central nervous system are the most common extrapulmonary sites involved. Clinically apparent gastrointestinal (GI) sarcoidosis is rare involving 0.1 to 0.9 percent of patients with sarcoidosis. The most commonly involved portion of the GI tract is the stomach, although sarcoidosis of the esophagus, appendix, colon, rectum, and pancreas have been reported in the literature.

CASE DESCRIPTION/METHODS:
A 73-year-old African American male was found to have pancreatic duct dilation on a computed tomography scan of abdomen done for investigation of mild epigastric abdominal pain that started a few months prior to presentation. He described the pain as dull, non-radiating, aggravated when hungry, subsided with food intake and associated with bloating. He had a past medical history of hypertension, hypothyroidism, and sarcoidosis involving lymph nodes and liver (not on treatment). He had no family history of GI cancer. He was a non-smoker and non-alcoholic. On presentation, his vital signs were normal; his abdomen was soft and non-tender, with normoactive bowel sounds and no masses or organomegaly. He had a normal calcium level of 9.7 mg/dL and his liver panel was significant for slightly elevated serum alkaline phosphatase, AST, ALT levels, with normal serum bilirubin. Magnetic resonance imaging showed 1.2 cm mass in the body of the pancreas obstructing the pancreatic duct and another 1.1 cm mass in the head of the pancreas concerning for malignancy. He underwent endoscopic ultrasonography with fine needle aspiration cytology of both pancreatic masses which showed numerous non-caseating granulomas consistent with sarcoidosis. Special stains for fungi and tuberculosis were negative.

DISCUSSION:
Less than 30 cases of biopsy-proven pancreatic sarcoidosis have been reported in the literature. Patients can have direct involvement of pancreas with sarcoidosis or 1, 25-dihydroxy vitamin D3 mediated hypercalcemia causing hypercalcemic pancreatitis. About three fourths of patients with pancreatic sarcoidosis have bilateral hilar adenopathy on chest radiography. On imaging, these patients demonstrate either a pancreatic mass (or masses) or a diffuse nodular pancreas. A biopsy is essential to distinguish between sarcoidosis, mycobacterial or fungal infection, and cancer. Treatment is usually conservative or with glucocorticoids.
1278 Often a Favorable Prognostic Factor: Unusually Elevated Alpha-Fetoprotein (AFP) in a Case of Hepatitis B Virus (HBV) Associated Intrahepatic Cholangiocarcinoma (ICC)
Authors: Yuridullah Ruhin , Estifan Elias , Vora Aarohi , Kumar Vinod , Michael Patrick , Maroules Michael 
Published: October 2019

INTRODUCTION:
Intrahepatic cholangiocarcinoma (ICC), often an incidental finding is a rare tumor of the epithelial cells of the biliary ducts that originate in the liver and extrahepatic bile ducts. Serum alpha-fetoprotein (AFP), as a tumor marker of hepatocellular carcinoma (HCC), and carbohydrate antigen 19-9 (CA 19-9), as a tumor marker of ICC, have been widely used in clinical practice. Although, a subset of patient with ICC (20-25%) present with elevated AFP levels, usually >100 ng/mL and very rarely >1000 ng/mL, its role remains significant in prognosis of ICC. Herein, we discuss a case of Hepatitis B virus (HBV) associated ICC in a young individual with exceptionally high serum AFP levels.

CASE DESCRIPTION/METHODS:
A 45-year-old male with no apparent past medical history was seen for complaints of fatigue, nausea, anorexia, and associated 34-lb weight loss of 6-weeks duration. Initial labs revealed a chronic HBV infection and an obstructive pattern on liver function tests. Computerized tomography (CT) scan of the abdomen showed a large heterogeneous mass originating from porta hepatis and invading the left lobe of the liver with multiple liver metastases and metastatic lymphadenopathy of the porta hepatis. CT also revealed a mass in the gallbladder along with thrombosed portal vein and intrahepatic biliary dilation (Figures 1 and 2). Magnetic resonance cholangiopancreatography (MRCP) confirmed initial CT findings. Labs revealed an AFP level of 9,715 ng/mL and CA 19-9 level of 554 units/mL. Percutaneous transhepatic cholangiography (PTC) and tissue biopsy revealed liver parenchymal poorly differentiated adenocarcinoma. Attempted internalization of a biliary stent by interventional radiology (IR) was unsuccessful. Management options were discussed with the patient and family who opted for a palliative approach without chemotherapy.

DISCUSSION:
Intrahepatic cholangiocarcinoma (ICC) is a rare tumor of the epithelial cells of the biliary ducts originating in the liver and extrahepatic bile ducts. ICC tends to be aggressive due to lymph node involvement at diagnosis with intrahepatic, and peritoneal dissemination. Several factors have been implicated in the pathogenesis of ICC including hepatitis B and C viral infections. Role of AFP, often a marker of HCC, is a significant one in prognostication of ICC. Elevated AFP levels, especially with HBV-associated ICC carries a favorable prognosis. Unfortunately, in the case of our patient, due to the advanced nature of his condition, his prognosis remained poor.
1284 Epstein Barr Virus (EBV)-Associated Acute Pancreatitis: Case Report
Authors: Hammami Muhammad B. , Aboushaar Reem , Musmar Ahmad , Azhar Mishah , Miller Stephen M. , Salomon Peter 
Published: October 2019

INTRODUCTION:
EBV infection is mostly subclinical and resolves spontaneously without complications. GI involvement manifests mainly with asymptomatic liver enzyme elevation. We report a case of acute pancreatitis complicating EBV infection.

CASE DESCRIPTION/METHODS:
An 18-year-old woman presented with 12 day history of moderate unremitting upper abdominal pain, nausea, and anorexia. She had a temperature of 36.8°C, bilateral non-tender cervical lymphadenopathy, mild pharyngeal injection, and moderate epigastric tenderness, but no splenomegaly or jaundice. She didn't take any medications and denied alcohol/illicit drug use. Leukocyte count was 14.5 cells/μL (15% neutrophils, 9% monocytes, 44% reactive lymphocytes), hemoglobin 12.7 g/dL, amylase 327 IU/L, lipase 2016 U/L, alkaline phosphatase 246 IU/L, aspartate aminotransferase 210 IU/L, alanine aminotransferase 283 IU/L, total/direct bilirubin 2/1.6 mg/dL. Calcium, blood glucose, and triglycerides were normal. Ultrasound showed mildly enlarged liver with coarse echotexture, contracted gallbladder, normal common bile duct, and mildly enlarged right upper quadrant lymph nodes, but no intrahepatic biliary ductal dilation. Computed tomography showed acute pancreatitis and mild splenomegaly. Anti-HAV IgM; HBsAg and anti-HBV core IgM; anti-HCV; HIV1 p24 antigen; anti-HIV1 and anti-HIV2 antibodies (AB); and CMV (quantitative PCR) were negative. EBV heterophile AB was positive, EBV IgG viral capsid AB 78.6 U/mL, EBV IgM viral capsid AB >160 U/mL, and EBV IgG early disease AB 70 U/mL. She was treated conservatively and discharged on the fourth day of hospitalization.

DISCUSSION:
Clinical pancreatitis is rarely associated with EBV infection; only 17 cases have been previously reported. As in our case, most patients were adolescent/young adults, have clear EBV infection picture, and have mild to moderate pancreatitis course with spontaneous recovery. Although acyclovir was tried, it isn't clear if it's required. Our patient was unique in that her hospital stay was 4 days in comparison to a mean of 10 days in other reported cases. EBV infection should be considered in the differential diagnosis of mild to moderate pancreatitis. It is not clear if subclinical pancreatitis in the setting of EBV infection is more common and why only few patients develop clinical pancreatitis.
1303 More Than Meets the Eye: Pancreatic Panniculitis as Presenting Sign of Invasive Pancreatic Adenocarcinoma
Authors: Gladys-Oryhon Jordan , Langhals-Totino Paige , Chaudhary Dhruv , Thakkar Shyam 
Published: October 2019

INTRODUCTION:
Despite its first description by Chiari in 1883, pancreatic panniculitis remains an atypical manifestation of pancreatic disease, appearing in only 0.3-2% of patients. Although the pathogenesis remains unclear, biopsy-proven subcutaneous liquefactive fat necrosis has implicated elevated lipase, amylase, and trypsin in dissemination and subcutaneous deposition/lipolysis, manifesting as edematous, erythematous superficial nodules of the lower extremities, thigh, and buttock.

CASE DESCRIPTION/METHODS:
A 91-year-old male presented with 2-week history of painful erythematous nodular rash of bilateral anterior lower extremities. Rash began as small singleton lesion, approximately 1 cm each in size, which grew in diameter with progressively worsening tenderness. Outpatient punch biopsy revealed lobular fat necrosis and local inflammatory infiltrate, consistent with pancreatic panniculitis. Labs were significant for amylase 1026 U/L (ULN 100), lipase of 4366 U/L (ULN 78), CA 19-9 1600 U/mL, and CEA of 9.4 ng/mL. CT-abdomen/pelvis without contrast showed a normal appearing liver, atrophic pancreas with 1.5 cm cystic structure at the pancreatic head, and a 9 mm cystic structure within the pancreatic body. EUS/ERCP for suspected choledocholithiasis with concomitant malignancy revealed 5 mm dilation of the main pancreatic duct with associated 21 mm × 17 mm mass of mixed solid and cystic consistency with multiple anechoic lesions throughout the pancreas suggestive of cysts. Fine needle biopsy revealed invasive ductal adenocarcinoma with associated high grade intraductal papillary mucinous neoplasm. He completed staging work-up and underwent Whipple Procedure with negative margins.

DISCUSSION:
Although a rare dermatologic manifestation of underlying pathology, pancreatic panniculitis serves as a herald of severe pancreatic pathology. Subcutaneous biopsy of suspicious lesions is invaluable in identifying the etiology and ultimately diagnosing underlying pancreatic pathology. Histologic evaluation following punch biopsy of nodules reveals liquefactive fat necrosis, surrounded by a neutrophil-rich mixed inflammatory infiltrate with pathognomonic “ghost cells”. Treatment of the underlying disease process can lead to resolution of the nodules. Our patient presented with pancreatic panniculitis as the initial manifestation of internal occult malignancy in the absence of typical symptoms. Prompt recognition and biopsy of suspicious nodules led to an expedient diagnosis of locally resectable disease.
1304 The Great Mimicker: Leptospirosis
Authors: Alegre-Boschetti Sergio M. , Betancourt-Guzmán Natalia , Fernández Carlos , De Jesús Henry , Magno Priscilla 
Published: October 2019

INTRODUCTION:
Leptospirosis is the most prevalent zoonotic disease with higher incidence in the tropical regions. Humans are infected after direct contact with urine of an infected animal or environmental exposure. Most infections are asymptomatic and self-limited while a severe life-threatening infection, known as Weil's disease, occurs in about 10% of patients. Among those with severe disease, hepatitis, acute kidney injury, myocarditis, and rarely, acute pancreatitis can develop. We herein report a case of an acute pancreatitis as an uncommon presentation of severe leptospirosis.

CASE DESCRIPTION/METHODS:
71-year-old male patient with past medical history of hypertension, diabetes mellitus, presented with complaints of abdominal pain, myalgia, nausea as well as vomiting for seven days prior to admission. Patient has not been able to tolerate food due to nausea and severe diffuse abdominal pain. Initial physical examination was remarkable for dry oral mucosa and jaundice. Laboratory evaluation demonstrated microcytic anemia with Hgb 9.4 g/dL, WBCs in 9.7 × 10-3/ul with neutrophil predominance, and acute thrombocytopenia. A complete metabolic panel showed a severe direct hyperbilirubinemia with normal liver enzymes and an increased creatine, 1.5 times baseline. Lipase levels were three times upper limit that along with presenting symptoms suggested an acute pancreatitis. Further examination with an abdominal sonogram revealed a diseased acalculus gallbladder with a positive Murphy sign and no obstruction of the biliary tree. Initial clinical diagnosis of severe acute pancreatitis was made, however, findings of non-obstructive jaundice along acute renal failure raised the suspicion of Weil's disease. Acute medical care included intravenous ceftriaxone with adequate clinical response. During admission Leptospira IgG titers were positive with specificity of 100%. Following treatment with ceftriaxone the patient was uneventfully discharged home to complete oral doxycycline therapy for a total of seven days.

DISCUSSION:
Leptospirosis in Puerto Rico accounts for approximately 50% of all the cases reported in the United States. It is of foremost importance to be aware of the diverse clinical manifestations of Weil's disease, often, confused with a viral illness. Unusual etiologies can lead to common complaints in this case an acute pancreatitis; therefore, early identification and acute care management of infectious diseases can positively influence patient's outcome.
1306 Endoscopic Mucosal Resection of Pancreatic Rest Presenting as a Submucosal Nodule in the Gastric Antrum
Authors: Bahirwani Janak , Duarte-Chavez Rodrigo , Mehta Sagar V. , Tayel Hussam , Tayel Hesham , Matin Ayaz 
Published: October 2019

INTRODUCTION:
Pancreatic rest (PR) is defined as ectopic pancreatic tissue outside the normal pancreatic parenchyma, with a vascular and nerve supply separate from the pancreas itself and has a prevalence of 0.55-14%. It is believed to arise during rotation of the foregut, when fragments of the pancreas become separated from the main body and are deposited at ectopic sites.

CASE DESCRIPTION/METHODS:
An 82-year-old male with a history of GERD presented with episodes of epigastric abdominal pain of 2 month duration that did not improve despite PPI therapy. He denied any other symptoms such as bleeding, weight loss or change in bowel habits. Physical examination revealed a non-distended abdomen and mid-epigastric tenderness. An EGD performed for evaluation of GERD 3 years prior found an antral nodule. A repeat EGD was done this time for evaluation of the epigastric pain and showed a mobile submucosal nodule in the antrum measuring 7-8 mm, unchanged from before. EUS was performed for further evaluation and showed a hypoechoic gastric submucosal lesion, arising from the muscularis mucosa, 8 mm in size. No high-risk features were present. The area was resected using EMR and the defect was closed with clips. The EUS also showed a cystic dilation of the pancreatic duct in the pancreatic head measuring 5 mm, suspicious for main duct IPMN. Results from the EMR biopsy demonstrated heterotopic pancreatic tissue with focal low grade pancreatic intraepithelial neoplasia (PanIN), with clear margins and reactive gastropathy with focal intestinal metaplasia. There was resolution of the abdominal pain after the procedure. A repeat EGD/EUS will be done in 1 year. MRI will be performed in 6 months for surveillance of the pancreatic duct dilation.

DISCUSSION:
PR can be found virtually anywhere along the GI tract, but they are typically found in the stomach along the greater curvature and antrum. Although usually asymptomatic, the most reported symptom is mid abdominal pain. Complications of gastric ectopic pancreas include acute or chronic pancreatitis, necrosis, pseudocyst, gastric outlet obstruction and rarely carcinoma. PanIN is neoplastic epithelial proliferation that occurs in the small caliber pancreatic ducts; it is divided in 3 degrees based on architectural and nuclear atypia and has potential progression to invasive ductal adenocarcinoma. In our case, PanIN 1 was found on histology and the lesion was completely resected. PR should always be considered when evaluating a submucosal lesion of the GI tract.
1309 Multi-Drug Resistant Burkholderia Cepacia Infected Pancreatic Pseudocyst
Authors: Rawi Sarah , Mago Sheena 
Published: October 2019

INTRODUCTION:
Burkholderia Cepacia is a gram negative bacillus that is most commonly associated with pneumonia in the immunocompromised, most specifically in the cystic fibrosis population. Pancreatic cysts have about 13.5% prevalence and are classified between non-neoplastic and neoplastic. Infected pseudocysts are non-neoplastic and a complication of pancreatitis.

CASE DESCRIPTION/METHODS:
A 45-year-old male with a past medical history of substance abuse, diabetes mellitus, and acute pancreatitis two weeks prior to admission presented to the ED unresponsive and hypoglycemic. Vitals were stable and physical exam was unremarkable on admission. With increased alertness he began endorsing epigastric abdominal pain, back pain, and early satiety. He then became febrile. Initially his labs were significant for: total bilirubin of 1.6 mg/dL, ALT 46 U/L, AST 65 U/L, and alkaline phosphate of 357 U/L. During the course of admission, his abdominal pain and satiety worsened, and his abdomen became distended. He became septic without a clear source. He underwent CT A/P, which demonstrated an 18.5 × 10.3 cm pseudocyst containing debris, thought to be a complication from his recent pancreatitis. The patient underwent CT guided biopsy for drainage and cultures, which grew MDR B. Cepacia. He was also found to have B. Cepacia bacteremia. The patient was started on Ceftazidime for a 2-month course. Unfortunately, after drainage the patient continued to have symptoms and his bilirubin peaked at 5.9 mg/dL and AP peaked at 1855 U/L. This led to a cyst gastrostomy stent placement via EUS. Two weeks later, a biliary sphincterotomy was performed by ERCP with stent removal and a single segmental biliary stricture was found in the lower and middle third of the main bile duct. Repeat CT A/P two weeks after the ERCP and one month after the start of antibiotics, showed a decrease in the size of the cyst to 8.5 × 3.2 cm and the patient's symptoms were improving.

DISCUSSION:
This was a unique case of a common complication of pancreatitis. Although infected pseudocysts are associated with mixed anaerobes and aerobes, B. Cepacia has not been commonly reported. To the best of our knowledge, this is the first case to be associated with B. Cepacia infected pseudocyst. As such, there is value in including uncommon MDR organisms in the differential for infected pseudocysts. Moreover, as this patient was immunocompetent, this poses an area of future study, as this patient's IVDA history may be an essential risk factor for these organisms.