bluuebunny/crossref_metadata_2025_split huggingface dataset:
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.