bluuebunny/crossref_metadata_2025_split huggingface dataset:
1392 Transjugular Liver Biopsy Causing Hemobilia and the Rarely Reported Hemocholecystitis
Authors: Gollol Raju Narasimha Swamy , Jayananda Sriraksha , Regan Kara , Rosenblatt Mark , Khalid Hamza 
Published: October 2019

INTRODUCTION:
Transjugular liver biopsy is a safe and effective tool in liver disease patients in whom percutaneous liver biopsy is contraindicated. Serious complications from transjugular liver biopsy are uncommon. Liver biopsy related hemobilia occurs in less than 1% of cases and hemobilia related hemocholecystitis is very rare.

CASE DESCRIPTION/METHODS:
A 56-year old Asian male with ESRD presented with abdominal pain and melena. 3 days prior to presentation he had undergone a transjugular liver biopsy for evaluation of abnormal LFTs and cirrhotic appearing liver on imaging. Vital signs were normal. Exam was significant for epigastric tenderness. Labs with Hb 10.4 gm/dL, Bili 1.1 mg/dL, ALP 307 U/L, AST 131 U/L, ALT 64 U/L, INR 1, and lipase 5069 U/L. CT abdomen showed a distended gallbladder with ovoid debris within (Figure 1). EGD was with no obvious luminal blood. MRCP showed distended gallbladder with a large sludge ball within, normal CBD, and mild pancreatic head edema. Tagged RBC scan was negative. With continued worsening of LFTs and ongoing gradual decline in Hb, patient was suspected to have intermittent hemobilia and biliary obstruction. ERCP showed bulging major papilla with a trace of blood at the orifice. Cholangiogram showed no obvious filling defects in the bile duct. Gallbladder was un-opacified denoting cystic duct obstruction (Figure 2). Biliary sphincterotomy was performed and balloon sweep of the biliary tree was unremarkable except for some minimal sludge. A plastic stent was placed in the CBD. Patient continued to have worsening right upper quadrant abdominal pain with clinical suspicion for acute cholecystitis. Patient underwent laparoscopic cholecystectomy revealing an edematous and severely inflamed gallbladder. Gallbladder lumen contained bloody bile and blood clots. Microscopic examination of gallbladder revealed extensive wall necrosis and acute inflammation (Figure 3). Patient had an uneventful post-operative course.

DISCUSSION:
Hemobilia after liver biopsy is rare and occurs in less than 1% cases. Acute cholecystitis from hemobilia (hemocholecystitis) is extremely rare and is due to thrombus obstructing the cystic duct. Diagnosing hemocholecystitis is challenging and clinicians need a high index of suspicion in making this diagnosis and thus prevent delay of much needed definitive treatment. Ultrasound and HIDA scan can be useful in making diagnosis. Risk of gallbladder perforation in these cases is 2-15% from gangrenous cholecystitis. Treatment of hemocholecystitis is early cholecystectomy.
1394 An Uncommon Cause of Hematochezia—A Case Report
Authors: Ishtiaq Rizwan , Wilhelm Darlene M. , Gaduputi Vinaya , Hamdani Uzair 
Published: October 2019

INTRODUCTION:
Pancreatic cancer is the leading cause of cancer-related mortality in developed countries. In the United States, 3% of the cancer-related mortalities are caused by pancreatic cancer. Pancreatic cancer commonly metastasizes to lungs, lymph nodes, liver, and peritoneum. Metastasis of pancreatic cancer to the colon is very rare, and few cases have been reported in the literature so far.

CASE DESCRIPTION/METHODS:
In this case report, we describe a case of a mass in the colonic site which was initially thought to be primary colon cancer. However, on further radiological and histological examination, the mass was confirmed to be a metastatic tumor from a primary pancreatic cancer (Figure 1 shows cancer in the tail of the pancreas). Immunohistochemical markers were used to differentiate between primary pancreatic and primary colon cancer (Figure 2).

DISCUSSION:
In consideration of this interesting finding, the importance of immunohistochemical markers in the differentiation between primary and metastatic colon cancers based on their expression is emphasized. We emphasize that the pattern of immunohistochemical markers especially the combination of CK7 and CK20 is a useful tool to differentiate between metastasis in the colonic sites and primary colon cancer. We have also described an interesting relation between the side of colonic metastasis and the involved segment of the pancreas which has not been described in the literature before. In this manuscript, we have also compared and analyzed ten previous cases in medical literature with similar presentation of colonic metastasis from pancreatic cancer.
1399 DLBCL Mimicking a Cholangiocarcinoma: Earlier Diagnosis, Better Outcome?
Authors: Khadilkar Arjun , Mateja Candice , Thomas Sarah 
Published: October 2019

INTRODUCTION:
Diffuse Large B-Cell Lymphoma (DLBCL) is the most common subtype (∼25%) of Non-Hodgkin's Lymphoma. In 40% of cases, disease arises in extra-nodal, extra-medullary tissues, primarily in the stomach or GI tract. This is a rare case presentation of DLBCL mimicking cholangiocarcinoma.

CASE DESCRIPTION/METHODS:
56-year old male with no significant past medical history presented to the ER with progressive abdominal pain for the past three months. Patient had early satiety and unintentional weight loss of sixty pounds over the past year. Labs on admission were significant for WBC: 13.55 (93% Neutrophils), Hemoglobin: 7.3, AST: 158, ALT: 150, Total Bilirubin: 17.7, Alkaline Phosphatase: 846, Albumin: 2.1, and LDH: 442. HIV was negative. Physical exam was notable for cachexia, scleral jaundice, and diffuse abdominal pain. CT of abdomen showed 2.6 × 3.4 cm mass encasing the common bile duct, intra and extra-hepatic biliary ductal dilation, retroperitoneal lymphadenopathy, suspicious liver metastases, significant ascites, and main portal, superior mesenteric, and splenic vein thrombosis, all concerning for cholangiocarcinoma. Patient was started on heparin drip for the vein thromboses. Gastroenterology attempted an ERCP, but was unable to cannulate the biliary tree. Analysis of ascitic fluid was negative for malignant cells. EGD showed large varices in lower third of esophagus and two non-bleeding gastric ulcers. Both ulcers were biopsied for histology. Gastric biopsy from EGD demonstrated diffuse large B-cell lymphoma with neoplastic cells, strongly CD20+ and weak BCL 6. Bone marrow biopsy showed no marrow involvement. Hematology Oncology recommended chemotherapy with R-CHOP. Few days later, the patient developed a GI bleed and transferred to MICU. Repeat EGD showed esophageal varices with blood clot covering fundus and body. The next day the patient was made comfort measures and passed.

DISCUSSION:
DLBCL has an incidence of approximately 7 cases per 100,000 persons per year. Per case report by Zakaria et al, there have been 28 reported cases of NHL to arise in the extra-hepatic bile ducts between 1982 and 2012. Diagnosis is best made by excisional lymph node biopsy or immunophenotyping. Treatment options primarily include surgery and chemotherapy. Prognosis varies among reported cases of DLBCL involving the GI tract from death within 32 days to survival greater than 72 months. DLBCL with biliary tract causing obstructive jaundice is a rare presentation, but it should among the differential diagnoses.
1412 A Rare Case of Post-ERCP Panniculitis
Authors: Shipley Lindsey C. , McGraw Timothy A. , Parrish Charles A. , Harrison Devin S. , Mitchell Rachel E. , Wilcox Charles M. , Ahmed Ali M. 
Published: October 2019

INTRODUCTION:
Pancreatic panniculitis affects 0.3-3% of patients with a wide variety of pancreatic disorders. It is characterized by subcutaneous fat necrosis following the release of pancreatic enzymes into the circulation. Endoscopic retrograde cholangiopancreatography (ERCP) is a rare cause of panniculitis. Based on our literature review, this is the fourth case report of post-ERCP panniculitis.

CASE DESCRIPTION/METHODS:
An 80-year-old female with a history of choledocholithiasis with biliary stent placement presented for elective ERCP. The procedure demonstrated a moderate, inflammatory distal biliary stricture, a migrated biliary stent and choledocholithiasis. A biliary sphincterotomy, cholangioscopy and laser lithotripsy and stent exchange was performed with approximately 80% of stone removal. Post- procedure the patient noted tender erythematous raised nodules on her legs. Skin biopsy was performed with findings consistent with pancreatic pannicultitis. Follow-up ERCP was normal with trace sludge and removal of the biliary stent. At follow-up she was improved without abdominal pain and reported healing of the lower extremity cutaneous lesions.

DISCUSSION:
Pancreatic panniculitis is a rare skin finding that is independent of disease severity and can occur at any point during the disease process. Post-ERCP panniculitis is rare and only reported in three other cases. Pancreatic panniculitis is typically tender, ill-defined, red-brown nodules located in the lower extremities. The gold standard for diagnosis is biopsy with histopathology significant for a mostly lobular panniculitis without vasculitis with the presence of the typical ghost cells, necrotic and calcified adipocytes. Treatment is aimed at addressing the underlying pancreatic disease and the lesions typically resolve with improvement in pancreatic inflammation.
1415 A Rare Presentation of Diffuse Large B-Cell Lymphoma as a Pancreatic Mass
Authors: Seifers Cole , Pottebaum Benjamin , Siniakowicz Karolina , Ruzkowski Charles 
Published: October 2019

INTRODUCTION:
Diffuse Large B-Cell Lymphoma (DLBCL) of Pancreas is a fast-growing Non-Hodgkin lymphoma (NHL), which accounts for only 0.5% of all pancreatic tumors. In most cases, it presents as a single, metastatic mass or diffuse nodules in the pancreas. DLBCL should be considered in patients with a pancreatic mass, especially if: personal history of lymphoma, presence of an immunodeficiency syndrome, or prior infection with EBV.

CASE DESCRIPTION/METHODS:
A 60-year-old type II diabetic male presented to the ED with nausea, vomiting, diarrhea and 40 lb weight loss. Patient's mother had known pancreatic adenocarcinoma. Social history revealed multiple sexual partners of both sexes. On exam patient had epigastric tenderness, and a 1 cm non-tender supraclavicular lymph node. A CT abdomen/pelvis with contrast revealed a 4.8 × 7.5 × 4 cm mass in the head of the pancreas and retroperitoneal metastatic adenopathy. Endoscopic ultrasound characterized a “U” shaped parenchymal mass extending from the head to the tail of the pancreas encircling the splenic artery. Fine needle aspiration and biopsy both revealed DLBCL. Bone marrow biopsy and imaging studies were unremarkable, therefore the pancreas was determined to be the primary site. Additional testing found the patient to be HIV positive with a CD4 count of 119 and thus diagnosed with AIDS. He was started on antiretroviral therapy prior to initiation of R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisone). Following his first chemotherapy dose, he was readmitted to the hospital with fever and weakness. Patient continued to decompensate and expired 23 days from his initial diagnosis.

DISCUSSION:
Most common sites of extranodal involvement of NHL are the gastrointestinal tract, liver, lung, bone marrow, and the central nervous system. DLBCL can present with extra-nodal involvement in about 50% of cases, but only 0.2-2% involve the pancreas. Clinically, most cases of Primary Pancreatic Lymphoma (PPL) are misdiagnosed as pancreatic adenocarcinoma. PPL generally carries a better prognosis once treatment is initiated in an immunocompetent individual. In this rare case, the patient was concurrently diagnosed with AIDS and Stage IV DLBCL of the pancreas. This case highlights an unusual presentation of a primary pancreatic malignancy that typically presents as a metastatic lesion. Furthermore, this case shows the utility of endoscopic ultrasound to better identify and characterize pancreatic masses when compared to other diagnostic modalities.
1418 A Troublesome Remnant
Authors: Zackria Rasiq 
Published: October 2019

INTRODUCTION:
Postcholecystectomy syndrome (PCS) is the persistence of symptoms of biliary colic after cholecystectomy. Although PCS is relatively common with multiple etiologies, a remnant cystic duct is a rare etiology accounting for only 2.5% of cases. Mirizzi's syndrome is a rare cause of PCS due to a remnant cystic duct stone.

CASE DESCRIPTION/METHODS:
A 34-year-old female with a history of choledocholithiasis status-post cholecystectomy 6 years prior presented with severe, constant, sharp right upper quadrant pain with nausea and vomiting for 1 day. She had abdominal tenderness with a negative Murphy sign. She was found to have elevated liver chemistries. Patient had two hospitalizations within the past year with similar presentations with the finding of choledocholithiasis requiring endoscopic retrograde cholangiopancreatography (ERCP) on both occasions. Magnetic retrograde cholangiopancreatography (MRCP) showed a dilated, remnant cystic duct with filling defect indicative of obstruction caused by the stone. ERCP was done with removal of one stone followed by surgical resection of the remnant cystic duct with an endoluminal stone.

DISCUSSION:
The cystic duct typically measures 2-4 cm in length, and formation of stone in the structure leads to symptoms of dyspepsia, nausea, vomiting, and possibly jaundice. Cholecystectomy provides symptom relief to 85% of patients. After cholecystectomy, an incomplete surgery can leave a residual duct of greater than 1 cm in length, defined as a cystic duct or gallbladder remnant. Formation of calculi in this structure can lead to PCS. PCS can present as continuation of symptoms after the operation or after an interval of 2 days to 25 years after disease free period. PCS has been reported in 5 to 40% of patients post-cholecystectomy. Most common causes are extrabiliary, however, biliary etiologies are not uncommon. The incidence of PCS due to remnant cystic duct has been reported to be less than 2.5%. Identifying and promptly treating the underlying etiology are important to minimize morbidity. Cystic duct remnant stones may predispose a patient to postcholecystectomy Mirizzi's syndrome. While difficult to diagnose with different imaging studies, this can be effectively diagnosed with MRCP and treated with ERCP. One study showed that ERCP/MRCP failed to identify 2 out of 3 patients with a remnant cystic duct. While endoscopic therapy is an effective and safe alternative to surgery for postcholecystectomy Mirizzi's syndrome, surgical intervention is a definite treatment.
1421 Pancreaticocolonic Fistula: A Rare Cause of Recurrent Infective Endocarditis
Authors: Samo Salih , Giles Karen , Mulki Ramzi , Taborda Cesar , Cassani Lisa S. , Goebel Stephan U. , Raja Shreya M. 
Published: October 2019

INTRODUCTION:
Pancreatic fistulas to adjacent organs may develop as a result of severe pancreatitis and pancreatic cystic lesions, which can lead to infectious complications. The aim of this case is to recognize pancreaticocolonic fistula (PCF) as an unusual cause of persistent infection such as infective endocarditis (IE).

CASE DESCRIPTION/METHODS:
59-year-old male with a history of chronic alcoholic pancreatitis, recurrent mitral valve IE (Proteus, Morganella and Enterococcus species), end stage renal disease, and heart failure (HF) was admitted after a fall. Initial labs showed almost 2 g drop in baseline hemoglobin (9.8 to 8.1 g/dL). Non-contrasted computed tomography (CT) of abdomen to assess for retroperitoneal bleed revealed a 1.3 × 1.6 cm air-filled cavity at the pancreatic tail communicating with the colonic splenic flexure in addition to moderate ascites. Contrasted CT showed similar findings (Figure 1), suggestive of a PCF. Ascites fluid analysis was consistent with a transudative process (attributed to HF) with amylase <10. An endoscopic ultrasound with fine needle aspiration for a pancreatic tail cyst two years prior revealed a hemorrhagic cyst. A colonoscopy two years ago showed 13 polyps up to 1 cm in size with histology consistent with tubular adenomas and tubulovillous adenomas. Given concern for colonic pathology as a nidus of the PCF, a colonoscopy was pursued. This revealed a small fistulous opening (Figure 2) 45 cm from the anal verge, which was closed with a clip. There was no evidence of malignancy. The PCF was thought to be the sequela of recurrent pancreatitis with cyst formation eroding into the colonic wall, resulting in recurrent polymicrobial bacteremia and IE. Endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic sphincterotomy and pancreatic stent placement is planned. Repeat culture data on broad-spectrum antibiotics has remained negative.

DISCUSSION:
PCF is a rare complication of severe acute necrotizing pancreatitis with a high mortality rate. Surgery is the main treatment modality, but conservative and endoscopic management are alternative options in non-surgical candidates. Our patient was deemed high surgical risk. Conservative management includes nutritional support (preferably enteral), electrolyte repletion, broad-spectrum antibiotics, somatostatin analogues, and percutaneous drainage. Endoscopic treatment with ERCP and subsequent pancreatic sphincterotomy and pancreatic duct stenting lead to fistula closure in many cases.
1423 Primary B-Cell Pancreatic Lymphoma Presenting as Acute Pancreatitis
Authors: Tikue Alay M. , Suchartlikitwong Sakolwan , Medrano Rita , Arevalo Meily , Zitun Mohamed , Khandewal Nuvneet , Thein Kyaw , Swarup Sriman , Nugent Kenneth , D'Cunha Nicholas 
Published: October 2019

INTRODUCTION:
Primary pancreatic lymphoma (PLL) is a very rare type of pancreatic malignancy and accounts for less than 1% of all pancreatic masses. Presenting symptoms are non-specific and may lead to delay in diagnosis.

CASE DESCRIPTION/METHODS:
A 71-year-old man with diabetes mellitus and hypertension presented to hospital with epigastric pain, nausea, and vomiting for 3 days. He had loss of appetite and weight loss for 2 months. On physical examination, his vital signs were normal, and he had tenderness on palpation at epigastric area without signs of peritonitis. Complete blood counts were within normal limits. He had transaminitis and elevated total bilirubin and alkaline phosphatase. Serum amylase and lipase were 123 IU/L (normal: 13-53) and 864 IU/L (normal: 13-60), respectively. Tumor markers, including CA 19.9 and CEA, were normal. Magnetic resonance imaging (MRI) of the pancreas showed a large mass at the pancreatic head measuring 8.3 × 7.6 cm in maximum diameter with peripancreatic and retroperitoneal adenopathy (Figure 1). Endoscopic ultrasound demonstrated the mass in the pancreatic head and malignant-appearing peripancreatic lymph nodes. Computer tomography (CT) guided biopsy of the pancreatic mass was performed. Pathology revealed a high grade B-Cell Lymphoma. Bone marrow biopsy did not show atypical cells. Staging CT scans revealed a 9 mm sized mediastinal node. He was diagnosed with stage III high grade B-Cell primary pancreatic lymphoma. An International Prognostic Index was 2 which predicts a 5-year survival of 51%. He received R-CHOP regimen for treatment and currently on cycle 5 with a good response.

DISCUSSION:
Primary pancreatic lymphoma is a rare malignancy accounting for 0.7% of all pancreatic malignancies and 1% of extranodal lymphomas. The disease is male predominant about 7 times more frequent than in females.2 Non-specific gastrointestinal symptoms are the most common presentations, including abdominal pain, obstructive jaundice, or acute pancreatitis. Imaging of the pancreas by MRI or CT scan may help to distinguish PPL from the more common pancreatic adenocarcinoma. However, cytohistology of the mass is required for diagnosis and to guide definitive treatment. Surgery has a limited role in management, and chemotherapy is the main treatment.
1425 A Stent Long-Forgotten: Obstructive Jaundice and Acute Cholangitis Due to Migrated Biliary Stent
Authors: Jacob Bobby , Das Kanak , Wankhade Charudatta , Stavropoulos Stavros , Rizvon Kaleem 
Published: October 2019

INTRODUCTION:
Long-term biliary stenting may be beneficial in high risk elderly patients or patients with multiple comorbidities with irretrievable CBD stones. However, the rate of complications increases with the longer duration that the stent has been placed and replacement or removal of biliary stents are recommended after 3-6 months. Little information exists on consequence of long-term biliary stents and management of its complications.

CASE DESCRIPTION/METHODS:
A 73-year-old Pakistani female with chief complaint of worsening right upper quadrant pain for 3 days, jaundice and intermittent fevers. Patient had a complex medical and surgical history of necrotizing gallstone pancreatitis complicated by bowel perforation status post partial pancreatectomy, common biliary duct stent placement and right-sided colectomy in 2009. Computed tomography revealed a dilated gallbladder with cholecystocutaneous fistula and dilated common bile duct and prior CBD stent which was migrated in the distal CBD. External drainage was performed by Interventional Radiology, followed by ERCP with the cholangiogram revealing choledocholithiasis and the migrated CBD stent lodged in common bile duct and common hepatic duct. Significant opacity was also noted suggesting that the stent was enclosed and cemented within the biliary duct. A few biliary sweeps with inflated balloon catheter to retrieve the migrated stent was attempted without success. Patient was then subsequently transferred to a tertiary facility for advanced endoscopic intervention with successful retrieval of the migrated biliary stent and various advanced endoscopic techniques with placement of metallic stent and nasobiliary drainage.

DISCUSSION:
Endoscopic management should be the primary management option prior to surgery, especially in those patients with significant comorbidities unfit for surgery. In our patient the ERCP was technically difficult and complex due to a large amount of stone burden in the setting of an up-migrated lodged stent placed 10 years ago within the bile duct. Multiple tools and interventions including biopsy forceps, adult and pediatric raptor forceps, web baskets, extraction balloons, cholangioscope, and electrohydraulic lithotripsy, metal stent placement and nasobiliary drainage. This specific case adds to current literature the various advanced endoscopic techniques that can be used in management of complications which can occur with biliary stenting.