bluuebunny/crossref_metadata_2025_split huggingface dataset:
1285 Elevated CEA and CA 19-9 Producing Carcinoma: Think Beyond the Digestive System!
Authors: Bhardwaj Gaurav , Shahid Tamoor , Hertan Hilary 
Published: October 2019

INTRODUCTION:
Carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9) are validated and well-known tumor markers for colorectal and pancreatic malignancies but data concerning these markers in bladder carcinoma are limited. We report a rare case of bladder carcinoma with metastasis to the bone marrow producing very high serum levels of CEA and CA 19-9.

CASE DESCRIPTION/METHODS:
A 68-year-old man with a medical history of hypertension, COPD presented with altered mental status. The patient further reported anorexia, unintentional weight loss of 50 lbs and intermittent hematuria over the last few months. He was confused but hemodynamically stable on presentation. Initial laboratory data showed pancytopenia, ALP of 712 U/L with normal transaminases and bilirubin, urine microscopy showed >100 red blood cells/HPF. A CT scan of the abdomen showed bilateral hydronephrosis with thickening of the urinary bladder and diffusely abnormal bone marrow. Bone marrow biopsy showed poorly differentiated metastatic carcinoma with positive immunohistochemical (IHC) stains for cytokeratin (CK)7 and CK20. In addition, very high levels of tumor markers CA19-9 42,635 U/ml, CEA 347 ng/ml raised a possibility of origin from the gastrointestinal or pancreatobiliary system. Subsequently, upper endoscopy, colonoscopy, EUS, and magnetic resonance cholangiopancreatography (MRCP) were performed and results were unremarkable. Finally, a cystoscopy was performed showing multiple papillary tumors throughout the bladder. Unfortunately, the patient died before any further workup and therapeutic interventions were initiated.

DISCUSSION:
Elevated levels of CEA and CA19-9 have been demonstrated in TCC of the bladder. The specificity of CEA for diagnosis of colorectal cancer is 89 percent while the specificity of CA 19-9 for pancreatic cancer goes up to 85% at a serum level >37 U/ml but neither are useful tools in the primary diagnosis of TCC. The pattern of staining with the CK20 and CK7 may be helpful in narrowing the diagnostic spectrum, but both can show positivity in pancreatobiliary and urothelial cancers. IHC allows limited determination of the tissue of origin in poorly differentiated carcinomas due to atypical staining patterns. In conclusion, when CEA and CA19-9 serum levels are elevated, a gastrointestinal malignancy should be excluded and one should be mindful of the existence of CEA and CA19-9 producing TCC and thus examine the urologic tract.
1286 Chylous Ascites in the Setting of Metastatic Pancreatic Cancer: A Case Report
Authors: Gribbin Caitlin , Martin Tracey , Wan David 
Published: October 2019

INTRODUCTION:
Chylous ascites, or milky-appearing peritoneal fluid rich in triglycerides, is an uncommon finding that occurs in the presence of lymph in the abdominal cavity. The incidence has been reported as one in 20,000 hospital admissions though this number may be increasing due to improved survival in the setting of gastrointestinal malignancies. Etiology is most commonly associated with malignancy and other causes include cirrhosis, congenital malformations, traumatic causes as well as postoperative complications, and infectious or inflammatory diseases.

CASE DESCRIPTION/METHODS:
A 52-year-old woman with a history of pancreatic cancer with metastases to the spine status-post C3-6 laminectomy and fusion as well as polycystic kidney disease (PCKD) status-post renal transplant presented with abdominal distension and fever. The patient underwent a paracentesis to rule-out spontaneous bacterial peritonitis (SBP) and was noted to have chylous ascites with a triglyceride level of 1323 mg/dL in the ascites fluid. The patient remained hemodynamically stable and received treatment with piperacillin/tazobactam for presumed pneumonia versus urinary tract infection underlying the patient's fever. Following rule-out of tuberculosis, the presence of chylous ascites was presumed to be secondary to tumor burden within the abdominal cavity and the patient was continued follow-up with oncology without further intervention from the gastrointestinal team.

DISCUSSION:
Chylous ascites is a rare finding associated with disruption of the lymphatic system in either the abdominal or thoracic cavity. It is most commonly associated with malignancy but can also be seen situations involving cirrhosis, trauma, postoperative complications, or congenital malformations. Occasionally, chylous ascites may be seen in inflammatory or infectious diseases, which must be ruled out if suspected. Associated symptoms include abdominal pain and distention, weight gain, and dyspnea. The condition is typically not suspected prior to performing a paracentesis, which is diagnostic. Treatment is aimed at correcting the underlying cause as well as addition of a low-fat, high-protein diet and therapeutic paracentesis as needed. In this case, the patient continued treatment with oncology alongside palliative measures to alleviate associated symptoms.
1290 Years of Undiagnosed Recurrent Hypoglycemia in a Child
Authors: Desai Koosh , Mehta Minesh 
Published: October 2019

INTRODUCTION:
Below we present a case of a child with an insulinoma, a rare and difficult to diagnose cause of hypogylcemia.

CASE DESCRIPTION/METHODS:
A previously healthy 12-year-old child presented to the emergency department with an unresponsive episode. Her father found her in bed, “unable to open her eyes” and extremely lethargic. Her blood sugar was noted to be less than 20 and she had ketones in her urine. Her glucose improved with oral intake and was discharged with a presumptive diagnosis of a well known cause of hypoglycemia in this age group, ketotic hypoglycemia. She remained well for around a year but then returned to the ED with lethargy. She was deemed have symptoms consistent with her originally diagnosed condition and was discharged. After an illness free period of 18 months, she presented to the ED with a low glucose of 33, high insulin of 14, and high c-peptide of 3.3. She had a negative CT scan was again discharged home. For the next few months, she having daily symptoms of fatigue and “cranky” behaviors, with only partial response to glucose intake. At age 16, after being seen by an endocrinologist, an insulinoma was considered as a possible diagnosis. MRI was ordered, but didn't detect a mass in the pancreas. Thus, GI was consulted for endoscopic ultrasound (EUS) and a 2 cm mass in the uncinate process was detected. FN-B of the pancreatic mass was consistent with neuroendocrine tumor. The patient had a surgical resection and, eventually, complete resolution of symptoms.

DISCUSSION:
Insulinomas are a very rare cause of hypoglycemia, with around 1 to 4 new cases occurring per million persons per year, and particularly uncommon in children with only limited number of published case reports. Classically, the “Whipple's triad” is expected with insulinoma: a low plasma glucose, symptoms consistent with hypoglycemia, relief of symptoms when the glucose is raised to normal. This patient did have certain aspects of the triad of symptoms, but she didn't always respond to glucose thus complicating diagnosis. This case is a reminder that, while rare, insulinoma is a important cause of hyperinsulinemic hypoglycemia in the pediatric population. Also important to know I is that while CT is generally considered first line for diagnosis of insulinoma and has good sensitivity and specificity and MRI has even better accuracy, neither test is perfect, thus EUS is sometimes required to identify lesions.
1291 Pancreatico-Biliary Stricture by Benign Hepatic Cysts
Authors: Kim Hyaehwan , Beck Gregory 
Published: October 2019

INTRODUCTION:
Hepatic cysts are frequently identified incidentally, and usually do not require any follow up. We present a case of benign, large hepatic cysts which were extrinsically compressing on biliary ductal system and caused a fusiform-dilitation of the hepatic ducts, distal dilation of the common bile duct (CBD) and a narrowing of the pancreatic duct.

CASE DESCRIPTION/METHODS:
A 77-year-old male presented to our facility for drainage of a large liver cyst. Initial discovery was incidental, but follow up imaging showed increased solid component in one of the cysts. At the time of presentation he was completely asymptomatic and laboratory studies were all within normal range. Computed Tomography (CT)-guided drainage of the hepatic cyst yielded 250 cc of brown fluid. The cytology was benign. Patient then presented to one-month follow up appointment with painless jaundice, and elevated total bilirubin of 6.7 mg/dL. Magnetic Resonance Cholangiopancreatography (MRCP) was performed and showed filling defects of the CBD and bilateral hepatic ducts. Elective Endoscopic Retrograde Cholangiopancreatography (ERCP) a few days later showed dilated CBD and strictures of biliary duct at the bifurcation and pancreatic duct at the neck. The stricture appeared to be from extrinsic compression. We were concerned about infected cyst, and repeated cyst drainage. Previsouly drained cyst yielded 200 cc for purulent fluid; the adjacent cyst was also drained and it yielded >1 L of clear fluid. At this time, patient had leukocytosis of 13.7 K, total bilirubin 6.2 mg/dL, ALP 433 IU/L. Patient was admitted post-procedure and was placed on broad-spectrum antibiotics. Culture grew Actinomyces species, and patient was discharged to home on long term oral antibiotics. ERCP was repeated two weeks later, and it showed fusiform dilation of intrahepatic duct, though stricture of the biliary tract and pancreatic duct were now resolved. There was no communication between the biliary tract and the hepatic cysts. CT of the abdomen showed persistent fluid collections, the patient ultimately underwent laparoscopic resection of hepatic cyst with partial hepatectomy, cyst fenestration and cholecystectomy. Pathology confirmed that it was indeed a benign cyst.

DISCUSSION:
It appears that due to close abutment of two large cysts caused compression of the ductal system. This unusual presentation of benign liver cyst leading to stricture of bile and pancreatic duct by extrinsic compression is worth a report.
1292 Combined Postcholecystectomy Bile Leak and Benign Biliary Stricture—Should a Temporary Placement of Fully Covered Self-Expanding Metal Stent Be the First Choice?
Authors: Al-Chalabi Ahmed , Kobeissy Abdallah , Javaid Toseef , Nawras Ali 
Published: October 2019

INTRODUCTION:
Bile leaks are common complications seen after cholecystectomy. Endoscopic Retrograde Cholangiopancreatography (ERCP) with the establishment of an enhanced transpapillary flow – through biliary stent placement and/or sphincterotomy – is considered the standard of care and usually has high success rates. Failure of initial endoscopic therapy (complex bile leak) can be managed with the placement of a fully covered self-expanding metal stent (FCSEMS) or surgery. We present a patient in which large postcholecystectomy biloma developed despite the presence of biliary plastic stent in place.

CASE DESCRIPTION/METHODS:
48-year-old female with history of chronic pancreatitis and benign distal biliary stricture was admitted with worsening abdominal pain for the last 2 days. One month prior to this episode, the patient was admitted with the diagnosis of acute on chronic pancreatitis. She underwent ERCP with balloon dilatation and placement of plastic biliary (10 Fr × 10 cm) and pancreatic duct (5 Fr × 7 cm) stents. She had cholecystectomy prior to her discharge. Her abdominal pain on readmission was associated with nausea, vomiting, loss of appetite. She has chronic loose stools, which remained unchanged. She denied fevers, chills, or hematemesis. Her vital signs were within normal range. Abdominal exam revealed sluggish bowel sounds and right upper quadrant abdominal tenderness. She had elevated white cell count at 13,900/µL. The rest of the labs including kidney and liver function tests were unremarkable. CT scan of the abdomen showed moderate to large subcapsular and intraperitoneal fluid. There was mild dilatation of the common bile duct with the biliary and pancreatic duct stents in place. Findings were consistent with post-cholecystectomy biliary leak. A right upper quadrant pigtail drain was placed followed by ERCP. Cystic duct stump bile leak was diagnosed and treated with placement of FCSEMS. The patient tolerated the procedure well with improvement of symptoms. Bile leak resolved and FCSEMS was removed after three months.

DISCUSSION:
Patients with postcholecystectomy bile leak superimposed on a benign biliary stricture are probably appropriate candidates for endoscopic therapy with FCSEMS. Despite their higher costs, initial temporary placement of FCSEMS may obviate additional ERCP sessions in cases of failure of plastic stents. FCSEMS improve drainage since they have larger lumens. They should be considered especially in the presence of biliary prestenotic duct dilatation and high-grade leaks.
1293 Non-Steroidal Anti-Inflammatory Drug-Induced Acute Pancreatitis: A Case Report
Authors: Reyes Jonathan M. , Gonzalez Manuel O. , Patel Bhavin , Malik Fahad , Weissman Simcha 
Published: October 2019

INTRODUCTION:
Ibuprofen-induced acute pancreatitis, a diagnosis secondary to the use of non-steroidal anti-inflammatory drugs (NSAID) is an extremely rare occurrence. Common culprits such as obstruction, alcohol consumption, infection, direct trauma, and medication (sans NSAID) adverse effect can be attributable to the majority of cases reported. The following case report describes a patient with acute pancreatitis secondary to a 3-week use of Ibuprofen for chronic shoulder pain. Alternative causes of acute pancreatitis were excluded through the patient's clinical history, laboratory findings, and diagnostic imaging. Although a rare risk factor, our aim is to further demonstrate that patients with chronic NSAID use can develop these complications and should be considered among the differential diagnoses.

CASE DESCRIPTION/METHODS:
Our patient was a 44 yo F with significant past medical history of hyperlipidemia, cholelithiasis status post cholecystectomy (2003), and acute pancreatitis (2010) secondary to choledocholithiasis who presented with a 2-week history of abdominal pain. The pain was described as an intermittent burning pain, rated 8/10 that radiated to the back. It was associated with nausea, vomiting and diarrhea but not associated with eating. She reported that she did not use any palliative measures for the pain, but indicated that she had been taking 800 mg Ibuprofen every 8 hours for the past 3 weeks for an acute flare of chronic right shoulder pain. She denied recent travel, sick contacts at home, or any change in eating habits. She also denied Ibuprofen use during the last episode of acute pancreatitis in 2010. She was a non-tobacco smoker, non-alcohol drinker, and did not use any illicit drugs.

DISCUSSION:
The incidence of drug-induced pancreatitis is low and generally includes HMG-CoA Reductase Inhibitors, ACE Inhibitors, Oral Contraceptives/Hormone Replacement Therapy, diuretics, HAART therapy, and Valproic acid as some of the more common offending agents. The mechanisms of these drugs are not well known but one case report of ibuprofen – induced pancreatitis suggests a possible mechanism related to a reduction in systemic glutathione, which therefore prevents an appropriate response against oxidative stresses. In this case of suspected diagnosis of Ibuprofen-induced acute pancreatitis, we did not perform a re-challenge test on the patient to confirm the suspected diagnosis; however, the patient demonstrated no other contributing factors that could be linked to the condition.
1297 Cheers to Budd: Pyogenic Liver Abscess Complicated by Acute Budd-Chiari Syndrome
Authors: Gupta Kamesh , Hans Bandhul , Rawat Saumya , Jobbins Kathryn 
Published: October 2019

INTRODUCTION:
Amebic liver abscess (ALA) is the most common extraintestinal manifestation of amebiasis with high mortality rates (20%). Complications include rupture; superinfection; anemia; and rarely vascular thrombosis. Budd-Chiari syndrome is characterized by post-sinusoidal portal hypertension caused by obstruction of either major hepatic veins or the inferior vena cava.

CASE DESCRIPTION/METHODS:
A 54-year-old alcoholic male, with a history of recent travel to India, presented with 2 weeks of fever, vomiting and abdominal pain. On exam, he was febrile, icteric, with generalized abdominal tenderness. Chemistries revealed WBCs 12000/mm3, total/direct bilirubin 6.5/3 mg/dL, AST/ALT 410/318 U/L, and ALP 310 U/L. USG RUQ showed hepatomegaly with multiple, thick-walled areas of central low attenuation, suspicious for LA. CT confirmed the presence of multiple ALAs along with rupture and delayed filling in the left and middle hepatic veins. Under USG guidance, brownish fluid (anchovy sauce-like) was aspirated and a pigtail catheter was placed. He was started on ceftriaxone and metronidazole for the treatment of pyogenic LA. Fluid serology was positive for Entamoeba histolytica and only metronidazole was continued for 21 days, along with rivaroxaban for six months for the treatment of Budd Chiari syndrome. His liver enzymes normalized in 21 days and a follow-up USG after 48 days of treatment with rivaroxaban showed no evidence of thrombosis in hepatic veins and IVC.

DISCUSSION:
ALA should be suspected in patients with fever & jaundice with a history of recent travel to an endemic area. The rates of complications are high, commonest being an abscess rupture. Thrombosis of IVC, hepatic and sometimes right atrium, are rare complications, caused by either direct spread of inflammation or external mechanical compression by the abscess. A diagnosis of Budd-Chiari syndrome should be considered in cases of prolonged fever unresponsive to treatment or ascites with leg edema and collateral abdominal venous circulation. Underlying prothrombotic affection must be excluded. To conclude, identifying a treatable cause of Budd-Chiari syndrome, such as liver abscess, can result in early, effective, and life-saving treatment.
1301 Bleeding Pancreaticoduodenal Fistula: An Unusual Case of Melena
Authors: Ahmed Zarir , Al-Taee Ahmad M. , Boumitri Christine 
Published: October 2019

INTRODUCTION:
Pancreatic fistulas have been described in the setting of pancreatic resection, trauma, and less commonly in acute or chronic pancreatitis (CP). Spontaneous pancreatic fistulas resulting in gastrointestinal (GI) bleeding are rare.

CASE DESCRIPTION/METHODS:
An 80 year-old woman presented to the emergency room with shortness of breath and melena. She was afebrile, normotensive, and had a heart rate of 93. Labs showed hemoglobin (Hgb) of 5.2 g/dL. EGD showed a 2 mm clean-based duodenal ulcer. As this did not account for melena, she had a colonoscopy and video capsule endoscopy which did not show a clear source of bleeding. As she continued to have melena with drop in Hgb, she had an abdominal CT scan showing a retroperitoneal fluid collection medial to the 2nd and 3rd portions of the duodenum, hyperattenuating material in the 2nd portion of the duodenum concerning for bleeding, and signs of CP with a pancreatic duct (PD) diameter of 14 mm. A second look EGD showed a duodenal mucosal defect suspicious for a fistulous opening into the PD with evidence of active bleeding (Figures 1 and 2). Repeat CT scan revealed extraluminal contrast extravasation into the retroperitoneum medial to the 2nd part of the duodenum and close in proximity to the superior mesenteric vein (SMV) (Figure 3). Abdominal MRI showed signs of CP and multiple small pseudocysts in the body and tail. Patient's melena resolved and Hgb stabilized prior to discharge.

DISCUSSION:
Bleeding is a rare complication of CP and occurs in 10-15% of CP patients. Pancreatic structures can be destroyed by enzyme digestion and necrosis. This may create pseudoaneurysms which may create cavities, fistulas, or rupture if they involve arterial or venous structures. The splenic and gastroduodenal artery are most commonly involved. Clinical presentation varies depending on location and severity of bleeding. Diagnosis involves abdominal CT and EGD, however laparotomy may sometimes be needed. Management involves embolization or surgery. Our patient's pancreaticoduodenal fistula was the result of previously undiagnosed CP. Bleeding may have resulted from spontaneous hemorrhage into the cystic cavity or as a result of erosion into the SMV given proximity on imaging. This case highlights the need to maintain a high clinical suspicion for pancreaticoduodenal fistulas in patients with a history of pancreatic disease presenting with GI bleeding.
1302 Bouveret's Syndrome: An Overlooked Cause of Duodenal Obstruction
Authors: Kothari Shana , Kobeszko Matthew , Kalinowski Michael , Almouradi Tarek 
Published: October 2019

INTRODUCTION:
Bouveret's syndrome is a rare clinical entity of gastric outlet obstruction from an impacted gallstone in the pyloric channel or duodenum. The stone travels from the biliary tree via a fistulous tract, formed in the setting of cholecystitis or pericholecystic inflammation. Diagnosis is typically made by computed tomography or magnetic resonance imaging, and treatment is focused on disimpaction via endoscopic, laparoscopic, or open intervention. We report a case of Bouveret's syndrome causing duodenal obstruction that was endoscopically managed with fusion lithotripsy basket extraction.

CASE DESCRIPTION/METHODS:
Patient is an 85 year-old male with a history of hypertension and coronary artery bypass grafting that presented with severe upper abdominal pain, vomiting, and melenic stools for three days. Vital signs were within normal limits. Laboratory data was significant for mild leukocytosis (11.7 thousand/mcl) and anemia (11.7 gm/dL; baseline 13 gm/dL). Abdominal ultrasound and computed tomography without contrast of the abdomen/pelvis revealed large gallstones, suspicious biliary air with intrahepatic ductal extension, superimposed gallbladder wall thickening suggestive of possible cholecystitis, and inflammatory changes extending to the distal stomach. Antibiotic therapy with piperacillin-tazobactam was initiated. Patient underwent esophagogastroduodenoscopy for evaluation of melena, which showed ulcerative esophagitis, erosive gastritis, and a large gallstone in the duodenal sweep with surrounding ulceration causing duodenal obstruction. Endoscopic lithotripsy with stone crushing basket was performed to fragment the large gallstone in smaller retractable pieces. For further evaluation, endoscopic retrograde cholangiopancreatography was performed and notable for a cholecystoduodenal fistula. Given his clinical state, the patient was not a surgical candidate during the hospitalization, but was recommended to follow up with general surgery outpatient.

DISCUSSION:
Bouveret's syndrome is commonly missed in clinical practice when it is not considered in the setting of intestinal obstruction, especially in males with no history of gallstone disease as seen in our patient. There are no formal management guidelines of this condition. However, endoscopic extraction with or without lithotripsy is preferable, particularly in cases when the patient is a poor candidate for surgical enterolithotomy. It is imperative to facilitate early diagnosis to improve prognosis and prevent adverse outcomes.