bluuebunny/crossref_metadata_2025_split huggingface dataset:
1249 National and Regional U.S. Antibiotic Resistance to Helicobacter pylori Identified From a Phase 3 Clinical Trial of Treatment Naïve Patients in the United States
Authors: Hulten Kristina G. , Graham David Y. , Bibliowicz Aida , Kalfus Ira N. 
Published: October 2019

INTRODUCTION:
Antibiotic resistance to Helicobacter varies by region. A 2001 report of H. pylori clinical trials noted 10.6% clarithromycin and 21.6% metronidazole resistance nationally. Regional clarithromycin resistance varied from 8.3% in the West to 13.0% in the Northeast and metronidazole resistance ranged from 22.1% in the Northeast to 27.5% in the Southeast. A 2015 Houston VAMC study noted resistance of 16.4% to clarithromycin and 20.3% to metronidazole. A recent clinical study found additional concerns for increasing resistance at both national and regional levels for H. pylori infection.

METHODS:
Isolates collected in a multi-center clinical trial (2017-2018) from de-identified patients were tested for minimal inhibitory concentrations (MICs) by agar dilution using Clinical and Laboratory Standards Institute (CLSI) methods. CLSI and EUCAST (The European Committee on Antimicrobial Susceptibility Testing) interpretive breakpoints were applied. MICs were obtained for amoxicillin, clarithromycin, metronidazole and rifabutin. Analysis provided resistance patterns for both national and regional levels.

RESULTS:
MICs were reported for 345 of 356 clinical isolates recovered from treatment-naïve patients at 55 centers (20 states) across the US. The regions were broken down as Northeast, Southeast, South, Central, and West. The MIC90 was 0.125 µg/mL for amoxicillin, 8 µg/mL for clarithromycin, 64 µg/mL for metronidazole, and ≤0.008 µg/mL for rifabutin. Across all US sites, resistance rates were: amoxicillin 6.7%; clarithromycin 17.4%; metronidazole 43.7% and rifabutin 0.0%. Regional assessment of amoxicillin, clarithromycin and metronidazole resistance was: Northeast 0.0% (n = 0), 31.6% (n = 6) and 36.8% (n = 7); Southeast: 6.1% (n = 8), 22.0% (n = 29) and 51.5% (n = 68); South 6.5% (n = 5), 11.7% (n = 9) and 45.5% (n = 35); Central 0.0% (n = 0), 44.4% (n = 4) and 22.2% (n = 2); and West 8.3% (n = 9), 11.1% (n = 12) and 35.5% (n = 38), respectively.

CONCLUSION/DISCUSSION:
Nationally, we found greater resistance rates for clarithromycin (17.4%) and metronidazole (43.7%) compared to previous reports from 2001 and 2015. Regionally, clarithromycin resistance was greater for the Northeast, Southeast and Central areas while metronidazole resistance was greater than previously reported across all regions. Amoxicillin resistance was low (6.7%: 0%-8.3%), and no resistance to rifabutin was reported. These emerging resistance patterns support the use of rifabutin based therapies for H. pylori eradication.
1254 Sarcomatoid Carcinoma of the Head of the Pancreas: A Rare Case
Authors: Tempera Patrick , Tempera Patrick 
Published: October 2019

INTRODUCTION:
To the best of our knowledge, a total of 23 cases of sarcomatoid or carcinosarcoma of the pancreas have been reported.
1
Sarcomatoid carcinoma of the pancreas (SCP) is a rare and aggressive malignant neoplasm with evidence of epithelial and mesenchymal features. Confirmation of this disease currently relies on detailed pathologic examinations. SCP is comparatively more aggressive with a poorer prognosis than that of conventional pancreatic carcinomas. Therefore, SCP can be a challenge both diagnostically and therapeutically for clinicians and surgeons alike. The presenting case illustrates and highlights potential indications that can be used to diagnose and treat SCP much earlier than conventional medicine currently allows.

CASE DESCRIPTION/METHODS:
We present a case of SCP in an 84-year-old male patient. He had experienced jaundice and epigastric abdominal pain for 4 weeks. An ultrasound revealed a hypoechoic mass at the pancreatic head which prompted referral to our gastroenterology group. Physical examination revealed scleral icterus, cutaneous jaundice, and left hip and lower back pain. Laboratory tests yielded the following results: total bilirubin of 13.4 U/L, AST/ALT of 171 U/L and 240 U/L respectively, and an alkaline phosphatase of 714 U/L. Imaging examinations were performed including MRCP, EUS, and CT noting a mass in the pancreatic head. Due to the aggressiveness of this patient's tumor and despite medical efforts, the patient succumbed to his illness shortly after the official diagnosis was discovered and before any therapeutic measures could have been initiated.

DISCUSSION:
Our final diagnosis of SCP was made via pathologic examination as high-grade malignant sarcomatoid neoplasm with spindled areas, ample mitosis, and necrosis. IHC analysis showed positive expression for cytokeratin, vimentin, CD56, and a Ki-67 with a proliferative rate of greater than 90%. Other immunomarkers for melanoma, smooth muscle, and lymphoma were negative. These findings are indicative of sarcomatoid morphology and phenotype. Although definitions of SCP vary, it is believed that SCP features spindle cells and possesses mesenchymal-like and epithelial-like appearances.
1
Due to the histological report of spindle cell patterns and the co-presence of mesenchymal-like and epithelial-like cells illustrated using immunostaining techniques, our case is most consistent with SCP.
1261 Chylous Ascites in the Setting of a Pancreatic Pseudocsyt: A Rare Cause of an Even Rarer Condition
Authors: Mukherjee Samiran , Harne Prateek , Sharma Anuj , Masood Umair , Badrinath Madhuri , Manocha Divey 
Published: October 2019

INTRODUCTION:
Chylous ascites is a rare entity. It is formed when triglyceride-rich fluid enters the peritoneal cavity. Although the most common cause of the same is trauma to the lymphatic ducts, rarer causes still exist for the same.

CASE DESCRIPTION/METHODS:
Our case is a 63-year-old lady who was admitted with a provisional diagnosis of severe pancreatitis with multiorgan failure. On admission, her lab results were significant for a WBC count of 23.7 and a lipase level of over 30,000. While in the hospital she had also developed acute kidney injury, requiring hemodialysis and a pulmonary embolism. On being managed for th aforementioned, she also subsequently developed an infected pancreatic pseudocyst with culture results being positive for Enterococcus spp. and Staphylococcus epidermidis. A few weeks later, the patient underwent repeat abdominal imaging to assess for the interval change in the pancreatic pseudocyst. CT of the Abdomen revealed the presence of ascites. It was initially thought to be a gynecological malignancy, but Ascitic fluid analysis revealed elevated triglyceride levels and was unremarkable for the presence of any malignant cytological cells. A diagnosis of chylous ascites was made, which had resolved on drainage of the pseudocyst. The CT of the abdomen also revealed the presence of necrotizing pancreatitis, which appeared to have resolved after the draiange of the pseudocyst.

DISCUSSION:
In summary, although the most common causes of chylous ascites are either malignancy or iatrogenic trauma, our case presents itself to be somewhat of an enigma. Our working hypothesis is that the pseudocyst may have potentially expanded to cause traumatic injury to the lymphatic channels. Although exceptionally rare, there have been a total of 13 cases of chylous ascites associated with pancreatitis, of which 7 of them happen to be chronic. This is the first case of an association with a pancreatic pseudocyst. Further, even though chylous ascites due to necrotizing pancreatitis has been reported, the fact that her symptoms resolved on drainage of the pseudocyst favours the latter as the etiological agent for the ascites.
1265 Endoscopic Ultrasound an Excellent Tool for Diagnosis of Early Stages of Cholangiocarcinoma
Authors: Arroyo-Mercado Fray Martin M. , Noel Jude , Likhtshteyn Michelle , Vignesh Shivakumar 
Published: October 2019

INTRODUCTION:
Cholangiocarcinoma (CC) is a biliary tract malignancy with a poor prognosis and 3-year survival rate of 95%.1 Due to late onset of symptoms, patients often present with metastatic disease. Data suggest that endoscopic ultrasound (EUS) is an excellent tool to diagnose cholangiocarcinoma with a sensitivity varying from 60 to 89%.2–5

CASE DESCRIPTION/METHODS:
Case 1 An 80-year-old man with a 3-week history of weight loss, jaundice, and generalized pruritus underwent both ultrasound and abdominopelvic CT scan which demonstrated dilatation of the intra and extrahepatic ducts and no masses. MR with MRCP revealed a common bile duct (CBD) measuring 18 mm and a biliary stricture at the head of the pancreas; masses were not noted in the pancreas or bile duct. He subsequently underwent EUS-guided fine needle aspiration (FNA) that revealed a 9 × 6 mm hypoechoic distal CBD lesion and normal pancreatic head; FNA cytology revealed adenocarcinoma consistent with biliary origin. Based on the EUS impression and cytology, the patient was diagnosed with T1N0M0 extrahepatic cholangiocarcinoma. Case 2 A 69-year-old male with history of weight loss, jaundice, and acholic stools was found to have several pancreatic cysts clustered together, 18 mm in conglomerate with a dilated CBD to 11 mm and no masses on MR of the abdomen. A subsequent EUS showed a normal pancreas, a 1 × 1.2 cm distal CBD lesion without evidence of invasion into the pancreatic head and a 1.2 cm peripancreatic lymph node with equivocal EUS features for malignancy. FNA cytology of lymph nodes was negative for malignancy. ERCP showed a distal CBD stricture of 2 cm suspicious for malignancy; brushings showed adenocarcinoma. EUS findings were consistent with T1N0M0 extrahepatic cholangiocarcinoma.

DISCUSSION:
EUS-FNA is an established, minimally invasive diagnostic modality for pancreatico-biliary tumors with high sensitivity to diagnose tumors less than 3 cm.6 EUS has demonstrated benefit in the diagnosis and staging of extrahepatic cholangiocarcinoma, as compared to other modalities such as MRI.7 While ERCP is primarily a therapeutic modality, it can also be used for diagnosis of CC via ERCP guided forceps biopsy, brush cytology or cholangioscopic biopsy.7 Our cases highlights the utility of EUS in diagnosing early stage cholangiocarcinoma, while other imaging modalities are indeterminate. The second case also illustrates how ERCP guided brush cytology complements EUS imaging in the diagnosis of T1 extrahepatic cholangiocarcinoma.
1269 Massive Life-Threatening Hemobilia Managed Successfully at ERCP: The Importance of Teamwork and Appropriate Interventions in a Catastrophic Situation!
Authors: Enslin Sarah , Tariq Raseen , Pisharoty Anil , Kothari Truptesh , Ullah Asad , Kothari Shivangi , Kaul Vivek 
Published: October 2019

INTRODUCTION:
Clinically significant bleeding at ERCP is encountered in 0.1% to 2% cases. Hemobilia is relatively uncommon and usually mild. Here we present a case of successful management of massive life-threatening hemobilia during ERCP.

CASE DESCRIPTION/METHODS:
A 79-year male with T2N0 pancreatic tail adenocarcinoma s/p distal pancreatectomy in 2007, cirrhosis and portal hypertension developed obstructive jaundice due to recurrent pancreatic head malignancy 11 years later. ERCP with placement of an uncovered 10 mm × 40 mm SEMS was performed. Recurrent cholangitis 4 months later required repeat ERCP, revealing extension of stricture to the CHD. A 10 F × 12 cm plastic biliary stent was placed through the metal stent into the right hepatic duct. At repeat ERCP six weeks later, the plastic biliary stent was removed easily with snare. Approximately one minute later, massive hemobilia ensued with complete occlusion of endoscopic visual field. Due to volume and rapidity of bleeding, it was suspected that bleeding was from tumor erosion of intraductal varices. Approximately 1.2 liters of blood was lost in less than 5 minutes resulting in hemodynamic instability. During this time, the following decisions and events were put into motion: 1. Anesthesia attending took charge of patient's hemodynamics, central venous access, pressor support and PRBC transfusion, 2. Charge nurse alerted ICU team, sent additional nursing and tech resources to room, 3. The endoscopist focused on clearing the duodenal luminal field with aim to re-establish biliary access, however this was very difficult due to amount of blood/clot in the visual field, 4. Two additional endoscopists helped re-position patient to left lateral position, enabling visualization & biliary access, 5. Per consensus, placement of a fully covered SEMS was the only endoscopic option that could achieve hemostasis, 6. A10 mm × 60 mm fully covered SEMS was placed into the CBD/CHD with tamponade of hemobilia and restoration of biliary drainage, 7. Patient was transferred to PACU, extubated, recovered uneventfully and discharged home × 48 hrs.

DISCUSSION:
Massive, life threatening hemobilia can occur from friable tumors/intraductal varices even with minimal manipulation. Teamwork and correct medical decision making are critical to a successful outcome during such catastrophic endoscopic events. Placement of a fully covered metal biliary stent served a dual purpose of tamponading hemobilia and relieving biliary obstruction in this case.
1276 Acute Pancreatitis Causing Multiple Aortic Thrombi and Multi-Organ Infarcts
Authors: Faris Mohamed M. , Balanchivadze Nina , Sherertz Robert , Edmison John 
Published: October 2019

INTRODUCTION:
There have not been many case reports of acute pancreatitis causing aortic thrombi. In this vignette we illustrate this rare but noteworthy clinical scenario.

CASE DESCRIPTION/METHODS:
A 44-year-old homeless man with a history of chronic pancreatitis and alcoholism presented with acute, sharp, diffuse abdominal pain. Vital signs were notable for hypotension and tachycardia. Abdominal examination revealed a diffusely tender abdomen with guarding and rigidity. Neurological examination revealed bilateral upper extremity weakness. White blood cell count, lipase, ESR, CRP, and D-dimer were all markedly elevated A CT abdomen revealed acute pancreatitis with diffuse acute multiple thrombi in the aorta with hepatic, splenic, bowel, and bilateral renal infarcts. There was diffuse ascites of the abdomen and pelvis with bilateral pleural effusions. Cervical MRI revealed C4-C6 cord infarct with diffusely abnormal signal. Brain MRI revealed two acute ischemic infarcts in the right occipital lobe. CTA chest revealed multiple large exophytic thrombi in the descending aorta with no evidence of pulmonary embolism. Duplex ultrasound of all extremities and echocardiogram with contrast were non-revealingHypercoagulability studies revealed mildly decreased factor II, antithrombin III, and protein C levels. Anticoagulation was started with IV heparin and later switched to a direct oral anticoagulant. Paracentesis revealed pancreatic ascites. The patient's abdominal pain resolved and he was transferred to a higher tertiary care center where he was found to have a pancreatic duct leak requiring stenting.

DISCUSSION:
There are only a few reports in the literature of acute pancreatitis causing aortic thrombosis. The pathophysiology remains unclear. However, there are a few hypotheses. First, proteolytic enzymes released in the setting of acute pancreatitis cause direct injury to the aortic wall, resulting in a nidus for mural thrombus formation. Second, trypsin released during acute pancreatitis causes the activation of several thrombogenic factors such as platelets and fibrinogens. Lastly, hypovolemia caused by acute pancreatitis increases the risk of vascular stasis and vasospasm. In conclusion, this is a rare case of acute pancreatitis complicated by multiple aortic thrombi and multi-organ infarcts in the setting of a mild coagulation disorder. The patient responded well to supportive measures for acute pancreatitis and direct oral anticoagulants thereafter.
1277 Female Predominance in Metronidazole-Induced Acute Pancreatitis: A Case Report and Review of Literature
Authors: Chang Eileen , Vaishnani Marvin , Chang Ian , Jennings Whitney 
Published: October 2019

INTRODUCTION:
Acute pancreatitis is a relatively common condition in the hospital. About 75% of cases are associated with excessive alcohol use or gallstones, and only 0.1 to 2% are drug-induced. The clinical and pathologic findings are similar regardless of the inciting cause. We have suspicion that metronidazole-induced pancreatitis occurs at a significantly higher incidence, or maybe exclusively, in females.

CASE DESCRIPTION/METHODS:
A 68-year-old Caucasian female with history of hyperlipidemia, cardiomyopathy and hypothyroidism presents to the ED with chief complaint of epigastric pain. Symptoms started few days prior with back pain that progressed to epigastric tenderness and fullness. Associated symptoms include nausea and vomiting. She denies fever, chest pain, hematemesis, hematochezia, melena or recent injury. She denies alcohol or tobacco use. About 2 weeks ago, patient underwent upper endoscopy for ongoing epigastric pain and family history of sister who passed away in her 50s from gastric cancer. EGD showed numerous pedunculated and sessile hyperplastic appearing gastric polyps in the fundus and body; biopsy was obtained. Pathology report revealed no dysplasia or malignancy. She completed a short course of metronidazole for abdominal bloating and diarrhea 4 days prior to hospital presentation. On admission, lipase was 10,347 with normal triglyceride and calcium levels. CT imaging demonstrated stranding around the pancreatic head and uncinate process. She was placed on bowel rest, IV hydration and supportive care. MRCP was performed to assess the pancreatic duct; it revealed acute pancreatitis, but no cholelithiaisis, choledocholithiasis or other complicating features. Repeat lipase was 2,533. Patient recovered well and was discharged home.

DISCUSSION:
Metronidazole-induced acute pancreatitis has been reported in prior English literature; in which all 8 cases involved female patients (O'Halloran E, et al. HPB Surgery, pp. 1–4, 2010). Proposed mechanisms include free radical production and immune-mediated inflammatory response. In a population-based case control study, there was a significantly increased risk of acute pancreatitis within 30 days exposure to metronidazole, especially when used in combination with other agents for H. pylori eradication (Barbulescu A, et al. Clinical Epidemiology, pp. 1573–1581, 2018). Physicians should maintain a high index of suspicion when prescribing metronidazole and avoid rechallenge. Further investigation may help reduce morbidity related with this phenomenon.
1281 Duodenobiliary Fistula: A Rare Complication of Peptic Ulcer Disease
Authors: Larson Brian , Bank Jeffrey S. , Walker Michael J. 
Published: October 2019

INTRODUCTION:
Spontaneous biliary enteric fistulas are usually late complications of cholelithiasis or choledocholitiasis. The incidence of biliary enteric fistulas in this population ranges from 0.3 – 0.9%. Biliary enteric fistula formation is usually occurs from a gallstone ulcer perforating into the normal duodenum. However in rare circumstances (3.5-10% of cases) fistula's can form from a duodenal ulcer penetrating into the biliary tree, as is the case with biliary enteric fistula's due to peptic ulcer disease (PUD). These fistula's often present with abdominal pain, malaise and/or hematemesis. We discuss a rare case of a duodenobiliary fistula as a result of long standing peptic ulcer disease.

CASE DESCRIPTION/METHODS:
A 57-year-old male with long standing abdominal pain who recently immigrated to the United States from the Democratic Republic of Congo presented to the ED with acute on chronic epigastric abdominal pain. He denied previous surgery. Notably, he had tested positive for h. pylori a few months prior and was questionably compliant with prescribed antibiotics. He was admitted with hypokalemia and renal failure. Persistent symptoms prompted a computed tomography (CT) of his abdomen and pelvis. Findings from the CT demonstrated air and oral contrast material within the common bile duct and intrahepatic bile ducts with a fistulous connection to the second portion of the duodenum. Endoscopic evaluation demonstrated esophagitis, gastritis and severe pyloric stenosis likely due to long-standing PUD. The standard endoscope was unable to traverse this stenosis, but was successfully traversed with an ultrathin scope. The ampulla was briefly visualized and was grossly normal. There was no definitive fistulous tract identified. The patient was placed upon high dose proton pump inhibitor therapy. A repeat CT of the abdomen and pelvis was done 6 weeks later and was unchanged. The patient was referred to surgical oncology for definitive management.

DISCUSSION:
Historically, biliary enteric fistulas were often diagnosed during surgical interventions. Currently, CT can often diagnose these fistulas by detecting minimal pneumobilia. Endoscopic evaluation may or may not demonstrate a biliary enteric fistula due to duodenal narrowing or edema. Antiulcer therapy usually allows clinical improvement and fistula closure for PUD associated fistulas. Surgery is reserved for cases refractory to medical care, poorly controlled symptoms, hemorrhage or biliary obstruction.
1282 Abrupt Onset of Acute Pancreatitis Following the Ingestion of Eluxadoline
Authors: Gonzaga Ernesto Robalino , Borgan Saif , Sourial Kirolus , Vanar Vishwas 
Published: October 2019

INTRODUCTION:
Acute pancreatitis is a common condition in the US, with high mortality and burden on the health care system. In the US, it is one of the main causes of gastrointestinal related admissions with more than 291,000 hospitalization per year. The most common causes are alcohol use (30%) and gallstones (40%). Less frequently, drug induced. Interestingly, drug induced pancreatitis has excellent prognosis and low mortality. The mechanisms of drug induced pancreatitis include immunologic reactions, direct toxic effect, accumulation of toxic metabolites, ischemia, and intravascular thrombosis.

CASE DESCRIPTION/METHODS:
A 78-year-old woman with surgical history of cholecystectomy presented to the emergency room with a sudden onset of sharp epigastric pain radiating to the back, that was associated with vomiting, 60 minutes after taking Eluxadoline for the first time. She had a history of hypertension, diabetes mellitus, and irritable bowel syndrome with diarrhea (IBS-D) for which Eluxadoline was prescribed. On exam, she was hemodynamically stable and had epigastric tenderness without rebound. Laboratory tests remarkable for elevated lipase, 2754 U/L. Based on the Revised Atlanta criteria, patient had mild pancreatitis. A computed tomography of the abdomen and pelvis was unremarkable without biliary pathology. She was admitted for acute pancreatitis presumed secondary to Eluxadoline ingestion. The patient was treated conservatively and Eluxadoline was discontinued. Five hours later, her lipase was 68 U/L and symptoms resolved. She was advised to discontinue Eluxadoline and discharged home.

DISCUSSION:
The diagnosis of drug induced pancreatitis requires first the diagnosis of acute pancreatitis based on symptoms, biomarkers or imaging. Common causes, such as alcohol use and gallstones, must be ruled out. A medication review should be conducted to look for potential culprits. Any medication of suspect should be discontinued and resolution of pancreatitis should be appreciated. Eluxadoline is used in treatment of IBS-D. It reduces abdominal pain and lessens diarrhea frequency, but has been noted to be associated with acute pancreatitis in 82% of patients who has previously underwent cholecystectomy. It is thought to be due to spasms in the sphincter of oddi, leading to pancreatic duct hypertension. The FDA has suggested to avoid the use of this medication in these cases. Careful attention should be made to the potential adverse events, especially acute pancreatitis, in those patients on Eluxadoline.