bluuebunny/crossref_metadata_2025_split huggingface dataset:
1366 Primary Antiphospholipid Syndrome, Acute Necrotizing Pancreatitis, and IgA Nephropathy in a Young Male: Single Pathogenesis or Rare Association?
Authors: Chandra Prasad Ram , Patro Pradeepta , Sahoo Srikanta Kumar , Narayan Jimmy , Singh Ayaskanta 
Published: October 2019

INTRODUCTION:
Primary Antiphospholipid syndrome (APS) is characterized by recurrent thrombosis, fetal loss and the presence of lupus anticoagulant (LA)/anticardiolipin antibodies. Primary APS is uncommon in males and poses diagnostic difficulties. Primary APS is considered as a rare cause of acute pancreatitis and IgA nephropathy (IgAN). We describe a patient of primary APS (probably the first reported case), who sequentially presented with cerebral venous thrombosis, later with recurrent episodes of acute necrotizing pancreatitis (ANP) followed by IgAN. Despite the initial diagnostic dilemmas, the patient was managed successfully.

CASE DESCRIPTION/METHODS:
A 30 year old male initially presented with sudden onset headache and generalized seizures. CECT brain revealed cerebral venous thrombosis. Cardiac and Pro thrombotic work up (including ANA and LA) was normal. He was treated with antiepileptics and warfarin. 3 months later, he presented with 3 episodes of acute pancreatitis. Each time the patient was managed conservatively with fluids and analgesics. However the last episode was very severe, CECT abdomen was suggestive of severe ANP with extensive splenic vein thrombosis (SVT). Anti-β2glycoprotein1 antibody test was strongly positive. APS was diagnosed according to revised Sapporo criteria. Low molecular heparin and steroids were started. After 5 months, although the patient recovered from ANP, he presented with hypoproteinemia and renal failure. Urine analysis showed RBC casts and proteinuria. Kidney biopsy showed mesangial IgAN with secondary segmental sclerosis. Patient recovered fully and is on follow up for two years. He is doing fine with low dose steroids, ACE inhibitors and warfarin with regular INR (target 2-3).

DISCUSSION:
This patient had multiple hospitalizations, all attributable to the rare manifestations of APS. It is perhaps the first case report where APS, ANP and IgAN are described in a single patient. Clinical suspicion can lead to early diagnosis, which makes it easy to manage such patients. Acute pancreatitis is considered as one of the rarest manifestation of APS, which is distinct from autoimmune pancreatitis. Renal biopsy was suggestive of IgAN, which is unusual and distinct from the APS nephropathy. Thrombosis of the pancreatic and renal microcirculation and vasculitis has been postulated as the underlying pathogenesis. To conclude, APS is a rare, yet treatable cause of acute pancreatitis. Urine examination is a must in cases of primary APS, with or without pancreas involvement.
1373 A Rare Case of Biliary Obstruction in Autosomal Dominant Polycystic Kidney Disease
Authors: Serrao Steve , Rodrigues Medora , Strilaeff Ryan , Che Kendrick 
Published: October 2019

INTRODUCTION:
Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most common genetic disease in adults. We present a rare case of biliary obstruction due to polycystic disease affecting the kidney and liver.

CASE DESCRIPTION/METHODS:
A 18 year old female patient with polycystic disease of the liver and kidney diagnosed in childhood, presented with new onset jaundice and abdominal pain radiating to the back. Initial labs suggested a predominantly cholestatic patter of liver injury with total bilirubin 3.1 mg/dl with a direct bilirubin of 2.3 mg/dl, aspartate aminotransferase 96 U/L, alanine aminotransferase 177 U/L, and alkaline phosphatase 237 international U/L. Lipase was noted to be 443 U/L. The patient did not exhibit signs of cholangitis and was started on intravenous fluids at 2 ml/kg/hr after a bolus of 2 L. The platelets were noted to be 123 with an INR of 1.3. A Magnetic Resonance Cholangiopancreatography showed near-complete replacement of hepatic, bilateral renal and pancreatic parenchyma with greater than 100 simple cysts. Also noted was dilatation of the common bile duct measuring up to 16 mm (Figure1). No internal filling defect was noted. An ERCP was performed. During endoscopy, multiple luminal “bulges” representing extrinsic compression of cysts were noted in the stomach and duodenal. A native ampulla was identified in the second portion and was displaced laterally by extrinsic luminal compression (Figure 2). Cholangiogram revealed dilated CBD and CHD with cystic dilations of the intrahepatic ducts more pronounced in the left lobe of the liver. There appears to be contrast seen in several liver cysts indicating possible communication of biliary tree with the cysts (Figure 3). We entertained the possibility of a choledochal cyst (4a). External compression of the intraduodenal CBD was the etiology of the obstruction and a 10 Fr × 10 cm plastic biliary stent was placed resulting in large volume of bile evacuating from the biliary tree. The placement of the biliary stent resulted in the normalization of total bilirubin to 0.5 mg/dl with, AST 23 U/L, ALT 24 U/L, and ALP 109 international U/L. We recognized the risk of cholangitis due to the stasis of contrast and provided Ceftriaxone 1 g IV intra procedure and Cephalexin once daily for 7 days.

DISCUSSION:
This patient with large number of hepatic cysts replacing the hepatic parenchyma and large renal cysts resulted in distal biliary compression in the intraduodenal portion. This patient is being considered for a liver kidney transplantation.
1374 Pancreatic Cancer: Leading to Failure of Rivaroxaban as an Anticoagulant
Authors: Vekaria Pratikkumar , Raiyani Chandrika , Robitshek Daniel , Raiyani Tejas 
Published: October 2019

INTRODUCTION:
Vascular Thromboembolism (VTE) is seen with hypercoagulable state and it can be a reason of significant morbidity and mortality. Cancer is considered as one of the most common causes of hypercoagulability and developing VTE. Since novel oral anticoagulants (NOAC) have been introduced in market for VTE prophylaxis and treatment, their use have been increased significantly as they are easy to use without episodic monitoring. Rivaroxaban is one of the commonly used NOACs and some of studies have shown its good efficacy for VTE.

CASE DESCRIPTION/METHODS:
71 year old female with PMH of persistent A-fib on Rivaroxaban, pulmonary hypertension, HTN, DM-2 who presented to ED with severe pain in both feet. On physical examination, they seemed ischemic with splotchy cyanotic/pallor discoloration on multiple toes of both feet. Patient was already on 20 mg PO daily dose of Rivaroxaban for A-fib which is also prophylactic dose for VTE. Her fibrinogen and D-dimer were elevated at 185 and >5000 respectively. Vascular surgery was consulted and they put patient on heparin drip. CTA Aorta with run off was ordered to find out source of VTE. Unfortunately, CT report showed pancreatic head cancer with metastasis to liver, adrenals and lumber vertebrae which was definitively diagnosed as “Primary Pancreatic Adenocarcinoma” on biopsy. Oncology was consulted and they recommended higher dose of Rivaroxaban 15 mg PO BID on discharge. Still patient came back to ED with worsening of symptoms and pain in both feet due to VTE exacerbation. Patient was then switched to fondaparinux and it helped her from keep getting recurrent VTE exacerbation.

DISCUSSION:
Traditionally, warfarin and enoxaparin have been used as first-line agents for VTE treatment. Their efficacy have been proven with acceptable risks of bleeding. As enoxaparin needs to be injected and warfarin requires regular monitoring of INR, patients were not complaint with using them. Conversely, NOACs were invented to provide innocuous and more compliant alternative to warfarin and enoxaparin. Rivaroxaban has been most commonly used NOAC for this purpose and some of the studies bolsters its efficacy for VTE. Nonetheless, few case reports are out that don't support Rivaroxaban's effectiveness as a prophylactic agents for preventing VTE. We propose that it still requires more post-marketing research in assessing Rivaroxaban's real efficacy/effectiveness as prophylactic agent for VTE in Pancreatic as well as other cancers.
1379 Immune Checkpoint Inhibitor-Induced Acute Pancreatitis and Colitis
Authors: Pagan Andrea , Gill Jeffrey , Arroyo Yadis , Bertran-Rodriguez Carlos E. 
Published: October 2019

INTRODUCTION:
Immune checkpoint inhibitors are gaining increasing popularity as an efficacious treatment for advanced malignancies. As their use increases, their side effects are more notable in this specific population. These adverse events can be severe enough to require interruption or withdrawal of immune checkpoint blockade therapy. The most common side effects involve the skin rashes and gastrointestinal symptoms. In order to provide the correct diagnosis and management, physicians should be aware of the different presentations. We present a case of a checkpoint inhibitor induced acute pancreatitis and colitis.

CASE DESCRIPTION/METHODS:
A 76-year-old male with medical comorbidities pertinent for hypertension and COPD that was being treated with Pembrolizumab for Stage IV oligometastatic clear cell renal carcinoma presented to the ED with abdominal pain, nausea, and vomiting. On physical examination, he was tachycardic, normotensive, and afebrile. Laboratory work pertinent for elevated Cr. 1.5 and Lipase at 436. CT abdomen showed edematous pancreas with loss of pancreatic lobulation. Patient was diagnosed with autoimmune mediated acute pancreatitis and was treated with high-dose steroids. Infusions of Pembrolizumab were held until the steroid taper was over. Once infusions were restored, he began having non-bloody diarrhea. Physical examination and laboratory data were normal. His infectious and inflammatory workup for diarrhea was negative. He underwent a colonoscopy with normal appearing mucosa. Random biopsies were obtained. Histological examination on the sigmoid colon showed chronic active colitis with crypts abscess, diagnosing the patient with checkpoint inhibitor-induced colitis. He was restarted on high dose steroids improving his symptoms. Immunotherapy was placed on hold indefinitely.

DISCUSSION:
Gastrointestinal toxicities are among the leading causes of immune-related adverse effects of checkpoint blockade with diarrhea being the most common. Other presentations include hepatotoxicity resulting in transaminitis and acute pancreatitis with the lowest incidence. Most immune-related adverse events appear within 1–2 months after the start of the checkpoint inhibitor. Treatment consists of high dose steroid with a gradual taper. Patients with moderate to severe immune-related adverse events usually require interruption of the checkpoint inhibitor. Early recognition of these toxicities is crucial in minimizing the impact of these complications on planned antineoplastic therapy.
1380 Delayed Presentation of a Traumatic Complete Pancreatic Duct Disruption Successfully Treated With Endoscopic Cystogastrostomy and Long-Term Plastic Stenting
Authors: Awad Christina , Cho Ryan , Miller Charles 
Published: October 2019

INTRODUCTION:
Blunt trauma injuries to the pancreas are rare but carry a significant mortality and high complication rate. Motor vehicle collisions are the leading cause for blunt pancreatic trauma in adults. Patients with pancreatic trauma typically present with features of acute pancreatitis, which is often difficult to diagnose due to other intra-abdominal injuries. The Organ Injury Scale is the most widely accepted grading system for pancreatic trauma. The higher the grade of injury, the more likely surgical intervention is required. Pancreatic duct (PD) disruption has traditionally required surgery if PD stenting during ERCP was not feasible. We report a case of delayed complete PD disruption following blunt trauma that was successfully treated endoscopically.

CASE DESCRIPTION/METHODS:
A 58 year-old female with no prior history of pancreatitis presented with intermittent abdominal pain four months after a motor vehicle collision. CT showed a 6.7 × 8 cm pancreatic body cyst. ED evaluation at the time of the MVC had not included abdominal imaging and a CBC and CMP were normal. EUS revealed a 7.5 × 6.7 cm pancreatic body cyst without septation or mural nodule. FNA with a 19 Ga needle fully collapsed the cyst. A pancreatic pseudocyst was confirmed with an amylase of 7500 U/L and CEA of 0.4 ng/mL. Patient reported alleviation of her pain following cyst aspiration, however MRCP 4 days after FNA revealed complete re-accumulation of cyst fluid (Figure1). ERCP with pancreatogram confirmed complete PD disruption (Figure2). Following surgical consultation, the patient opted for EUS-guided intervention for long-term cyst stenting. EUS with cystogastrostomy was successfully performed with a 15 × 10 mm Axios lumen-apposing metal stent (LAMS) and 7 Fr × 7 cm double pigtail stent. At planned LAMS removal, the pigtail stent had migrated making repeat pigtail stenting challenging, but successful. Three month follow-up imaging showed the pigtail stent in the prior cyst cavity with plan to leave the stent indefinitely (Figure 3).

DISCUSSION:
This is a rare case of PD disruption presenting 4 months after blunt trauma and without preceding pancreatitis. While PD disruption has traditionally required surgical intervention, endoscopic cystogastrostomy with long-term plastic stenting is a novel option to avoid surgery. Given difficulty placing the plastic pigtail at the time of LAMS removal and to avoid a second procedure, it is worth considering placement of plastic pigtail stents rather than a LAMS during the initial procedure.
1382 A Case of Candidal Infection of Large Biloma After CT-Guided Liver Biopsy
Authors: Kolli Sindhura , Long Kathleen , Shahnazarian Vahe , Reddy Madhavi , Gurram Krishna C. 
Published: October 2019

INTRODUCTION:
Bilomas are collections of bile, either intra- or extrahepatic, with or without a capsule. They typically occur due to disruptions or injuries within the biliary. Complications include peritonitis and sepsis due to secondary infections. Clinical symptoms range from abdominal fullness, dull right upper quadrant pain to nausea, vomiting, and fever. Therapy includes drainage and if persistent, then possibly even surgery. This case describes an atypical presentation of a biloma infected with an uncommon pathogen.

CASE DESCRIPTION/METHODS:
A 64-year-old male with a medical history of alcohol abuse and CT-guided liver biopsy 7 days prior (confirming autoimmune hepatitis) presented to the ED with lethargy, dizziness, anorexia and intermittent diffuse abdominal pain. A CT on admission showed multiple lobulated cystic lesions in the right hepatic lobe communicating with the intrahepatic biliary ducts indicating bilomas. Zosyn was started empirically given his symptoms and leukocytosis. An ERCP was performed, demonstrating a large biloma in segment seven and eight. A 7 Fr × 12 cm stent was placed and the biloma was drained. Culture of the biloma fluid showed candida and numerous neutrophils, prompting the addition of fluconazole. An ERCP was repeated to replace the previous stent with a 10 Fr × 12 cm stent. The patient finished his course of antibiotics and antifungals and signed out against medical advice. He was lost to follow up at our hospital.

DISCUSSION:
Bilomas, while relatively rare, mainly occur due to disruptions of the biliary tree from laparoscopic cholecystectomies, Billroth II procedures, blunt abdominal trauma, radiofrequency ablation or in our case, a liver biopsy. Complications include peritonitis and sepsis as well as secondary infections with gram-negative bacteria. While our patient's biloma was infected, he had a candidal infection, making his case even more unusual. The gold standards for diagnosis are either hepatobiliary cholescintigraphy with Tc-99m-iminodiacetic acid chelate complex as a tracer or an ERCP which can simultaneously identify and treat bilomas. Treatment involves drainage, either endoscopically or percutaneously. The approach is dependent on the patient's clinical status and if he or she can tolerate an endoscopy. Post-procedure imaging is necessary to confirm drainage of the biloma. If it persists, then further drainage or surgical resection of the biloma are options once the patient is no longer septic.
1383 Making It Work With the Tools at Hand: Use of a Biliary Stent to Repair a Pancreatic Leak
Authors: Ludvik Nicholas , Kumar Manoj , Fahmawi Yazan , Mizrahi Meir 
Published: October 2019

INTRODUCTION:
Pancreatic duct leaks (PDL) are primarily managed by advanced endoscopist, interventional radiologists, and sometimes by pancreatic surgeons. The mainstay of endotherapy for PDL is trans-papillary pancreatic duct stent placement bridging the PDL. Fully covered biliary metal stents are widely accepted in biliary leaks due to its radial force but there is no conventional fully covered metal stent (FCMS) in US for pancreatic duct for refractory PDL. We describe a patient with refractory PDL where biliary SEMS was used to successfully treat PDL.

CASE DESCRIPTION/METHODS:
Case Presentation A 43-year-old African American male presented to our hospital one month after admission for hemorrhagic pancreatitis attributed to dyslipidemia. Course was complicated by loculated retroperitoneal abscess tracking from pancreas to scrotum. Patient underwent exploratory laparotomy with pancreatic necrosectomy along with broad-spectrum antibiotics resulting in mild improvement in condition. Magnetic resonance cholangiopancreatography revealed PD injury confirmed on abdominal CT with contrast. ERCP confirmed PDL. A 5 F × 8 cm single pigtail plastic pancreatic stent (PPS) was placed. Unfortunately, PPS failed to maintain drainage and prevent leak as observed on contrasted abdominal CT 6 days later. PDL was confirmed again on repeat ERCP and an 8 mm × 6 cm biliary fully covered SEMS was placed in PD. Post stent placement, occlusion pancreatogram (OP) showed no leak. Four days later, repeat CT showed improving fluid collections without leak. After 4 weeks, third ERCP was performed, SEMS was removed with rat tooth forceps without complications, ERCP showed no PDL and a 7 F × 7 cm PPS was placed. Six weeks later, PPS was removed, ERCP showed no PDL and a 7 F × 4 cm PPS was placed. At this time, patient has continued to follow on outpatient basis without further incident.

DISCUSSION:
Discussion Endoscopic treatments for PDL have replaced surgical interventions in number of situations. Biflanged fully covered metal stents for PDL are only available outside US. In the meantime, cases like this emphasize the importance of considering alternative approaches in the treatment of PDL.
1384 Expanding the Horizons of Endoscopy: Cholangioscopy and Radiofrequency Ablation via Percutaneous Transhepatic Biliary Drainage
Authors: Bolanos Gabriel , Kumar Manoj , Fahmawi Yazan , Mizrahi Meir 
Published: October 2019

INTRODUCTION:
A variety of transhepatic percutaneous biliary interventions are applicable for the management of biliary system pathologies, including: percutaneous transhepatic cholangiogram (PTC), percutaneous transhepatic biliary drainage (PTBD), and percutaneous transhepatic cholangioscopy (PTCS). These methods are useful to visualize the biliary system for diagnostic and/or therapeutic purposes; however they are generally reserved when endoscopic retrograde cholangiopancreatogram (ERCP) or peroral cholangioscopy is unsuccessful or not feasible. We present a novel approach in the management of malignant hilar biliary obstruction (MHBO).

CASE DESCRIPTION/METHODS:
A 63-year-old male with history of decompensated HCV/EtOH cirrhosis presented with painless jaundice, weight loss, and CT/MRI findings suggested hepatic mass with biliary duct dilation, concerning for hilar cholangiocarcinoma. Interventional Radiology (IR) performed PTC and then PTBD to decompress the biliary tree and placed external bilateral biliary drains. Our Role: With assistance from IR, PTCS was performed with evidence of malignant hilar biliary obstruction however, cytology and biopsies were negative for malignancy. CT guided percutaneous hepatic mass biopsy was reported as poorly differentiated adenocarcinoma. PTCS was again performed with evidence of right-sided malignant stricture and subsequently RFA (RFA catheter with 8 F bipolar probe (soft mode effect of 8-10 watts) and two ring electrodes (8 mm long and 6 mm apart) with ablation length of 25 mm ± 3 mm) of right and left hepatic biliary duct was performed under fluoroscopy guidance (3 cycles). Biliary drains were removed and bilateral biliary stents were placed. Post ablation PTCS showed excellent ablation of malignant tissue and patent ducts on PTC. Excellent toleration and no post-procedural symptoms were reported.

DISCUSSION:
Malignant biliary tumors are often unresectable. Biliary RFA using the bipolar radiofrequency catheter is a new endoscopic therapy for malignant or benign tissue in the pancreatic and biliary tract. This novel approach for PTC/RFA via PTBD provides an alternative for the management of biliary tract obstruction whenever ERCP and peroral cholangioscopy guided treatments are not feasible.
1385 Fire in the Hole! Role of Radiofrequency Ablation for Biliary Stent Occlusion: Prolonging the Stent Patency
Authors: Ludvik Nicholas , Kumar Manoj , Fahmawi Yazan , Mizrahi Meir 
Published: October 2019

INTRODUCTION:
Management of malignant biliary obstruction (MBO) is largely palliative yet critical to maximizing patients' quality of life. Uncovered Self-expanding metal stents (SEMS) are widely used in that context. However, the uncovered nature of these stents allows tissue ingrowth and intraluminal obstruction requiring frequent endoscopic retrograde cholangiopancreatography (ERCP), mechanical cleaning with a balloon or a second stent insertion in stent-in-stent fashion. Radiofrequency ablation (RFA) is a new intraductal procedure to ablate the tissue ingrowth and improve the patency of biliary stents. Here we are discussing one such case.

CASE DESCRIPTION/METHODS:
Case A 54-year-old male with pancreatic adenocarcinoma with numerous metastases status post ERCP with uncovered metal stent placement. He was referred with hyperbilirubinemia and concern for stent occlusion. Endoscopy reveled a severely narrowed and distorted duodenum. ERCP was planned. Due to heavy tissue ingrowth and sludge, guidewire had to be placed under cholangioscopic guidance. A RFA catheter with 8 F bipolar probe and two ring electrodes (8 mm long and 6 mm apart) with ablation length of 25 mm ± 3 mm was advanced over guidewire under fluoroscopy. Intraductal RFA of the tissue ingrowth with in the stent was delivered with bipolar soft mode effect of 8-10 watts over 3 cycles. Post-ablation balloon sweeps produced large amounts of debris. A stricture noticed prior to RFA was seen again but with improved caliber. A fully covered 10 mm × 80 mm SEMS was placed across stricture. No procedure related complication was reported and patient continued with his chemotherapy.

DISCUSSION:
Use of RFA in conjunction with SEMS placement appears promising. RFA appears to delay tumor ingrowth, thereby decreasing need for repeat intervention. Furthermore, a recent clinical trial demonstrated that this can prolong not only stent patency but also improves survival. This case emphasizes the increased applicability of RFA not only in gastrointestinal tract but also in biliary disease.