bluuebunny/crossref_metadata_2025_split huggingface dataset:
3012 Pancreatic Ascites in a Patient With Thromboembolic Disease
Authors: Ali Birmaji , Fahim Peter , Kindel Robert 
Published: October 2019

INTRODUCTION:
Pancreatic ascites is a rare condition characterized by abdominal pain, weight loss and progressive ascites. It is a complication of pancreatic duct disruption leading to leakage into the peritoneal cavity. The epidemiology is not well studied, which makes diagnosis challenging for clinicians.

CASE DESCRIPTION/METHODS:
A 54-year old female with a history of alcohol abuse, alcoholic cirrhosis, and chronic pancreatitis with pseudocyst presented to the Emergency Department with pleuritic chest pain, right calf pain and swelling for several days. She also had chronic abdominal pain, nausea, vomiting and poor appetite with 10-pound weight loss in 3 months. Her pseudocyst was routinely followed up with no significant change. The patient's significant vitals included BMI of 14.45 kg/m2, tachypnea and tachycardia. Physical examination revealed epigastric tenderness, abdominal distension and right calf swelling. Significant labs included hypoalbuminemia 1.3 g/dL, D-dimer 13.68 mcg/mL and Pro-calcitonin 19.92 mcg/L. CTA of chest revealed bilateral pulmonary emboli with right heart strain. Lower extremity duplex was positive for right femoral DVT. Patient was subsequently started on heparin infusion. A CT scan of abdomen and pelvis revealed an unchanged 2.2 × 1.1 cm pseudocyst in head of pancreas. Diagnostic paracentesis showed fluid analysis of albumin 0.5 g/dl, protein 1.4 g/dl and elevated amylase 836 U/L. The SAAG score was 0.8, which was clinical congruent with pancreatic ascites. MRCP identified the pseudocyst having a thin tubular extension along anterior pancreatic body. ERCP with pancreatic duct sphincterotomy and stent placement did not provide clinical improvement. EUS visualized a 6.6 cm fluid collection between stomach and spleen, with the pseudocyst was 1 cm adjacent to the gastric wall. It was aspirated and metal stent was placed to dilate entry into pseudocyst via endoscopic cystogastrostomy. The fluid content was finally suctioned out. The patient clinically improved and was discharged on warfarin. The stent was removed a month later.

DISCUSSION:
This case illustrates the importance of immediate paracentesis in diagnosing pancreatic ascites, a rare and potentially fatal condition if left untreated. Diagnosis is made with elevated fluid amylase, low SAAG score and clinical picture congruent with chronic pancreatitis with accompanied pseudocyst or severe acute pancreatitis. Early endoscopic intervention has shown highly successful at reducing mortality, hospital length of stay and recurrence.
3014 A Rare Case of Fioricet-Induced Acute Pancreatitis
Authors: Sonpal Niket , Olaosebikan Kikelomo 
Published: October 2019

INTRODUCTION:
Acute pancreatitis is the inflammation of the pancreas leading to a very severe line of symptoms of which a very prominent one is excruciating abdominal pain; it is a common acute surgical presentation in the western world. The organ which has an important role in digestion due to hormone production including insulin (Santhi et al 2019). The annual incidence of acute pancreatitis is ∼20-40/100,000 population (Dhiraj Yadav et al 2014). About 40% are due to gallstones, 25.6% idiopathic, 22% alcohol induced and 3.9% post ERCP (Nesvaderani, M. et al 2015). Fioricet (Butalbital-Acetaminophen-Caffeine), a medication used in tension headaches due to the combination of acetaminophen for pain, caffeine to increase effects of acetaminophen and butalbital a sedative which helps to decrease anxiety and cause relaxation. We present a case of a female suspected to have acute pancreatitis due to fioricet.

CASE DESCRIPTION/METHODS:
A 46-year-old female with a BMI of 27 came to the ED with complaints of epigastric abdominal pain which had started the day before, radiates to back and right flank pain with the severity of 10/10 on the pain scale with associated nausea and with no vomiting. Previous history of Kidney stones, cholelithiasis (with a cholecystectomy), Hypothyroidism and Migraines for which she had been on Fioricet for over five years and takes the medication with the frequency of attacks. The patient denies any history of drinking and alcohol or drug abuse, with a known allergy to Hydrocodone. Ultrasound showed no acute pancreatitis, Ct Imagining with i.v contrast depicted acute pancreatitis, although labs showed; amylase-43, lipase-226, ast- 35, alt- 30, total bilirubin-0.3, WBC- 16.6 (left shift). To rule out autoimmune activity due to the history of hypothyroidism, Immuno-serology showed; Igg- negative, Ana- negative. An MRCP was performed showed no evidence of intra and extra-hepatic duct dilation, heterogeneous signal intensity was noted around the pancreas, compatible with pancreatitis. With all arrows pointing at the medication Fioricet.

DISCUSSION:
In conclusion, one of the active ingredients acetaminophen is documented as a class II medication (medications implicated in more than 10 cases of acute pancreatitis) (Trivedi CD et al 2005) due to the evidence stated above, we need to be cautious with long term therapy of fioricet in patients with chronic migraine and implement better screening techniques to avoid such complications which could lead to a more devastating outcome.
3018 Not Only Bullets Kill in War: A Case Report of Klatskin Tumor in a Veteran
Authors: George Justin , Alkayali Talal , Campdesuner Victoria , Ramos-Chaves Belissa , Wiese-Rometsch Wilhelmine 
Published: October 2019

INTRODUCTION:
Cholangiocarcinoma (CAA) is a rare GI malignancy in the United States with a reported incidence of 1-2 per 100,000 person. Classification is based on location within the biliary tree with 50% of cases occurring at the perihilum. CAA located at the bifurcation of the common hepatic duct are called Klatskin tumors. Curative treatment is by complete resection versus palliative approach to non-resectable tumors.

CASE DESCRIPTION/METHODS:
77 year old male veteran with history of CAD, DM II, and CKD III presented to the emergency department with sudden onset, painless jaundice associated with 20 pound weight loss, fatigue, and loss of appetite over the past 3 months. He appeared cachetic, jaundiced with scleral icterus noted. Abdomen was nontender without organomegaly. Diagnostic studies revealed ALP 1056, AST 266, ALT 416, and direct bilirubin 12. Abdominal US revealed cholelithiasis without biliary tract dilation or gallbladder wall thickening. MRCP showed obstruction at the hepatic hilum at the confluence of the left and right hepatic lobes with moderate intrahepatic bile duct dilation. ERCP revealed diffuse biliary ductal dilation with a mass in the common bile duct. EUS guided fine needle aspiration of the mass at the common hepatic duct was done. Bloodwork showed elevated levels of CEA. Complete staging showed a portocaval lymph node. Medical and surgical oncology teams agreed that the tumor was unresectable. Palliative gemcitabine and cisplatin were initiated.

DISCUSSION:
Risk factors for the development of CAA include hepatitis B, C, and primary sclerosing cholangitis. Vietnam war Veterans have unique risk factors including exposure to Agent Orange and parasitic infections including Clonorchis sinensis and Opisthorchisviverrini. Our patient spent 14 months on a naval base outside Cambodia. He admits exposure to raw and freshwater fish. The causal relationship between the two liver flukes and CAA is well documented. Of the 700 claims made to the Department of Veterans Affairs (VA), 75% have been rejected. Pilot prospective studies performed by the VA have shown exposure to these parasites in Vietnam veterans. To date, there is no commercial serologic test in the US to identify previous exposure to these parasites. Our case raises the question whether these veterans are at increased risk of CAA and whether there is any utility in screening for CAA in this population. Further studies are needed to establish whether this unique population is at increased rates for CAA.
3020 A Case of Necrotizing Pancreatitis Post-Cardiac Surgery and Exposure to Sulfamethoxazole-Trimethoprim
Authors: Ji Hyun , Lee Paul , Hafdahl Luke 
Published: October 2019

INTRODUCTION:
Necrotizing pancreatitis is a serious complication of acute pancreatitis with high morbidity and mortality. We present a case of a 58 year old male diagnosed with necrotizing pancreatitis after cardiopulmonary bypass surgery and exposure to sulfamethoxazole-trimethoprim (TMP/SMX).

CASE DESCRIPTION/METHODS:
A 58 year old man presented with one week of jaundice and dyspnea. His history is significant for a recent cardiac surgery with coronary artery bypass grafts (CABG) and aortic valve repair (AVR) with a prolonged cardiopulmonary bypass time (CPBT) aortic cross-clamp time (ACCT). After the surgery, he was prescribed a course of TMP/SMX for an unknown indication. On assessment, he denied any other symptoms and had no history of alcohol use. He was hemodynamically stable with physical examination notable only for generalized jaundice. Lab findings were significant for hemoglobin 6.2 g/dL, WBC 19 × 10(9)/L, K 5.8 mmol/L, BUN 82 mg/dL, Cr 2.82 mg/dL, total calcium 6.7 mg/dL, serum glucose 110 mg/dL, total/direct bilirubin 8.7/6.8 mg/dL, alkaline phosphate 503 U/L, ALT 343 U/L, AST 640 U/L, lipase 540 U/L, and triglycerides 212 mg/dL. CT of the abdomen showed acute necrotizing pancreatitis. He was treated with fluid resuscitation and antibiotics. ERCP was deferred as his cholestasis was thought to be due to extrinsic compression. His course was complicated by hemorrhagic conversion, acute renal failure, shock liver and gastric ischemia. Ultimately, he expired on hospital day 20.

DISCUSSION:
Drug-induced pancreatitis accounts for 0.1-2% of cases of acute pancreatitis. Although TMP/SMX is classified as a potential cause of pancreatitis, the data is sparse with limited reported cases and a broad latency period ranging from 3 days to 20 years. Acute pancreatitis has also been described as a complication of cardiac surgery with an incidence of 0.4% per prior report. Notably, many of these patients are often asymptomatic, which makes early diagnosis of utmost priority. Factors that increase the risk of developing pancreatitis include prolonged CPBT/ACCT and combined CABG and valve repair, possibly related to splanchnic ischemia. Given that our patient with a recent cardiac surgery received a culprit antibiotic within several weeks of presentation, it is unclear whether TMP/SMX, cardiac surgery, or a combination caused our patient's episode of acute pancreatitis. Although rare, each of these factors should be considered when determining the cause of pancreatitis.
3023 Necrotizing Pancreatitis Following Ampullary Biopsy Without Biliary Cannulation
Authors: Stepanek Rachel , Bilal Mohammad , Parupudi Sreeram 
Published: October 2019

INTRODUCTION:
Patients with familial adenomatous polyposis (FAP) have an almost 100% lifetime risk of developing colorectal cancer (CRC). In addition, they are at increased risk for developing cancers in the duodenum and ampulla. While pancreatitis is a known complication of ampullary manipulation, it typically presents within hours and is relatively mild. We present a unique case of a patient with FAP who underwent an excision biopsy for a diminutive ampullary adenoma and presented with necrotizing pancreatitis 12 days following the procedure.

CASE DESCRIPTION/METHODS:
A 70-year-old male with a history of FAP and CRC who is status post-total abdominal colectomy was found to have a 2-cm sessile polyp on the lateral wall of the duodenum and a diminutive ampullary polyp (Figure 1) on surveillance esophagogastroduodenoscopy (EGD). The lateral polyp was removed via piecemeal endoscopic mucosal resection. The ampullary polyp was cautiously removed via biopsy excision with an attempt to biopsy along the left lateral margin deliberately away from the tentative pancreatic duct orifice. Both lesions were tubular adenomas. The patient did well for 12 days post-procedure until he presented to the emergency department for epigastric pain, nausea and vomiting. On presentation, serum lipase was 2000 U/L. A CT scan of the abdomen showed necrotizing pancreatitis with an 11-cm peripancreatic fluid collection. The patient denied alcohol use, and imaging did not reveal any cholelithiasis. Serum triglycerides and IgG-4 levels were within normal limits. The patient was admitted, managed with intravenous hydration and early nutrition, and was discharged on hospital day 10. CT abdomen pelvis performed 3 months later showed an 8-cm pancreatic fluid collection consistent with walled-off necrosis (WON). The patient is completely asymptomatic and is being followed clinically with plan for repeat imaging in 3 months.

DISCUSSION:
Acute pancreatitis is a common complication following endoscopic retrograde cholangiopancreatography (ERCP), but is exceedingly rare without attempts at biliary/pancreatic duct cannulation. In our case, the patient developed necrotizing pancreatitis following an excision biopsy of a diminutive ampullary adenoma without any attempts at cannulation of the ampulla. Patients need to be adequately counseled about the risks of severe pancreatitis, and a high level of suspicion should be maintained for up to two to three weeks after a procedure.
3026 Rare Complication of Chronic Pancreatitis: Chronic Portal Vein Thrombus Causing Pre-Hepatic Portal Hypertension
Authors: Elbanna Ahmed , Aishwarya Shyamraj , Mustafa Al-Shammari , Watson Andrew , Pompa Robert , Gordon Stuart 
Published: October 2019

INTRODUCTION:
Portal vein thrombosis (PVT) is an uncommon complication of chronic pancreatitis. PVT more commonly occurs as a complication of acute pancreatitis and is an indicator of severity of disease. Patients with chronic pancreatitis can develop a pre-hepatic portal hypertension (HTN) in the setting of PVT. These patients are at risk for variceal hemorrhage. Early identification and management is critical.

CASE DESCRIPTION/METHODS:
A 34 year old female with a history of familial hypertriglyceridemia leading to necrotizing pancreatitis complicated by PVT in the past presented with sudden onset dizziness. She was documented to have a history of liver cirrhosis. On presentation to the outside hospital (OSH), patient was hypotensive and was noted to have a 5 g drop in Hb compared to baseline. She was transferred to the ICU and required support with blood transfusions and vasopressors. EGD at OSH demonstrated grade 1 non-bleeding esophageal varices and portal hypertensive gastropathy. Patient was transferred to our institution for TIPS evaluation. On presentation to our institution, patient remained hemodynamically stable. Examination was consistent with ascites and a R sided pleural effusion, which was confirmed by imaging. She underwent a work-up for chronic liver disease, which was negative. Her ascitic fluid volume was insufficient for paracentesis. Thoracentesis was performed with removal of 1.4 L of transudate consistent with hepatic hydrothorax. Her course was complicated by worsening jaundice. She subsequently underwent liver biopsy with hepatic venogram and pressure gradients. Biopsy did not show evidence of cirrhosis and hepatic venogram was consistent with pre-hepatic portal HTN. MRCP demonstrated dilated common bile duct and main pancreatic ducts. ERCP demonstrated stenosis in the main bile duct, which was treated with plastic stent placement. Following endoscopic intervention, patient's jaundice dramatically improved. TIPS was deferred given patient's history of PVT as well as limited efficacy in the absence of cirrhosis.

DISCUSSION:
Among reported cases of pre-hepatic portal HTN, chronic PVT secondary to chronic pancreatitis is rare. More commonly, splenic vein thrombus is described, resulting in a sinistral portal HTN with a predominance of gastric varices. Therapeutic considerations for pre-hepatic portal HTN are mainly focused on the prevention of variceal hemorrhage. Medical and endoscopic therapy is the standard of care. TIPS is an option for refractory cases.
3029 Complications from Hypertriglyceridemia-Induced Acute Pancreatitis
Authors: McKitish Kristin , Lee Clara , Sotiriadis John 
Published: October 2019

INTRODUCTION:
Pancreatitis accounts for 275,000 hospital admissions annually. While alcohol consumption and gallstones are responsible for the majority of cases, hypertriglyceridemia accounts for only 7%. Most are treated successfully with intravenous hydration, pain control and triglyceride-lowering agents but complications do occur 15% of the time. We present a case of one such complication.

CASE DESCRIPTION/METHODS:
A 40-year-old previously healthy female presented with a 12-hour history of nausea and severe LUQ abdominal pain. She was admitted with acute pancreatitis secondary to hypertriglyceridemia. Labs revealed a lipase of 3653 U/L and triglycerides of 6160 mg/dL. Abdominal CT scan confirmed acute pancreatitis. She was treated supportively with aggressive IV hydration. Repeat imaging 5 days later showed a large fluid collection inferior to the gastric antrum, an extensive amount of free fluid layering the abdomen and a small to moderate left pleural effusion. Eventually her symptoms due to the evolving pseudocyst improved and she was discharged on day 22 with Fenofibrate and Omega-3-Acid Ethyl Esters. Six days later she was admitted for sepsis secondary to infected pancreatic pseudocyst. CT showed an extensive multi-locular fluid collection and worsening left pleural effusion. Ultrasound-guided drainage was performed and cultures reported E. coli. Antibiotics were tailored but patient remained hypotensive and tachycardic. At that point the patient underwent a diagnostic laparoscopy, which was converted to Roux En Y pancreatic cystjejunostomy for continuous drainage. Repeat imaging on post-op day one demonstrated an interval decrease in size of fluid collection. Eventually the patient was discharged home in stable condition.

DISCUSSION:
While pancreatitis due to hypertriglyceridemia remains common, life threatening complications are rare. Aggressive supportive care is the mainstay of therapy with early surgical intervention as needed.
3030 Klatskin Tumor: Dive in to Take a Closer Look…
Authors: Mulat Baruh , Shahid Tamoor , Figueredo Carlos , Hertan Hilary 
Published: October 2019

INTRODUCTION:
Malignant tumors of the biliary tract are rare and highly lethal. Further sub classification of Cholangiocarcinomas defines Klatskin tumors, as extrahepatic bile duct tumors involving the hepatic duct bifurcation with distinct finding on dedicated imaging.

CASE DESCRIPTION/METHODS:
An 80-years-old former smoker female was referred by outpatient neurologist for unintentional 30-40 lb weight loss over 6 months, jaundice and abnormal LFTs. Her examination was unremarkable. Patient was found to have abnormal LFTswith ALP of 1210 U/L, GGT 1350 U/L, AST 388 U/L, ALT 300 U/L, TB 2.5 mg/dL (DB of 2.1 mg/dL). Tumor markers were grossly normal including CA 19-9 of 5 U/ml, CEA of 5 ng/mL and AFP of 5 ng/ml. CT abdomen and pelvis with IV contrast showed moderate to significant intrahepatic biliary ductal dilatation with a caliber change at the level of the porta hepatis, where there is abnormal soft tissue extending centrally to the liver. These findings are worrisome for Klatskin type tumor. Diagnostic EUS was started, however aborted once an infiltrating mass found in the gastric body causing luminal gastric narrowing restricting passage of EUS scope. Biopsies obtained from gastric mass, showed adenocarcinoma, poorly differentiated with signet-ring cell features and Helicobacter pylori positive stain.

DISCUSSION:
Despite progress, gastric cancers in the United States are still being diagnosed at an advanced stage, when become symptomatic and often incurable stage. Unintentional weight loss, early satiety and occasionally vague epigastric pain are often the presenting symptoms of an already advanced cancer. Gastric ulcers and H. Pylori infection have been shown to be precursors with potential carcinogenic effect. More unusual presentations give signs and symptoms secondary to direct extension of the tumor to nearby organs (most common to liver), or distant metastases to liver, peritoneum, Virchow's node (Supraclavicular lymph node), Periumbilical nodule (Sister Mary Joseph's node, or a left axillary node (Irish node). When metastases to liver are present, they are often diffuse or multifocal and rarely unifocal. Our case is interesting as the initial CT imaging was highly suggestive of a rare and lethal Klatskin tumor type of cholangiocarcinoma. The final decision to pursue a tissue diagnosis with a high risk procedure (EUS) was aborted by a surprising finding of a locally advanced gastric adenocarcinoma.
3031 Severe Acute Pancreatitis Secondary to Topical Cannabinoid Use
Authors: Ahuja Ashish C. , Aijazi Muaz 
Published: October 2019

INTRODUCTION:
Acute pancreatitis is one of the most frequent gastrointestinal causes of hospital admission in the US. While almost 80% of cases are associated with alcohol or gallstones, the remainder often remain idiopathic with no identifiable cause. Here, we present the case of 74-year old male who presented with severe pancreatitis after topical cannabinoid use who eventually expired from complications of the disease.

CASE DESCRIPTION/METHODS:
74 year-old male with history of HTN, ischemic cardiomyopathy, stage 3 CKD, multiple strokes and lumbar spinal stenosis presented with sudden onset of abdominal pain. The pain began one day prior and was described as a sharp sensation in the epigastrium radiating to the chest. It was associated with dry heaving but no vomiting. The patient was having non-bloody diarrhea since the pain began. No fevers, but chills and diaphoresis were present. He denies any recent alcohol use and is s/p cholecystectomy. He endorses recently using topical cannabinoid oil for chronic low back pain. He was afebrile on arrival but hypertensive to 214/97. His labs were remarkable for WBC 23, H&H 17/54, lipase 47082, Cr 1.56, Tbili 1.9, ALT 210, AST 330, Alk Phos 211, EtOH level <5. CT abdomen/pelvis showed moderate acute, interstitial pancreatitis with small, non-loculated fluid collections. Despite aggressive fluid resuscitation, the patient required pressor support and was intubated. Abdomen US revealed no pancreatic or biliary dilation and surgically absent gallbladder. His condition continued to worsen and Nephrology initiated CRRT for anuric renal failure. He developed atrial fibrillation with hypotension requiring continuous amiodarone infusion. H&H began to drop and DIC developed rapidly. The patient expired after 10 days.

DISCUSSION:
After extensive work-up, no specific etiology was found for acute pancreatitis in this patient. The recent use of topical cannabinoid oil for chronic back pain showed a temporal correlation with the patient's medical condition and was thought to be the inciting factor leading to this patient's demise. Given the increased availability of cannabis in managing chronic pain, patients should be aware of the association between cannabis and acute pancreatitis. Additionally, health care providers should include cannabis (including all marijuana varieties and methods of consumption) in the differential diagnosis of acute pancreatitis cases with unknown etiology.