bluuebunny/crossref_metadata_2025_split huggingface dataset:
1339 Gastro-Colic Fistula: A Delayed Complication of Whipple's Procedure for Tropical Pancreatitis
Authors: Tageldin Omar , Itani Wafic , Mansoor Muhammad Sohail , Parsa Nour 
Published: October 2019

INTRODUCTION:
Gastrointestinal (GI) fistula is a serious condition that can lead to electrolyte disturbance, severe debility and even death. It occurs as a complication of gastrointestinal surgery mostly involving malignancies. We present a case of a gastro-colic fistula (GCF) occurring six years after Whipple's procedure.

CASE DESCRIPTION/METHODS:
A 58 years old Guyanese male with current alcohol abuse was admitted for 2 months of diarrhea. He reported more than 2 dozen watery bowel movements a day including nocturnal episodes, fecal incontinence, chills and a 15 lbs weight loss. Lab work showed significant hypoalbuminemia, hypokalemia and normal anion gap metabolic acidosis. He reported a history of tropical pancreatitis complicated by acute necrotizing pancreatitis followed by Whipple's procedure 6 years ago. Patient underwent CT abdomen which showed diffuse wall thickening of the ascending colon while colonoscopy revealed circumferential ulcerated mucosa in the same area. The colonoscope was not advanced further due to high risk of perforation. Biopsies from ulcer base and margin showed benign colonic mucosa with regenerative changes. An EGD was performed that revealed a 3 cm peri-anastomotic gastric ulcer and a large GCF in ulcer base. Fecal material was found in stomach and fistula was easily traversed with gastroscope. Patient was put on TPN and underwent exploratory laparotomy with partial greater omentectomy, distal gastrectomy with Roux-en-Y gastrojejunostomy, transverse colectomy with end colostomy, long Hartmann's pouch and a partial small bowel resection. Post-procedure he was slowly advanced to a regular diet with resolution of his diarrhea.

DISCUSSION:
GCF happens most commonly in surgeries involving GI malignancies. Imaging of choice is barium enema with barium seen in the stomach via a pressure gradient created from the colon to the stomach. GCF can be diagnosed endoscopically but may be missed if the fistula opening is small or obscured by adjacent mucosal changes as we encountered during colonoscopy in this case. Risk factors for developing GCF after Whipple's procedure include infection, sepsis, breakdown of intestinal anastomosis due to ischemia, tension in anastomotic tissue, distal obstruction hypoproteinemia, radiation injury and underlying IBD. Controlling fistula output by keeping patient NPO, proton pump inhibitors and maintaining adequate nutrition are key factors in healing GCF. Endoscopic or surgical approaches for fistula closure should be considered on individual basis.
1344 Sump Syndrome With Massive Choledocholithiasis Requiring Electrohydraulic Lithotripsy
Authors: Duarte-Chavez Rodrigo , Matin Ayaz , Martinez-Tapia Ana , Tayel Hussam , Tayel Hesham , Bahirwani Janak , Geme Berhanu 
Published: October 2019

INTRODUCTION:
Cholelithiasis is highly prevalent and affects 10-15% of the United States population. About 10-20% of the patients with symptomatic cholelithiasis have also choledocholithiasis; this is treated with ERCP and subsequent cholecystectomy. Recurrent CBD stones after ERCP occur in 4-24% and are caused mainly by bile stasis.

CASE DESCRIPTION/METHODS:
A 76-year-old female presented to our practice 3 years ago with cholangitis, requiring ERCP with removal of multiple stones and sludge. Balloon dilation with plastic stent placement was also performed due to distal CBD stenosis. She had a history of cholecystectomy and ERCP 25 years ago, complicated with bowel perforation. We performed 9 ERCPs subsequent to her first visit with us due to recurrent cholangitis. Because of the CBD stenosis and recurrent choledocholithiasis, biliary bypass with side-to-side choledochoduodenostomy (CDD) was performed. Six months after the CDD she had another episode of cholangitis. ERCP was performed but there was massive lithiasis in the CBD and stones could not be removed (Figures 1 and 2). Electrohydraulic lithotripsy (EHL) had to be used under direct visualization through the CDD and stones were removed using a combination of snare, balloon and basket (Figure 3). The CBD was completely cleared and a double-pigtail stent was placed at the CDD. Two days after the procedure the patient was discharged home and her LFTs were normal during follow up.

DISCUSSION:
CDD is a procedure performed to improve biliary drainage but its use has dramatically decreased after ERCP. Sump or “cul-de-sac” syndrome (SS) is a complication of CDD that results from bile stasis and the accumulation of debris in the segment of CBD between the anastomosis and the ampulla of Vater, facilitating bacterial proliferation and stone formation. The prevalence of SS after CDD is estimated to be between 0-9.6%. The current treatment for SS is decompression of the CBD distally with sphincterotomy and CBD clearance with basket and balloon. With our patient, we decided to avoid sphincterotomy since there was a long segment of distal CBD stenosis and the CDD opening was also wide enough to allow access to the CBD. The massive lithiasis in this patient might have been caused by the reflux of duodenal content into the CBD trough the CDD, but she also had recurrent choledocholithiasis even prior to the CDD and other factors were perpetuating the stone formation in the CBD. We present a unique case of SS with massive CBD lithiasis that required use of EHL through the CDD.
1345 Pancreatic Pseudocyst Leading to Gastric Outlet Obstruction: A Hard Diagnosis to Swallow
Authors: Falde Sam , Kamboj Amrit K. , Dines Virginia 
Published: October 2019

INTRODUCTION:
Recurrent pancreatitis with pseudocyst can present with gastric outlet obstruction. Endoscopic evaluation should be utilized in certain contexts, especially to exclude more sinister causes of this presentation.

CASE DESCRIPTION/METHODS:
A 43-year-old woman with a history of alcohol use disorder presented with a gastric outlet obstruction. This was felt secondary to a pancreatic pseudocyst given multiple episodes of recurrent pancreatitis, the last being 1 week prior to her current admission. On presentation, physical exam was significant for ascites and epigastric tenderness. Labs were notable for AST 214 U/L, ALT 99 U/L, alkaline phosphatase 147 U/L, lipase of 203 U/L, and negatives serum alcohol. Notably, Ca 19-9 was elevated to 154 IU/mL during admission 2 weeks prior. Computed tomography chest and abdomen revealed bilateral pleural effusions, pseudocyst, and abdominal ascites. A thoracentesis and paracentesis were performed with cytology for both peritoneal fluid and pleural fluid confirming metastatic adenocarcinoma. Given her refractory symptoms, an esophagogastroduodenoscopy (EGD) was performed which showed an obstructing tumor at the gastric outlet with biopsies revealing poorly differentiated gastric adenocarcinoma. A gastric stent was placed; however, she had continued nausea and vomiting. Repeat EGD showed gastric stent failure and subsequent endoscopic gastrojejunostomy with Axios stent was placed. The patient's functional status declined rapidly as a result of her advanced malignancy and on hospital day 8 she suffered a cardiac arrest, passing shortly after being transitioned to comfort cares.

DISCUSSION:
The patient's prior history of alcohol use disorder, recurrent pancreatitis, and imaging consistent with pancreatic pseudocyst made this case prone to numerous cognitive errors initially obscuring the etiology of her gastric outlet obstruction and pancreatitis. By reframing the presentation, we were able to question pancreatic pseudocyst as the sole source of the gastric outlet obstruction. Traditionally, Ca 19-9 is associated with pancreatic adenocarcinoma. It also can be elevated in the setting of other gastric malignancies and acute pancreatitis. In pancreatitis, absolute value and trends of Ca 19-9 can help differentiate between pancreatitis and malignancy. The diagnostic uncertainty around this patient's presentation with recurrent pancreatitis, pseudocyst, and gastric outlet obstruction required endoscopic evaluation to ultimately diagnose metastatic gastric adenocarcinoma.
1346 CA 19-9: Elevation in Mycobacterium Avium-Intracellulare Infections
Authors: Turse Erica , Chuang Keng-Yu 
Published: October 2019

INTRODUCTION:
Carbohydrate antigen 19-9 is usually associated with pancreatic malignancy. However, other causes as bronchiectasis can cause lab elevation. Here we present a case of an elevated CA 19-9 with pulmonary mycobacterium avium-intracellulare.

CASE DESCRIPTION/METHODS:
66 year old HIV negative female with MAI (Figure 1) on Ethambutol, Rifampin, Azithromycin (started 4/2017, stopped 10/2017, restarted 1/2018) presented to clinic with complaints of epigastric pain with unintentional weight loss. She was started on proton pump inhibitor and H2 blocker therapy and underwent EGD and colonoscopy with biopsies positive for Helicobacter pylori. She received quadruple therapy with eradication on stool antigen. She complained of a mass in her supra-pubic region and given this with her weight loss and normal endoscopies, a CT Abdomen and Pelvis was performed which showed no hepato-biliary abnormalities but significant bladder distention (Figure 2). This resolved on its own prior to her seeing urology or coming in for follow up. A CA 19-9 remained elevated at 105, 94, and 111 during this time frame.

DISCUSSION:
Mycobacterium is a masquerader causing hydronephrosis to bronchiectasis, both seen in our patient, with the mechanism of CA 19-9 elevation unknown. Shin et al presented a patient with MAI and elevated CA 19-9 levels, which improved with treatment.
1
Studies have shown an elevated CA 19-9 may be from MAI infection or other causes of bronchiectasis, such as Chang et al in 2013.
2
Yamazaki et al compared CA 19-9 in patients with deteriorated (96.9) vs non-deteriorated (19.2) disease.
3
Hong and colleagues in their analysis showed that CA 19-9 could be elevated in patients with MAI and improved with treatment.
4
Here, we highlight the importance of a differential diagnosis of non-pancreatic etiologies for elevated CA 19-9 levels.
1348 The Ketamine Connection: Ulcerative Cystitis and Biliary Dilatation in the Setting of Chronic Ketamine Abuse
Authors: Tarzi Davood , Pradhananga Jyoti 
Published: October 2019

INTRODUCTION:
Recreational ketamine abuse can present with a unique constellation of symptoms, and limited literature on this topic makes this case a rare learning opportunity.

CASE DESCRIPTION/METHODS:
A 37-year-old male with diffuse psoriasis and a one-year-history of ketamine inhalation presented to the ER complaining of recurrent episodes of epigastric pain. The pain was described as colicky, non-radiating, and 10/10 in intensity; he related the pain acutely worsened in the 3 days prior to admission. He also had a remote history of cocaine and marijuana abuse. He denied vomiting, diarrhea, melena, dysphagia, odynophagia, fevers, or chills. Physical exam findings were negative for a Murphy's sign. Laboratory studies were significant for eosinophilia and an elevated lipase. A CT of the abdomen revealed hypodensities in the liver parenchyma and dilatation of the intrahepatic biliary ducts, common bile duct, gallbladder, and pancreatic duct. These findings suggested an obstructing stone or mass lesion at the ampulla. Furthermore, a pelvic CT also revealed an asymmetric, markedly thickened anterior urinary bladder wall and bladder dome; these findings were concerning for underlying malignancy of the bladder. A urinalysis revealed elevated white blood cells and red blood cells, but cytology was negative. A re-evaluation of the patient revealed symptoms of difficulty urinating, with sensation of having to push to void and dysuria at the end of micturition. Of note, the patient denied any history of freshwater swimming or exposure to factory chemicals. The patient underwent an EUS, which revealed a dilated common bile duct without stones, an acalculous gallbladder, and a deformed ampulla. A bedside cystoscopy was performed, revealing no tumors or strictures, but revealed a high-riding median lobe of the prostate at the bladder neck. Additionally, the posterior dome showed a thickened, erythematous area, and another rounded area consistent with ulcerative cystitis. Urology scheduled the patient for a repeat cystoscopy with biopsy, but unfortunately he left against medical advice as his pain and other symptoms had resolved.

DISCUSSION:
Ketamine, known for its hallucinogenic effects, is used recreationally among various populations. Hepatic-dominant metabolization, with urinary (90%) and biliary (10%) excretion leave these organs exposed to ketamine metabolites and their effects. This case emphasizes the importance of drug history in patients presenting with biliary colic and urinary symptomatology.
1350 Small Pancreatic Cyst Progressed to Metastatic Pancreatic Neuroendocrine Tumor in Three Months
Authors: Jin-Dominguez Fangyuan , Ahmad Dina , Faulx Ashley , Chak Amitabh 
Published: October 2019

INTRODUCTION:
We report a case of an incidentally found asymptomatic pancreatic tail cyst that rapidly grew from 1 cm to 3.4 cm in a 3-month period. The final diagnosis is metastatic pancreatic neuroendocrine tumor (NET).

CASE DESCRIPTION/METHODS:
A 72-year-old male was referred for EUS to evaluate an incidental 13 mm pancreatic tail cyst found on CT chest. He was asymptomatic and had no prior history of pancreatitis or family history of pancreatic cancer. EUS showed a 10 mm microcystic lesion in the pancreatic tail with a central echogenic area suggestive of a serous cystadenoma (Figure 1a). CT performed three months later for follow up on lung nodules demonstrated interval enlargement of the pancreatic lesion to 3.4 cm. The lesion appeared isodense and solid. EUS confirmed the rapid increase of size from 1 to 3 cm (Figure 1b). FNA was performed and cytology was interpreted as malignant cells derived from adenocarcinoma. Serum CA 19-9 was 1.88 U/ml. Pancreatic protocol CT (Figure 2) found a new 4 cm low-attenuation liver lesion within segment IV B. Biopsy of the liver lesion was negative for neoplasm. Patient was referred to surgery and the plan was to perform laparoscopy, excisional wedge liver biopsy, followed by distal pancreatectomy and splenectomy if the wedge biopsy did not show metastatic adenocarcinoma. Intraoperatively, a very small subcapsular lesion was excised from the liver and sent for frozen section to pathology. By the time pathology came back reporting a 2.5 mm lesion with evidence of poorly differentiated carcinoma, the surgeon has already transected the splenic artery. Therefore, distal pancreatectomy and splenectomy were completed. Final pathology reported grade 3 well differentiated NET of distal pancreas with metastasis involving 1/13 LNs and liver, negative margins achieved. Ki-67 labeling index was 75% (Figure 3). Patient has had no sign of cancer progression six months after the initial diagnosis.

DISCUSSION:
Our interesting case raises many important points to consider; Pancreatic NET can uncommonly have a cystic component. Additionally, pancreatic NET can mimic pancreatic adenocarcinoma and cytology alone cannot reliably differentiate between high grade neuroendocrine tumors and adenocarcinoma. This patient could have been erroneously treated for metastatic adenocarcinoma. Endosonographers should be alert to this possibility when a presentation is not typical for adenocarcinoma and/or the lesion has cystic components with a smooth border.
1353 Beware of When a Pancreatic Cyst Is Not a Cyst: Endoscopic Ultrasound Guided FNB of Neuroendocrine Tumor in the Pancreas
Authors: Sharma Neil , Kota Sharwani , Krishnakurup Jay 
Published: October 2019

INTRODUCTION:
We present a case of pancreatic NET was assessed by EUS guided FNB at our institution during 2018 presenting initially as an incidental cyst on cross sectional imaging. Further evaluation was performed via EUS after patient sought a second opinion. EUS imaging characteristics favored a solid mass rather than a cyst. FNB of a 9.0 mm × 10.5 mm in the head of the pancreas was performed.

CASE DESCRIPTION/METHODS:
A 73 year old female was referred after having an incidental finding on recent CT and MRI indicating abnormal cyst in the head of the pancreas. Her symptoms included dyspepsia, fatigue, and dizziness. She has a past medical history of hypothyroidism, hypertension, hypercholesterolemia, gout, and neuropathy. Initial CT scan done showed an incidental cystic mass in the head of the pancreas which was “benign cyst versus cystic neoplasm,” and an MRI was recommended. Further evaluated through an MRI to be a “cystic neoplasm – possible IMPN.” We performed a history and physical exam in the office and then proceeded with an EGD which showed esophageal candida confirmed by cold forceps biopsy that showed PAS and GMS stained positive for invasive fungi Candida esophagitis. We then proceeded with an EUS which revealed a hypoechoic, heterogeneous solid mass in the neck of the pancreas measuring 9.0 mm × 10.5 mm in size and in the head of the pancreas adjacent to the pancreatic duct (Figure 1). The mass was not cystic. The remainder of the pancreatic parenchyma without ductal dilation, normal biliary system, gallbladder, and liver. We performed EUS guided FNB rather than aspiration in order to obtain a large core of histologic tissue. Pathological analysis of the mass reveals a diagnosis of well-differentiated neuroendocrine tumor, grade 1 at a rate of less than 2 mitoses/2 mm2. T1N0M0, grade 1 neuroendocrine tumor was confirmed at tumor board review.

DISCUSSION:
In conclusion, PNETS are increasing in incidence due to increased use of EUS and cross sectional imaging. Pancreatic cysts have also become a common incidental finding. The complexity arises in determining which cysts seen on cross sectional imaging require further evaluation. Some “cysts” or hypodense pancreatic structures on imaging may not be cystic in nature. EUS provides a greater sensitivity and specificity than high resolution CT scans, and allows for tissue sampling. The shift from EUS-FNA to EUS-FNB has allowed for improved tissue acquisition and true histology via EUS and disgnosis of even subcentimeter lesions.
1355 Accessory Spleen: An Unusual Pancreatic Mass Posing a Diagnostic Dilemma
Authors: Dellatore Peter , Schwartz Mark , Zhang Lanjing , Skole Kevin , Katz Kristina , Saumoy Monica 
Published: October 2019

INTRODUCTION:
There are two main causes of accessory spleen; failure of fusion of the splenic anlage during the fifth week of fetal life and following autotransplantation after a splenectomy. They are structurally identical to the spleen and are most commonly found in the splenic hilum or pancreatic tail. Although rarely noted on radiograph due to low spatial resolution, their detection is increasing with more advanced modalities. This can result in the finding of a pancreatic mass that poses a diagnostic dilemma.

CASE DESCRIPTION/METHODS:
The patient is a 62-year-old man with a history of hepatitis B infection. On routine surveillance he had ultrasound findings of a liver calcification with inability to determine the presence of cirrhosis and a mildly elevated alpha-fetoprotein level. He was sent for an MRI, which revealed a 2.3 × 1.9 cm mass in the pancreatic tail showing mild hyperintense T2 signal and hypointense T1 signal. A CT from 2011 showed a slight contour bulge to the pancreatic tail in the same region, without appreciation of a discrete lesion. He underwent EGD with endoscopic ultrasound (EUS). A 21.4 × 13.7 mm well-circumscribed, homogeneous lesion was found in the pancreatic tail and biopsied. The pathology shows an immunohistochemical-staining pattern consistent with splenic tissue, confirming the diagnosis of an intrapancreatic accessory spleen (IPAS). No further intervention was needed and the patient was sent home.

DISCUSSION:
Pancreatic cancer has a 5-year survival rate of 9%, therefore it is imperative that all pancreatic masses are investigated thoroughly and promptly. In cases of an IPAS, its differentiation from a pancreatic mass is difficult as splenic tissue can mimic pancreatic tumors, especially on MRI. It is essential to differentiate between the two as IPAS are only clinical relevant when there is torsion, rupture, hemorrhage, or the patient carries a diagnosis of idiopathic thrombocytopenic purpura requiring the removal of all splenic tissue. Imaging modalities such as ultrasound, CT, MRI, and scintigraphy can aid in the diagnosis of IPAS. However, these have limitations and have not shown to provide a definitive diagnosis. EUS with fine needle aspiration is being increasingly used to characterize pancreatic lesions. In this case, it enabled adequate tissue sampling while avoiding unnecessary procedures. This case illustrates another use for EUS in an otherwise difficult diagnostic scenario.
1356 A Case of IgG4-related Sclerosing Cholangitis Initially Mistaken for Cholangiocarcinoma
Authors: Agrawal Rohit , Attar Bashar M. , Majeed Muhammad , Randhawa Tejinder , Vohra Ishaan , Gandhi Seema 
Published: October 2019

INTRODUCTION:
IgG4 related disease is an orphan immune-mediated fibro-inflammatory disorder histopathologically characterized by lymphoplasmacytic infiltrates, storiform fibrosis and phlebitis with elevated serum IgG4 levels. It has a diverse range of presentation and often mimics malignant, infectious and other inflammatory conditions. We present a case of IgG4 related cholestasis- obstructive typethat was initially worked up for cholangiocarcinoma.

CASE DESCRIPTION/METHODS:
A 42-year-old male was admitted for right upper quadrant discomfort, dark urine, pale stools and pruritus for 2 weeks. He had lost around 30 pounds in the last 3 months. Physical examination revealed jaundice, submandibular lymphadenopathy and right upper quadrant tenderness. Laboratory findings were total bilirubin of 4.7 mg/dl, direct bilirubin 2.5 mg/dl, alkaline phosphatase (ALP) 733 U/L, gamma-glutamyltransferase 767 U/L, aspartate aminotransferase 240 U/L and alanine aminotransferase of 572 U/L. Computed tomography of the abdomen revealed intrahepatic biliary dilatation, thickened common bile duct, enlargement and hypo-enhancement of the pancreatic body and tail which was confirmed by magnetic resonance cholangiopancreatography (Figure 1). Endoscopic retrograde cholangiopancreatographydemonstratedstricturing in the intrahepatic, common hepatic and common bile ducts, and a stent was implanted. Histopathology of submandibular lymph node biopsy revealed small non-necrotizing granulomas and biliary brushings had no evidence of malignancy with features of acute and chronic inflammation. IgG4 levels were >300 mg/dl. Given the high suspicion for IgG4 related disease, he was treated with prednisone 40 mg daily for 4 weeks. Follow up liver chemistries revealed an ALP of 135 U/L with marked improvement of symptoms.

DISCUSSION:
IgG4 related autoimmune pancreatitis (AIP) presents as cholestasis- obstructive typedue concomitant sclerosing cholangitis (SC). It is crucial to differentiate this entity from malignancy due to the availability of effective treatments. Although the typical histopathology was absent in our patient on both lymph node and pancreatic needle biopsy, it is important to highlight that fibrosis is rarely seen in lymph nodes and needle biopsy can miss the involved tissue due to its patchy involvement. In summary, we emphasize on the limitations of biopsy and propose treating patients with steroids when the clinical picture if highly suggestive of IgG4 related disease.