bluuebunny/crossref_metadata_2025_split huggingface dataset:
1321 A Choledochodoudenal Fistula Without Gallstones: A Case Report
Authors: Patel Reema , Abidian Mohamed Modar , Mehta Ripple , Patel Mitesh R. 
Published: October 2019

INTRODUCTION:
Choledochoduodenal fistulas (CDFs) are abnormal connections that form between the common bile duct and the duodenum. CDFs are rare and result from biliary tract diseases like biliary tract stones and/or infections, peptic ulcer disease, Crohn's disease and surgery. They are more common in elderly patients. CDFs may present with cholangitis-like symptoms and the diagnosis is confirmed with endoscopic retrograde cholangiopancreatography (ERCP). Treatment include therapeutic ERCP or surgery.

CASE DESCRIPTION/METHODS:
Our patient was a 31 year-old Hispanic female who immigrated recently from El Salvador. The patient presented with symptoms of right upper quadrant pain along with nausea/vomiting and low grade fever. Initial laboratories results were remarkable for white blood cell count (WBC) 14.3 × 109 L, acetate aminotransferase (AST) 493 U/L, alanine aminotransferase (ALT) 438 U/L, total bilirubin 2.4 mg/dl, direct bilirubin 0.56 mg/dl, and Alkaline phosphatase 192 U/L. Abdominal ultrasonography showed non-specific gallbladder wall thickening with dilation of the intrahepatic and extrahepatic bile duct (common bile duct diameter of 1.2 cm), and no gallbladder stones (Figure 1). The patient was admitted to the floor and started on broad-spectrum intravenous antibiotics. An urgent ERCP demonstrated a 3 mm choledochoduodenal fistula seen superior to the major papilla. The fistula was draining purulent materials (Figure 2). The common bile duct (CBD) was dilated to 12 mm with no filling defects (Figure 3). The biliary tree was drained and no stones were found (Figure 3). To ensure adequate biliary drainage, a 10 Fr × 5 cm plastic stent was placed into the CBD (Figure 3). Soon, patient clinical and laboratory profile dramatically improved and was discharged two days later with plan for outpatient follow-up.

DISCUSSION:
We are reporting a unique case of CDF that developed spontaneously in a patient who has no significant past medical history. No underlying pathology like biliary tract stones was found during the ERCP. This case may raise a question that CDFs could be sometimes idiopathic with no predisposing factors. Spontaneous CDFs are uncommon especially in young population. Only few cases in young patients had been reported in literature. The youngest patient reported in literature was a 6-year-old female who had an unusual case of recurrent cholangitis due to CDF.
1322 A Known Complication With a Delayed Presentation: A Rare Case of Biloma Formation Post-Cholecystectomy
Authors: Bergagnini Isabella , Alexandre Cassidy , Okeke Francis , Zlatanic Jusuf 
Published: October 2019

INTRODUCTION:
Biloma is an uncommon complication post cholecystectomy with a reported incidence of approximately 0.3-1.5%. While biloma formation is typically seen within weeks of surgery, there are very few documented cases of biloma formation seen years after an uncomplicated cholecystectomy, as seen in the case below.

CASE DESCRIPTION/METHODS:
A 35-year-old female with a medical history of cholelithiasis requiring cholecystectomy eight years prior presented with worsening dull right upper quadrant pain with early satiety and abdominal distention for two months. Vitals were stable with her exam notable for a palpable abdominal mass. Labs revealed a mild transaminitis. MRI demonstrated dilated bile ducts and a large 16.1 cm cystic lesion in the gallbladder fossa consistent with a biloma. 1.5 liters of proteinaceous material was drained by interventional radiology. Cultures and cytology were negative for an infectious or malignant process. HIDA scan revealed a bile leak for which she underwent an ERCP where two biliary stents were placed for a segmental duct leak. The patient clinically improved and was discharged home on antibiotics. Two outpatient ERCPs were performed, the first revealing a persistent small leak requiring stent exchange and the subsequent ERCP three months later demonstrating complete closure of the leak.

DISCUSSION:
A biloma is a demarcated collection localized outside the biliary tree often secondary to iatrogenic, traumatic and even spontaneous injury to the biliary tree. With the introduction of laparoscopic cholecystectomy, incidence of biliary injury has increased from 0.1% to about 0.3-1.5%. The pathophysiology is often secondary to either a leakage of bile from an improper closure of a cystic duct stump, transection of an accessory bile duct or duct of Luschka, or rarely from inadvertent injury of the segmental ducts. Presentation varies and can manifest with abdominal pain, nausea, fever and if large enough can result in obstructive jaundice. Diagnosis is typically 1-2 weeks post-surgery with few cases reported years post-op as seen here. Management is dependent on the size of the biloma and leak. Large bilomas often require percutaneous catheter drainage combined with ERCP with sphincterotomy and biliary stenting whereas small bilomas are treated conservatively. If refractory to endoscopic intervention, surgery may be warranted. We present this case to raise awareness of this uncommon, pathologic entity to help facilitate prompt diagnosis and treatment to avoid poor outcomes.
1338 A Rare Case of Duodenal Windsock Diverticulum; Simultaneous Biliary, and Small Bowel Obstruction
Authors: Bashir Muhammad H. , Gonzalez Lilly , Lescaille Yaniuska , Gallagher Bridget , Cheung Derrick 
Published: October 2019

INTRODUCTION:
Windsock intraluminal duodenal diverticulum (IDD) is rare congenital anomaly due to incomplete recanalization of foregut during embryogenesis. Most of the IDD are found incidentally and rarely cause symptoms. More common symptoms associated with IDD are nausea, abdominal pain and abdominal fullness. Rarely IDD can cause small bowel obstruction (SBO), pancreatitis and biliary obstruction.

CASE DESCRIPTION/METHODS:
This is the first reported case in literature of a windsock diverticulum causing SBO and biliary obstruction. A 44 year old man with no prior medical and surgical history presented to our hospital with acute onset abdominal pain, nausea, vomiting and inability to pass flatus or bowel movement for 3 days. Patient was clinically jaundiced and initial lab work up showed a total bilirubin level of 13.0 mg/dl. A CT abdomen and pelvis showed complete duodenal obstruction with suspected etiology of duodenal intussusception as well intra and extrahepatic biliary ductal dilatation (Figure 1). After NG decompression, patient underwent an upper endoscopy and small bowel enteroscopy with findings of a false lumen in second portion of duodenum showing focal areas of mucosal ulcerations but no intussusception was seen (Figure 2). An EUS was performed which did not show any intramural or extraluminal mass lesions. An ERCP was attempted for biliary obstruction but was unsuccessful due to lack of localization of ampulla of vater. Later during the endoscopic procedure, large amount of fresh bile flow was noted in the distal portion of duodenum. False lumen mucosal biopsies were reported negative for malignant cells. Patient's bilirubin level quickly and persistently trended down toward normal range post EGD. Clinically, his symptoms of bowel obstruction resolved completely. He underwent an upper GI series which showed contrast filling of large duodenal diverticulum which further confirmed the diagnosis of large windsock duodenal diverticulum (Figure 3).

DISCUSSION:
Windsock diverticulum is a true intraluminal diverticulum. In rare cases it can cause serious complications including SBO and biliary obstruction. ERCP can be challenging in case of ampullary proximity to diverticulum. Timely recognition and intervention is necessary for improved clinical outcomes. Endoscopic intervention for diagnosis and management is necessary. Endoscopic diverticulectomy can be a less invasive option for prevention of recurrence of IDD related complications especially especially in case of close proximity of ampulla to IDD.
1340 Variable Effect on the Sphincter of Oddi From Narcotics
Authors: Salas Noain Jesus M. , Gudipally Sindusha , Zheng Shengnan , Minupuri Arun , Amaral Rafael , Kinachtchouk Oleg 
Published: October 2019

INTRODUCTION:
Several studies have shown an increase in biliary pressure after administration of narcotics. Direct sphincter of Oddi (SO) manometry has demonstrated that the sphincter of Oddi is particularly sensitive to all narcotics including morphine, meperidine, pentazocine, fentanyl, and codeine. Opiates are known to increase the phasic wave (via mu receptors) as well as basal pressure (via non-mu receptors) of the SO. This case report illustrates a possible difference in affinity among narcotics to these receptors leading to SO dysfunction.

CASE DESCRIPTION/METHODS:
54 years old male with a history of knee meniscal repair presented to the emergency department with epigastric pain associated with nausea and vomiting for one day. The patient described the pain as severe, sharp, and worsening with food intake. He denied alcohol use, illicit drug abuse, or taking any medication. He had a lipase of 200 U/L, with normal transaminases and bilirubin. Physical exam revealed severe tenderness on the epigastric area. CT showed acute edematous interstitial pancreatitis. Ultrasound of the liver and HIDA scan demonstrated a patent cystic and common bile duct. The patient was started on IV fluids and IV morphine. The patient reported slight relief of abdominal pain with low doses of IV morphine. Therefore, the frequency and dose of morphine were increased. Interestingly, the patient reported acute worsening of the epigastric pain a few minutes after administration of higher morphine doses lasting for approximately 2 hours. Laboratory studies drawn during pain exacerbation showed no elevation of transaminases or lipase. IV morphine was discontinued resulting in immediate abdominal pain relief. Upon further questioning, the patient reported recent use of oxycodone and tramadol for knee pain without any side effects from these medications.

DISCUSSION:
Opiates have been reported to incite biliary colic pain and their effect on the SO represents the most likely etiology. Our patient showed a particular susceptibility to morphine, but not to other narcotics previously prescribed suggesting a possible variable effect on the OD from different narcotics. It is worth noting that our patient denied cholecystectomy, a known risk factor that predisposes to SO dysfunction. In conclusion, SO dysfunction should be considered in patients with pancreatitis reporting worsening of abdominal pain while on opioids. SO manometry is contraindicated during acute pancreatitis, therefore discontinuation of the narcotic helps guide diagnosis.
1343 A Rare Case of Lemmel Syndrome
Authors: Kumar Anila , Gollapudi Lakshmi Asritha , Lebovics Edward , Georgostathis Dimitrios 
Published: October 2019

INTRODUCTION:
Lemmel syndrome is a rare condition in which a periampullary duodenal diverticulum compresses the distal common bile duct (CBD) resulting in obstructive jaundice in the absence of choledocholithiasis or tumor. We present a rare case of Lemmel syndrome in an elderly patient below.

CASE DESCRIPTION/METHODS:
An 83-year-old woman with a past medical history of Crohn's disease and pancreatic cysts was transferred to our facility for management of biliary obstruction. She had noted a four-month history of progressive early satiety, post-prandial right upper quadrant abdominal pain, post-prandial emesis, poor oral intake, and significant weight loss. On presentation, labs were significant for WBC of 11.6 k/mm3, AST of 242 U/L, ALT of 1677 U/L, alkaline phosphatase of 1347 U/L, total bilirubin of 3.4 mg/dL, and lipase of 260 U/L. She underwent ERCP and was found to have a large periampullary diverticulum containing the major papilla. Cholangiogram revealed a tortuous bile duct and severe intra- and extrahepatic biliary dilation. A sphincterotomy was performed and multiple balloon sweeps were done with no stone extraction. A 10 F × 8 cm fully covered metal biliary stent (FCSEMS) was placed in the bile duct and she had improvement in her appetite, abdominal pain, and liver function tests. On follow up ERCP, the bile duct maintained a straightened position.

DISCUSSION:
Lemmel syndrome is characterized by obstructive jaundice caused by periampullary duodenal diverticulum (PAD) compressing the intra-pancreatic part of the CBD with resultant upstream dilatation of the extra- and intra-hepatic bile ducts. PAD is a pseudo-diverticula consisting of an extraluminal out-pouching of duodenal mucosa and lacks a muscularis layer. PAD develops within a 2-3 cm radius from the ampulla of Vater. Periampullary duodenal diverticuli are mostly asymptomatic and majority are diagnosed incidentally. When inflamed, they can cause pancreaticobiliary complications such as obstructive jaundice, cholangitis, pancreatitis, and stone formation. They are diagnosed on imaging such as CT scan, MRCP, and barium studies, which can show lateral compression of the distal CBD by the diverticulum. ERCP with sphincterotomy and biliary stent placement has shown to reduce the risk of morbidity and mortality, although diverticulectomy remains standard of care for PAD. Lemmel syndrome is rare but should be considered in the differential diagnosis for obstructive jaundice in patients with a periampullary duodenal diverticulum.
1352 Doxycycline-Induced Acute Pancreatitis: A Likely Source Rarely Seen
Authors: Hoffman Paul , Civil Wilco 
Published: October 2019

INTRODUCTION:
The diagnosis of drug-induced acute pancreatitis compared to the others causes of acute pancreatitis is estimated between 1.4 and 2%.1 Despite this association, the clinical evidence on doxycycline-induced acute pancreatitis is sparse as proving the association with a particular drug may not always be straightforward.2 In this case, we report an episode of an acute pancreatitis (AP) where well-known etiologies were ruled out and the patient was deemed to have doxycycline induced acute pancreatitis (DIAP).

CASE DESCRIPTION/METHODS:
A 71-year-old female with significant past medical history of cholecystectomy, hyperlipidemia and bullous pemphigoid presented to Regional Medical Center Bayonet Point with one-day history of epigastric pain with nausea and non-bilious emesis while eating. She denied prior history of AP or recent alcohol use. Review of systems was otherwise unremarkable. Patient did admit to using doxycycline twice daily starting a month prior to treat her bullous pemphigoid. Her only other home medication that has an association with drug induced acute pancreatic was simvastatin, which has not been changed or adjusted for several years. On physical examination, vital signs were within normal limits. Abdominal examination was positive for epigastric tenderness, otherwise unremarkable. Laboratory studies revealed: white blood cell count of 28,100 mm3; (neutrophils 92.9%); blood urea nitrogen 25 mg/dL; serum creatinine 1.33 mg/dL; sodium 138 meq/L; and serum lipase 6204 IU/L. Abdominal and pelvis tomography revealed peri-pancreatic fat stranding and fluid suggestive of acute pancreatitis. The patient was immediately started on intravenous normal saline. A magnetic retrograde cholangio-pancreatography was obtained to rule out choledocholithiasis, which revealed no extrahepatic biliary dilation, choledocholithiasis or choledochal filling. After an exhaustive work up, we determined the patient had DIAP. Doxycycline was immediately discontinued. The following day her symptoms improved. The patient recovered and was discharged.

DISCUSSION:
Tetracyclines have long been designated as causative agents in AP. Unfortunately, there have only been a few case reports of DIAP.3–5 Interestingly, several report a female patient as in this case. What makes our case unique is that doxycycline as the sole source of drug induced acute pancreatitis has rarely been reported.6–9 Further research is required to identify the mechanism of DIAP, true incidence, and additional risk factors.
1362 A Rare Case of Obstructive Jaundice and Acute Pancreatitis
Authors: Bofill Aliana , Rodriguez Esteban , Martin-Ortiz Jose 
Published: October 2019

INTRODUCTION:
Gallstones is the most common cause of both biliary pancreatitis and obstructive jaundice. Rarely, periampullary diverticula (PAD) and choledochal cysts can present with the same symptomatology. PAD is usually asymptomatic, but complications can occur in about 5% of cases. Among these, Lemmel's syndrome defined as obstructive jaundice in absence of choledocholithiasis or neoplasm and pancreatitis have been rarely reported. Choledochal cysts are abnormal dilatations of the biliary tree with type III (choledochocele) being the least common subtype, representing <5% of reported cysts. Pancreatitis is the most common clinical complication and is normally the inciting event that leads to identification of the choledochocele. We present a case of recurrent pancreatitis and obstructive jaundice secondary to Lemmel's syndrome and choledochocele.

CASE DESCRIPTION/METHODS:
Case of a 60-year-old male with history on uncomplicated pancreatitis, who presented with nausea, vomiting, epigastric pain and fever of 2 days of duration. Physical examination with diffuse abdominal tenderness. Laboratories with leukocytosis, alkaline phosphatase 202 U/L, total bilirubin 8.3 mg/L, lipase 700 U/L and amylase 1089 U/L. Abdominopelvic CT showed acute pancreatitis, no cholelithiasis or biliary tree dilation. Magnetic resonance cholangiopancreatography showed duodenal diverticulum and choledochocele. Endoscopic retrograde cholangiopancreatography revealed a large diverticuli next to the ampulla with debris and sacular appearance of the intraduodenal portion of the common bile duct (CBD) as seen in choledochocele. The pancreatic duct was normal. A pre-cut sphincterotomy was performed. There was normalization of laboratories for which he was discharge home.

DISCUSSION:
Lemmel's syndrome is caused by a periampullary duodenal diverticula causing extrinsic compression of the CBD and preventing secretion of the bile. In choledochocele, there is a dilatation of the intramural portion of the distal CBD within the duodenal wall. Both diagnoses should be included in the differential of benign biliary obstruction or pancreatitis when PAD or cyst are present in imaging. In both cases, symptomatic patients can be approach with sphincterotomy. As in our case, the patient had no further episode of pancreatitis or obstructive jaundice after successful sphincterotomy. Maintaining a high index of suspicion is required to establish an accurate diagnosis since they can mimic other cystic or solid lesions around the pancreas head.
1369 Not Feeling so Groovy: A Case of Groove Pancreatitis
Authors: Lamb Bernie , Bhat Ishfaq 
Published: October 2019

INTRODUCTION:
Groove pancreatitis is a rare form of chronic segmental pancreatitis that affects the anatomical area between the pancreatic head, duodenum, and common bile duct. Definitive etiology is unknown, however, it predominantly affects males 40 to 50 years of age with a significant alcohol use history. Groove pancreatitis is an important diagnosis to consider in the evaluation of pancreatic head lesions.

CASE DESCRIPTION/METHODS:
A 35-year-old male with past medical history significant for chronic pancreatitis and alcohol use disorder presented with complaint of acute-onset epigastric abdominal pain with associated nausea and vomiting. He reported that his last use of alcohol was three weeks prior to presentation. Laboratory studies were significant for elevated lipase at 1,591 IU/L and normal liver enzymes. CT abdomen and pelvis demonstrated an enlarged peripancreatic fluid collection between the uncinate process and horizontal portion of the duodenum. The horizontal portion of the duodenum was narrowed secondary to mass effect from the peripancreatic fluid collection. MRI with MRCP revealed fluid collections interposed between the pancreatic head and third portion of the duodenum. EGD with endoscopic ultrasound was performed and showed induration and edema of the second portion of the duodenum and anechoic cysts present in the duodenal wall. Biopsies were obtained during EUS via FNA and were negative for pancreatic adenocarcinoma. Together, these findings were consistent with a diagnosis of groove pancreatitis. The patient clinically improved with conservative medical management: fluid resuscitation, analgesia, antiemetics, and pancreatic enzyme supplementation.

DISCUSSION:
Groove pancreatitis is characterized by fibrosis in the “groove” area between the pancreatic head, duodenum, and common bile duct. Characteristic findings include cystic lesions in the duodenal wall and duodenal stenosis. It poses a challenge to clinicians, as its presentation may be similar to that of pancreatic adenocarcinoma. It is important for clinicians to be aware of this disease entity and consider it in evaluation of pancreatic head lesions.
1381 Bile Reinfusion in Obstructive Jaundice
Authors: Khurana Shruti , Larson Scott 
Published: October 2019

INTRODUCTION:
Bile acid and salts depletion from percutaneous transhepatic cholangiodrainage (PTCD) in obstructive jaundice can lead to fat malabsorption causing malnutrition and fat-soluble vitamin deficiencies, dehydration, acute kidney injury (AKI) and electrolyte abnormalities. Bile reinfusion (BR) is a method of enteral feeding of biliary drain secretions for restoration of bile salts in the gut. We describe a case of oral BR in a patient with PTCD for choledocholithiasis.

CASE DESCRIPTION/METHODS:
A 64 year-old Caucasian woman with history of gastric adenocarcinoma requiring subtotal gastrectomy and roux-en-y gastric reconstruction presented with nausea, vomiting, and epigastric pain. Imaging showed a stone in the mid common bile duct (CBD) measuring 0.7 × 0.6 cm causing mild biliary dilation. An endoscopic retrograde cholangiopancreatography (ERCP) was attempted with unsuccessful cannulation due to abnormal anatomy from prior surgeries. Hence, an open CBD exploration was performed for stone extraction and a 14 French percutaneous T-tube was placed for PTCD. Post-operatively, she developed large volume output (∼1-2 L/day) from the T-tube, loose stools and AKI with rise in creatinine from 1.12 to 2.96 mg/dL. She was started on BR 4 times/day by mouth (mixed with juice in 1:1 ratio). Over the next few weeks, she had resolution of diarrhea with a slow renal recovery.

DISCUSSION:
BR has shown variable success as reported in a few case reports and small studies mainly focusing on patients with pancreatitis with enteric fistulae, and obstructive cholangiocarcinoma.
1,2
Tripathy et al. demonstrated that it is a cost-effective method for hastened renal recovery, a common complication in patients with obstructive jaundice.
3
In conclusion, BR should be considered in patients with PTCD as an alternate to exogenous bile salt administration for improved enterohepatic equilibrium.