bluuebunny/crossref_metadata_2025_split huggingface dataset:
1427 Minimally Invasive Treatment for Severe Acute Pancreatitis With Colonic Stenosis
Authors: Cen Dong , Shen Bo , Wang Yanting , Wan Zhe , Cai Xiujun 
Published: October 2019

INTRODUCTION:
Colonic stenosis is a rare complication of acute pancreatitis (AP). It may be the consequence of inflammation and necrosis caused by AP. Early intervention is necessary, since the progression of colonic stenosis in AP leads to high mortality. We present a case of stenosis of right colic flexure in AP with total minimally invasive treatment.

CASE DESCRIPTION/METHODS:
A 73-year-old male patient with severe AP due to biliary lithiasis was transferred to our hospital because of recurrent infection and fever at the local hospital. The patient had upper and right lower quadrant abdominal pain at admission. Computed tomography (CT) revealed enveloping necrosis around pancreatic head and exudation of the ascending mesenteric side. CT-guided percutaneous catheter drainage was performed to relieve abdominal and peripancreatic abscess. One week after admission, the patient experienced acute onset severe dull pain in the lower right abdomen. CT showed closed loop ileus from ascending colon to transverse colon (Figure 1a). The colonoscopy revealed the stenosis of right colic flexure and adjacent part of transverse colon and the narrow section was 6 cm (Figure 2a). A fully covered intestinal stent (2 cm × 10 cm) was implanted under colonoscopy (Figure 2b, c). Postoperative CT revealed intestinal stent was in place (Figure 1b). The symptom was quickly controlled after implantation. Meanwhile, pancreatic duct stent was implanted to control the pancreatic fistula. The patient recovered smoothly with the supportive treatment and irrigation tubes were removed before discharge. After 2 months of discharge, CT presented a little necrosis around pancreas and colonic stenosis disappeared (Figure 1c). It was found that the stent had been extruded and right colonic flexure was slightly narrow by colonoscopy (Figure 2d).

DISCUSSION:
Colonic stenosis secondary to AP is uncommon. It may result from diffusion of inflammation by pancreatic enzymes and pancreatic necrosis. The anatomic relationship of the pancreas and large bowel is an important factor. In this case, stenosis of right colonic flexure is related with necrosis around pancreatic head. Colonic stenosis in AP can progress to colonic ischemia, necrosis and perforation, leading to very poor prognosis It needs operation and resection. Therefore, timely treatment is important. Here, we used total minimally invasive techniques, including implantation of pancreatic duct stent and colonic stent, to prevent detrimental consequence. The prognosis of the patient is good.
1430 Spontaneous Perforation of an Acalculous Hydropic Gallbladder in a Diabetic Patient With Neuropathy: An Under-Diagnosed Entity
Authors: Amarnath Shivantha , Polavarapu Abhishek , Gumaste Vivek 
Published: October 2019

INTRODUCTION:
Gallbladder hydrops (HGB), a gradual increase in volume of the gallbladder in the absence of inflammation or abnormalities of the biliary tract, is under-reported due to various diagnostic criteria used worldwide. The primary cause is cholelithiasis, and initial management is often conservative as they are mostly clinically silent. Surgery is considered for complications of HGB. The universal rise in prevalence of diabetes mellitus (DM) has led to a concomitant increase in the incidence of gallbladder diseases. We report a case of a diabetic patient who presented with viral gastroenteritis and was found to have non-traumatic spontaneous rupture of a HGB.

CASE DESCRIPTION/METHODS:
78-year-old male with a complicated cardiac history including heart failure with placement of an automated implanted cardioverter, and non-insulin dependent DM with neuropathy exhibited one-day history of crampy, epigastric abdominal pain with non-bilious, non-bloody vomiting and watery diarrhea. Recently, his grandson was diagnosed with viral gastroenteritis. Patient was afebrile with unremarkable laboratory findings. CT of the abdomen with contrast highlighted a 6.7 cm × 11 cm HGB without cholecystitis or biliary ductal dilatation. Gallbladder ultrasound demonstrated sludge without evidence of wall thickening, gallstones, or pericholecystic fluid. Surgery recommended medical optimization and outpatient cholecystectomy due to his high risk (ASA III). He was admitted for viral gastroenteritis and began IV hydration. Hours later, patient endorsed worsening epigastric pain radiating to the right flank. HIDA scan revealed patency of the cystic duct with evidence of free biliary leak within the right peritoneal cavity. IV antibiotics were initiated followed by emergent cholecystectomy which uncovered a spontaneously perforated gallbladder with ruptured biliary contents into the peritoneum. Later, he developed septic shock, multi-organ failure, and expired on day 6.

DISCUSSION:
HGB, although rare, is frequent in the DM population and can present with serious complications. Our literature review uncovered that diabetics can develop HGB even in the absence of gallstones. Autonomic dysfunction affecting gallbladder contractility and reduced sensitivity of the gallbladder wall to cholecystokinin are key mechanisms. A sonogram may be used to screen for gallbladder dysfunction in diabetics, and if HGB is identified, we propose prophylactic cholecystectomy at an appropriate moment to significantly reduce morbidity and mortality.
1433 A Case of Cocaine-Induced Pancreatitis
Authors: Tian Frances , Strzepka Jessica , Garcia-Bedoya Olga , Yazici Cemal 
Published: October 2019

INTRODUCTION:
Cocaine-induced pancreatitis is a rare and likely under-reported entity. Physicians must maintain a index suspicion when treating patients with cocaine use who present with abdominal pain especially if they are also on other concomitant medications that increase the risk of acute pancreatitis.

CASE DESCRIPTION/METHODS:
A 61-year-old male with cocaine abuse and heart failure with reduced ejection fraction (HFrEF) presented with 3 days of epigastric abdominal pain, nausea, and vomiting. His last intranasal use of cocaine was a few days prior to onset of symptoms. Lipase was 2300 (U/L) and computed tomography of the abdomen (CT) demonstrated an edematous and homogeneously enhancing pancreas with a small amount of peripancreatic fluid. Abdominal ultrasound was negative for cholelithiasis. Patient had a remote history of alcohol use but denied recent alcohol abuse. Toxicology was positive for cocaine on day of admission. An ethanol level was not obtained. Triglyceride, IgG4, and calcium levels were within normal limits. Notably, the patient was also hospitalized two months prior to present presentation for new onset left cerebellar stroke. Upon further evaluation, the patient was found to have a left ventricular ejection fraction of 30-35%, consistent with new diagnosis of HFrEF. The patient was started on metoprolol prior to discharge. Based on lack of other identifiable causative factors, patient's pancreatitis was attributed to concurrent cocaine and beta-blocker use.

DISCUSSION:
Pancreatitis is the most common gastrointestinal diagnosis resulting in admission, costing 2.6 billion dollars annually. The most common etiologies are gallstones and alcohol. Few cases of cocaine-induced pancreatitis have been reported in the literature. Cardiovascular and central nervous system (CNS) toxicities of cocaine such as acute coronary syndromes, chest pain, agitation, and strokes are well documented. Acute gastrointestinal complications of cocaine use are less common however usually include ischemic bowel and related perforation. There are only 5 reported cases of cocaine-induced pancreatitis. The mechanism of action of cocaine is inhibition of noradrenaline re-uptake, which produces vasoconstriction and thrombosis of mesenteric vessels. The pathophysiology of cocaine-induced pancreatitis is postulated to be related to vasoconstriction and thrombotic microangiopathy. In this patient, prior heavy alcohol may have led to underlying parenchymal disease and concomitant use of a beta-blocker were likely additive.
1434 A Rare Case of Multiple Myeloma Presenting as Pancreatic Plasmacytoma Causing Obstructive Jaundice
Authors: Achufusi Ted George 
Published: October 2019

INTRODUCTION:
Extramedullary plasmacytomas represent a rare type of plasma cell tumors which can present outside of the bone marrow. Although extremely uncommon, they should be considered in the differential diagnosis when it comes to obstructive jaundice and pancreatic malignancy. Here, I present a case of obstructive jaundice caused by extramedullary plasmacytoma mimicking an adenocarcinoma, diagnosed by endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA).

CASE DESCRIPTION/METHODS:
A 72-year-old Caucasian male patient presented to our hospital with complaints of fatigue and painless jaundice. On admission, his liver biochemistries were abnormal with ALT 417, AST 414, ALP 1309, T bili 15.9, D bili 13.4, with normal lipase, amylase and WBC. CT abdomen was significant for a large mass adjacent to the pancreatic head along with multiple retroperitoneal and intra-abdominal nodules. Subsequently, patient underwent EUS with FNA of the pancreatic lesion. Tissue biopsy was positive for plasmacytoma. Follow up ERCP was unsuccessful as CBD could not be cannulated due to bulging papilla. As such, IR guided biliary drainage was placed with successful decompression of the biliary tree and corresponding improvement in liver biochemistries. Further workup showed evidence of widespread plasmacytomas including involvement of heart and bone.

DISCUSSION:
Pancreatic plasmacytomas remain a rare entity, with only five percent of all plasma cell tumors occurring outside of the bone marrow. This case documents a rare occurrence of visceral involvement of multiple myeloma, brought to clinical attention by atypical involvement of pancreatic head and body. Gastrointestinal plasmacytomas are usually limited to the liver and stomach, with only a limited amount of cases describing pancreatic involvement. Most reported cases describe microscopic plasma cell infiltration of the pancreas, making this presentation of a well-formed mass unusual. Availability of EUS and FNA sampling has made it easier for clinicians to diagnose plasmacytomas, as radiological differentiation of these tumors from other pancreatic malignancy is difficult. Furthermore, it is imperative to make the correct tissue diagnosis as prognosis and management differs from other pancreatic malignancy. This case highlights the importance of keeping a broad differential when suspecting a pancreatic malignancy in a patient with obstructive jaundice and those with history of plasma cell disorders.
1435 Pancreaticoenteric Fistula: A Very Unique Complication of Acute Pancreatitis
Authors: Rodriguez Ramos Roberto J. , Amill Reinaldo Ramirez 
Published: October 2019

INTRODUCTION:
Pancreaticoenteric fistulas are a rare complication of acute pancreatitis. Spontaneous fistulation has been described in the literature in cases where acute pancreatitis is complicated with infection or necrosis. As a direct consequence to the fistula formation, direct vascular injury may occur, resulting in blood loss and rapid clinical deterioration.

CASE DESCRIPTION/METHODS:
A 77-year-old male with past medical history of essential hypertension, type 2 diabetes mellitus and coronary artery disease status post coronary artery bypass grafting in 2017 was brought to Emergency Room due to sudden onset right leg pain. He was admitted due to subacute limb ischemia and started on antiplatelet and anticoagulation medical therapy. Hospital course complicated with abdominal pain and four episodes of large volume port wine stools per rectum and significant drop in hemoglobin levels. After initial resuscitation measures, which include intravenous hydration and supportive blood products transfusions, patient was consulted to Gastroenterology service for evaluation and recommendations. Esophagoduodenoscopy revealed large clean base ulcerated lesion with an associated fistulous process in the first portion of the duodenum. No active bleeding nor blood remnants were noted. Abdominopelvic CT scan was immediately done and showed extensive devitalization of the pancreas along with large peripancreatic fluid collection with abundant internal gas suggestive of a contained perforation of duodenum. Interventional radiology and General surgery was consult.

DISCUSSION:
Spontaneous pancreaticoenteric fistula in the setting of pseudocysts formation secondary to necrotizing pancreatitis is a very rare and unique complication. Typical management is conservative, with medical therapy resulting in closure of the vast majority of fistulas. The infrequency with which pancreaticoenteric fistulas are encountered makes them a formidable diagnostic and treatment challenge. Even though it has been described in the literature, there still much to investigate regarding upper gastrointestinal fistulas and its associated vascular complications after acute pancreatitis.
1436 Extreme Elevation of Pancreatic Enzymes in Severe Acute Renal Failure
Authors: Saliaj Merjona , Llukani Elton , Saeed Mariam , Bachan Moses 
Published: October 2019

INTRODUCTION:
Serum amylase and lipase are important biomarkers to diagnose acute pancreatitis with a specificity of 89 and 93%, and sensitivity of 72% and 79%, respectively. Their elevation is common in pathologies such as acute cholecystitis, ketoacidosis, inflammatory intestinal disease, sepsis and renal insufficiency.

CASE DESCRIPTION/METHODS:
58 y/o male with type 2 diabetes mellitus, hypertension, and hyperlipidemia was admitted with generalized weakness, dizziness and multiple episodes of non-bloody watery diarrhea for one week. Physical exam was remarkable for left lower quadrant (LLQ) abdominal tenderness, bilateral lower extremity edema, and pulmonary congestion. Laboratory tests showed pre-renal acute kidney injury (AKI) with creatinine of 10.3, BUN of 121, metabolic acidosis, and hyperkalemia requiring emergent hemodialysis, leukocytosis of 17 per nL, and stool studies were positive for clostridium difficile infection (CDI). Interestingly he also had extremely elevated lipase of 3913 U/L and amylase of 1046 U/L in the absence of clinical and radiographic findings (CT and ultrasound abdomen) of acute pancreatitis. CDI was successfully treated with oral vancomycin. After a prolonged hospital course patient, his kidney function improved, and he did not require additional dialysis upon discharge.

DISCUSSION:
The diagnosis of pancreatitis requires the presence of two out three criteria including elevation of pancreatic enzymes 3 times or more above the upper normal limit (UNL), clinical presentation and radiologic findings suggestive of pancreatitis. Up to 10% of acute pancreatitis patients lack classic epigastric pain. In our patient the abdominal pain was located on the LLQ, likely related to CDI. The only suspicion for acute pancreatitis in this clinical case was the impressive 60 folds elevation of lipase and 10 fold elevation of amylase. In AKI, amylase has been shown to increase up to 10 folds the upper normal limit, while the lipase increase is usually less dramatic, reaching 3-5 folds the UNL. To identify the pancreas-originated enzyme increase we can perform additional tests including isoenzymes (isoamylase and isolipase), trypsin, and elastase levels. Elastase 1 is a highly specific enzyme for pancreatitis, not affected by reduced renal clearance found in AKI. In conclusion, an extreme elevation of amylase and lipase in the setting of severe AKI can be noted in the absence of acute pancreatitis. Interpretation of these laboratory values must be correlated with the clinical presentation.
1448 Acute Pancreatitis in a Patient With Left-Sided Diverticulitis
Authors: Ahmad Minhaz , Bella Saif , Saleem Atif 
Published: October 2019

INTRODUCTION:
Acute pancreatitis is a leading gastrointestinal cause of hospitalization. Several conditions are associated with pancreatitis, with gallstones and chronic alcohol abuse causing approximately two-thirds of cases. In rare instances, acute pancreatitis has been associated with intraluminal or periampullary duodenal diverticulitis and right-sided colonic diverticulitis. We present a case of acute pancreatitis associated with left-sided colonic diverticulitis.

CASE DESCRIPTION/METHODS:
43-year-old non-alcoholic female with history of sigmoid diverticulosis presented to the ambulatory clinic with worsening epigastric pain radiating to the neck and back. Epigastric tenderness was evident on physical examination. Initially, she was treated empirically with proton-pump inhibitor for presumed gastritis. Her symptoms persisted for one month and was associated with hematochezia. CT of the abdomen and pelvis with contrast revealed inflammatory change within proximal descending colon, with ovoid fluid distended structure consistent with acute diverticulitis and fat stranding of the pancreatic tail. She was admitted to the hospital where labs revealed serum lipase of 1202, Calcium 9.2, liver biochemical tests were within normal range. Further workup showed triglycerides and immunoglobulins were unremarkable, tissue transglutaminase reported being negative, calprotectin was elevated to 380 mcg/g. Ultrasound showed no evidence of cholelithiasis. In addition to bowel rest, she was treated with IV antibiotics for diverticulitis and IV Ringer's Lactate for pancreatitis. Later on, symptoms resolved. CT abdomen-pelvis with contrast was repeated and demonstrated resolution of the inflammatory changes in both the colon and pancreas. Outpatient endoscopy showed a small hiatal hernia, non-erosive gastritis and normal duodenum. Colonoscopy showed moderate diverticulosis in the descending colon and sigmoid colon. Gastric, duodenal and colonic biopsy did not show any abnormality. Her acute pancreatitis may be associated with diverticulitis of the proximal descending colon.

DISCUSSION:
There have been many cases of duodenal diverticulitis associated with acute pancreatitis. There has been one case report of acute pancreatitis associated with right-sided colonic diverticulosis. There is no case report available with any association of acute pancreatitis and left-sided diverticulitis. Pancreatitis may also be associated with left-sided diverticulitis.
1451 A Caroli Look-Alike
Authors: Rodriguez-Berrios Frances , Santiago Loscar , Acosta Eduardo , Class-Vazquez Walisbeth 
Published: October 2019

INTRODUCTION:
Peribiliary cysts are a rare entity usually found in patients with chronic liver disease and polycystic kidney disease. Patients are mostly asymptomatic therefore it is identified at times incidentally by abdominal imaging. Differential diagnosis include cholangiocarcinoma, Caroli disease and primary biliary cirrhosis. Awareness is essential to avoid misdiagnosis and unnecessary procedures including biopsies and surgeries.

CASE DESCRIPTION/METHODS:
A 67-year-old female with cirrhosis secondary to NASH and portal hypertension, among other comorbidities was evaluated at GI clinics. Abdominal sonogram performed for hepatocellular carcinoma surveillance showed right and left intrahepatic biliary ductal dilatation. The common bile duct measured 0.35 cm and the gallbladder showed intraluminar posterior acoustic shadows suggestive of cholelithiasis without wall thickening or pericholecystitic fluid collections. Patient denied fever, chills, abdominal pain, nausea or vomits. Abdomen was benign. Laboratories remarkable for baseline thrombocytopenia of 71, normal ALT and AST, elevation of alkaline phosphatase to 171 and hyperbilirubinemia of 3. MRCP was performed for further evaluation which showed multiple hyperintense rounded lesions tracking along the intrahepatic and extrahepatic biliary as seen with peribiliary cysts.

DISCUSSION:
Peribiliary cyst are usually associated to alcoholic cirrhosis with a prevalence of 9%; while in they have not been described in NASH. Pathophysiology may be due to intrahepatic circulatory disturbances of the portal venous system. Possible complications include biliary tract dilatation, obstructive jaundice and cholangitis.
1456 A Case of Syphilitic Proctitis in a Newly Diagnosed Patient With HIV
Authors: Agrawal Rohit , Attar Bashar M. , Mutneja Hemant , Majeed Muhammad , Randhawa Tejinder , Omar Yazan Abu , Chicas Oscar Rivas 
Published: October 2019

INTRODUCTION:
Rectal pain and hematochezia are common symptoms of anorectal pathology. Sexually transmitted infections such as gonorrhea, chlamydia and syphilis are often implicated as infectious etiologies of such symptoms in men who have sex with men. We report a case of young male who presented with rectal pain, hematochezia and weight loss and was concomitantly diagnosed with syphilitic proctitis and HIV.

CASE DESCRIPTION/METHODS:
A 35-year-old bisexual male presented with a 9 months history of rectal pain, hematochezia and involuntary 30 pounds weight loss. Initial laboratory tests revealed normocytic anemia with a hemoglobin of 9.2 gm/dl, ferritin of 81.1 ng/ml, a positive HIV test with CD4 count of 50 cells/microL. Colonoscopy demonstrated large, semi-circumferential ulcers around 10 cm from the anal verge (Figure 1). Biopsy of the ulcerated lesions revealed chronic active colitis with cryptitis, crypt abscess and destruction. Numerous spirochetes were identified on Warthin-Starry and Steiner stains in the ulcerated mucosa and random biopsies of colon (Figure 2). Enzyme immunoassay (EIA) and rapid plasma reagin (RPR) for syphilis were positive with a RPR titer of 1:256. He was treated with benzathine penicillin 2.4 million units intramuscularly once a week for 3 weeks for syphilits proctitis along with anti-retroviral medications. He had resolvement of symptoms on subsequent follow up visit at 6 months with a repeat RPR of 1:64 suggesting an adequate serological response.

DISCUSSION:
Anorectal syphilis can either present as a chancer in primary infection or proctocolitis as a manifestation of secondary infection. Establishing a diagnosis often requires endoscopy for visualization of colonic inflammation, histopathology for documentation of spirochetes and serological test such as EIA and RPR to identify Treponema palladium. The histopathological features of syphilitic proctitis can mimic that of inflammatory bowel disease in which case the microbiological stains such as Warthin-Starry and Steiner aid in diagnosis. As proctocolitis is a manifestation of secondary syphilis, treatment includes Penicillin G benzathine 2.4 million units IM once. With the rise in the MSM population, cases of syphilis are more frequently being encountered and therefore syphilitic proctitis should be a common differential in such patients presenting with lower gastrointestinal symptoms.