Abdominal Computed Tomography Angiography Research Articles

An Evaluation of Firearm Injuries in the Emergency Department.

IntroductionFirearm injuries are a significant cause of mortality and morbidity. Our study aims to evaluate the injury patterns, results of imaging studies, treatment methods, outcomes, and mortality rates of patients who were admitted to the emergency department with firearm injuries.MethodsOur study was designed as a retrospective descriptive study. To this end, adult patients who were admitted to our hospital with gunshot wounds between January 1, 2017, and July 31, 2021, were screened. The files of 527 patients who were admitted with gunshot wounds were analyzed. A total of 30 patients were excluded from the study due to missing data. Statistical analyses were performed using the data of a total of 497 patients. Independent variables of the study included sex, age, systolic blood pressure (SBD), diastolic blood pressure (DBD), pulse, respiratory rate, Glasgow Coma Scale (GCS) score, range of shot, injury site, X-ray, cranial CT, thorax CT, abdominal CT, and extremity CT angiography findings, and the need for treatment and referral. Mortality was the dependent variable of the study. A logistic regression model was created to predict factors affecting the survival of the patients who were admitted to the emergency department with gunshot wounds and to identify the independent variables affecting survival. A p-value of <0.05 was considered sufficient for significance.ResultsThe majority of patients who were admitted to the emergency department due to gunshot wounds were male and the median age of the patients was 32 years (18-70 years). The comparison of the descriptive characteristics with respect to survival revealed that the systolic and diastolic blood pressures and GCS scores of the deceased patients were significantly lower than those of the survivors. The rate of shooting at short range was significantly higher in the deceased patients when compared to that of the survivors. In addition, the rate of the need for surgical intervention and the incidence of pneumocephaly in cranial CT were higher in the deceased patients than in the survivors. Significantly higher rates of deceased patients required referral to neurosurgery and thoracic surgery clinics than survivors. The patients who were referred to the thoracic surgery clinic had an increased death rate by 29-fold and the patients who were referred to the thoracic surgery clinic had an increased death rate by about nine-fold. On the other hand, the probability of death was reduced by about half when the GCS scores of the patients were higher.DiscussionWe evaluated GCS in our patient group and determined a significantly lower score in the patients who did not survive, which agrees with the findings of other studies. Patients with higher SBD and DBD showed a higher probability of survival, which agrees with the results in other studies. Most patients were shot from their extremities and none had died while the death rate was significantly higher in the patients who suffered injuries to the head or neck. The patients with pneumocephalus had a very low chance of survival. Compared to wound care and dressing, patients who received surgical treatment were more likely to die as these patients had more critical injuries.ConclusionAlthough most injuries were to the extremities, there were no mortalities in the cohort of patients referred to orthopedics. The patients who suffered injuries to the head/neck had the highest mortality rate.

S1615 Empagliflozin-Associated Pancreatitis: A Consideration for SGLT2 Inhibitors

Introduction: Empagliflozin is a drug in the new class of diabetic medications sodium-glucose cotransporter-2 (SGLT2) inhibitors, indicated for treating type 2 diabetes mellitus. The mechanism of action of empagliflozin is to reduce renal reabsorption of glucose and increase its urinary excretion. Although rare in occurrence (less than 0.1%), drug-induced acute pancreatitis (DIAP) should be considered an adverse effect in patients treated with SGLT2 inhibitors. We report a case of a 47-year-old man who presented with severe epigastric abdominal pain found to have DIAP in the setting of empagliflozin use. Case Description/Methods: 47-year-old man with a history of abdominal aortic aneurysm status after stent placement, hypertension, and type 2 diabetes mellitus presented with severe, epigastric abdominal pain, nausea and vomiting for 2 days duration. The patient denied a history of pancreatitis, consuming alcohol, narcotic use, recent trauma, surgical procedures, or exposure to venomous animals. The patient was admitted for management of pancreatitis. Social history was negative for smoking, alcohol ingestion or illicit drug use. Home medications included empagliflozin (initiated 2 months prior), atenolol, and hydrochlorothiazide (HCTZ). He had no significant family history. Vital signs were within normal limits on admission. On physical exam the epigastrium was tender to palpation. Laboratory workup revealed an elevated lipase of 220 mg/dL. Other laboratory findings were unremarkable, including no eosinophilia, triglyceride level of 123 mg/dL (drawn fasting 1 day after admission), normal electrolyte levels, and liver function tests. Abdominal computed tomography angiography was obtained to evaluate the aortic stent and the pancreas, which revealed fat stranding and pancreatic inflammation in the head of the pancreas (Figure 1). Conservative treatment was initiated included intravenous hydration and pain management. Empagliflozin was held and discontinued on discharge. The patient has not had any further episodes of pancreatitis or gastrointestinal complaints at the 2-month outpatient follow-up. Discussion: As mentioned above, our patient had been started on empagliflozin therapy approximately 60 days before presentation. We believe that this timeframe further supports the likelihood of a causal relationship. This case demonstrates that SGLT2 inhibitors, although a rare cause, should be considered an important part of a clinician's differential when other common etiologies of pancreatitis have been excluded.Figure 1.: Abdominal computed tomography angiography—pancreatic fat stranding around the head of the pancreas consistent with acute pancreatitis (white arrow). Normal gallbladder without the presence of gallstones (red arrow).

S3011 Caught up in You: A Rare Complication of Roux-en-Y Gastric Bypass Surgery

Introduction: Internal hernias are the most common complication of Roux-en-Y gastric bypass surgery. A large percentage are through Petersen’s space: a potential space between the transverse mesocolon and retroperitoneum. If present, internal hernias can cause significant morbidity due to small bowel obstruction and mesenteric or bowel ischemia. Case Description/Methods: A morbidly obese 72 year old woman with a history of Roux-en-Y gastric bypass surgery 7 years ago, atrial fibrillation, COPD, cirrhosis, and treated hepatitis C, presented with acute post-prandial epigastric abdominal pain radiating retrosternally with nausea and vomiting. Patient was hemodynamically stable but uncomfortable. Her abdomen was diffusely tender with guarding. Upon admission, she was febrile (38.4°C). She also developed large volume hematochezia with an acute drop in hemoglobin from 12.3 to 9.3g/dl. Abdominal CT angiography revealed a superior mesenteric artery occlusion, extensive small bowel ischemia of the jejunum and ileum, and changes consistent with a post-bariatric internal hernia. Exploratory laparotomy revealed herniation of the distal Roux limb through Petersen’s space with ischemic bowel segments; 42cm of ischemic bowel proximal to the jejunojejunal junction was resected. Post-operative course was complicated by prolonged intubation and ventilator associated pneumonia. She expired after 30 days in the intensive care unit. Discussion: This is one of the first recorded cases of SMA occlusion due to an internal hernia following a Roux-en-Y gastric bypass procedure. The retrocolic Roux limb approach taken during her bypass and the absence of mesenteric defect closure attributed to this complication. Meta-analysis shows the incidence of internal hernia nearly doubles in patients who undergo the retrocolic Roux limb approach in contrast to antecolic. In a retrospective study, the incidence of internal hernias nearly doubled when the mesenteric defects were not sutured closed intra-operatively. Our case emphasizes the need to consider small bowel ischemia in patients with a history of Roux-en-Y gastric bypass presenting with abdominal pain and hematochezia.Figure 1.: Superior Mesenteric Artery within the Petersen's space internal hernia causing obstruction

Application of 70 kVp in abdominal CT angiography to reduce both radiation and contrast dosage and improve patient comfort for children.

Low-tube voltage scanning improves CT attenuation value of contrast medium (CM). Thus, we hypothesized that 70 kVp in pediatric abdominal CT angiography (CTA) could be used to reduce both radiation and CM dose and improve patient comfort at the same time. To evaluate the feasibility of using 70 kVp in pediatric abdominal CTA to reduce radiation dose and CM dose and improve patient care for children. Forty-six children needing abdominal CTA were enrolled in the study group using low-dose scanning protocol with 70 kVp and 0.7-1.1 ml/kg contrast dose, and reconstructed with 50%ASIR-V. They were compared with other 46 children in control group with matching body weight and underwent conventional CT scans with 100 kVp, 1.2-1.8 ml/kg contrast dose and reconstructed using 50%ASIR. Image quality of large vessels was evaluated using a 5-point scale. CT value and standard deviation of descending aorta (Ao) was measured, and signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. Radiation dose, contrast dose, the maximum injection pressure between the two groups were also compared. Score for displaying large vessels by 70 kVp images was 3.91±0.28, lower than that (4.17±0.38) of the control group (p < 0.05), but fully met the diagnostic requirements. CT value of Ao was 390.87±86.79HU in study group, which is higher than 343.93±49.94HU in control group, while there was no difference in SNR and CNR between two groups; the radiation dose, contrast dosage and injection pressure of the study group were 1.23±0.39mGy, 12.67±7.27 ml and 43.83±17.16psi, respectively, which are significantly lower than the 1.95±0.37mGy, 22.67±7.39 ml, and 77.59±19.68psi of control group. Use of 70 kVp in pediatric abdominal CTA provides diagnostic quality images while significantly reduce radiation and contrast dose, as well as injection pressure to improve patient comfort for children.

Anatomy of testicular artery: A proposal for a classification with MDCT angiography

PurposeKnowledge of normal anatomy and variations of testicular arteries are critical for planning before minimally invasive surgery. In this article, we aimed to evaluate the morphological characteristics of testicular arteries by MDCT and propose a new classification system. MethodA total of 400 adult patients (total of 819 testicular arteries) who underwent abdominal CT angiography examination for several unrelated reasons were enrolled in this study. Testicular arteries (TAs) were evaluated in terms of number, origin, course, and caliber. Based on our findings, we also proposed a novel anatomical classification for the TAs according to their origin (divided into 5 types—type 1–5—) and course (divided into three types—type a-c—). Type 4 origin and type a course are the expected normal origin and course of bilateral TAs. ResultsThe most common type based on the origin was type 4, with the testicular artery originating from the abdominal aorta, inferior to the level of the renal artery within 5 cm distal to the renal arteries. 70.7% of the right and 75.6% of the left testicular arteries were type 4. The most common type of the vessel course was the normal expected trajectory (type a) with an incidence of 76.3% for the right and 82.6% for the left testicular arteries. ConclusionNormal anatomy and variations of testicular arteries may be effectively evaluated by CT angiography in a non-invasive manner.

Splenic artery pseudoaneurysm complicated by haemorrhage into pancreatic pseudocyst: a clinical case

Background. Splenic artery pseudoaneurysm is a rare complication of acute and chronic pancreatitis caused by an arterial wall lesion with aggressive pancreatic enzymes and followed by arrosive bleeding into pseudocyst lumen and the formation of a dense fibrous capsule prone to growth.Clinical Case Description. Patient M., 61 yo, was emergently admitted to Territorial Clinical Hospital No. 2 with a preliminary diagnosis: Chronic pancreatitis, incomplete remission. Pancreatic pseudocyst. Condition after endoscopic papillosphincterotomy, pancreatic duct stenting. Gastrointestinal haemorrhage. The patient complained of moderate persistent belting upper abdominal and left subcostal pain, nausea, general weakness, black liquid stool over last five days. Pancreonecrosis in history. Pseudocyst formation in two months, endoscopic papillosphincterotomy and pancreatic stenting in hospital, the aforementioned complaints appeared past three months. Moderate anaemia (haemoglobin 73 g/L, erythrocyte count 2.8 x 1012), hyperamylasaemia (amylase 170 U/L), no other pathology in general and biochemic blood panels. The patient was rendered urgent oesophagogastroduodenoscopy for large duodenal papilla, with no evident bleeding detected. Abdominal CT angiography revealed a haemorrhagic mass connected with splenic artery lumen in the projection of pancreatic tail. The patient was transferred to an interventional radiology room for coil embolisation of splenic artery. The postoperative period was benign, and the patient discharged on day 3 after surgery for outpatient surgical patronage. Definite clinical diagnosis: Chronic pancreatitis, incomplete remission. Splenic artery pseudoaneurysm with haemorrhage into pancreatic pseudocyst. Condition after endoscopic papillosphincterotomy, pancreatic duct stenting.Conclusion. Splenic artery pseudoaneurysm with haemorrhage into pancreatic pseudocyst is reluctant to early diagnosis due to a lacking definite clinical picture and tractable only at an interdisciplinary institution disposing with a rich diagnostic toolkit and sufficiently qualified medical personnel. Endovascular treatment is overall most effective and enables a reliable aneurysm isolation from the splenic artery basin.

Visualization of small visceral arteries on abdominal CT angiography using ultra-high-resolution CT scanner

PurposeTo evaluate the image quality and ability to delineate the small visceral arteries of high-resolution (HR) abdominal CT angiography (CTA) using an ultra-high-resolution computed tomography (UHR CT) scanner.Materials and methodsThirty-seven patients were enrolled who underwent abdominal CTA using a UHR CT scanner. The images were reconstructed with a matrix of 1024 × 1024 and 0.25 mm thickness for HR CTA and with a matrix of 512 × 512 and 0.5 mm thickness for normal resolution (NR) CTA. Maximum CT value, image quality, and delineation of the small arteries were compared between HR CTA and NR CTA.ResultsHR CTA showed significantly higher maximum CT value, higher image quality, and better delineation of the small arteries than did NR CTA (P < .005).ConclusionHR CTA using a UHR CT scanner showed higher image quality than NR CTA and enhanced the delineation of visceral arteries.

Catastrophic Presentation of a Ruptured Pheochromocytoma

Background: Pheochromocytoma is a catecholamine-secreting tumor, encountered in less than 0.5% of patients with hypertension and around 4% of patients with adrenal incidentaloma.1 It classically presents with episodic headache, sweating, and hypertension but rarely can present with serious complications such as hypertensive, pheochromocytoma crisis, and hemorrhagic shock. Clinical Case: We report a 49-year-old male patient with a history of hypertension for five years on Amlodipine but not compliant. Presented to the Emergency Department with sudden onset left severe flank pain associated with one episode of vomiting for six hours. Vital signs were stable, and basic labs were within normal. Bedside ultrasound couldn’t appreciate any abnormality due to obesity, urinary tract CT-scan showed a large heterogeneous non-enhancing mass, possibly hematoma arising from left adrenal gland. Afterward, his condition deteriorated rapidly, he became hypotensive, and hemoglobin level dropped from 14 to 8gm/dl within a few hours. He became agitated with a worsening level of consciousness, so he was admitted under the medical intensive care unit (MICU) and required intubation and started on mechanical ventilation. Abdominal CT-angiography was done to look for any active bleeding, showed re-demonstration of the same lesion in the left adrenal without contrast enhancement or extravasation. He underwent urgent explorative laparotomy that showed ruptured large left adrenal hematoma, which was entirely evacuated with the adrenal tissue, his vital signs were maintained stable during the surgery. Postoperative course showed uncontrolled blood pressure requiring three anti-hypertensive medications; otherwise, he had gradual improvement until successful weaning, and returned to his baseline. The histopathology result was suggestive of pheochromocytoma with extensive bleeding. Conclusion: Ruptured pheochromocytoma is an extremely rare presentation of hemorrhagic shock and needs a high index of suspicion. In our patient, the lack of classical presentation and imaging features of pheochromocytoma combined with the condition rarity, made the diagnosis very challenging. Urgent surgical intervention may be warranted, and multidisciplinary perioperative preparation is the key to a favorable outcome.

Abdominal Computed Tomography Angiography and Venography in Evaluation of Hemorrhagic and Thrombotic lesions in Hospitalized COVID-19 patients

PurposeTo report imaging findings at computed tomography angiography (CTA) and venography (CTV) of the abdomen and pelvis in evaluation of hemorrhagic and thrombotic lesions in hospitalized patients with COVID-19. MethodsIn this retrospective observational study, patients admitted to a single tertiary care center from April 1 to July 20, 2020, who tested positive for SARS-CoV-2 and developed acute abdominal pain or decreasing hemoglobin levels over the course of hospitalization were included. Abdominal CTA/CTV imaging studies performed in these patients were reviewed, and acute hemorrhagic or thromboembolic findings were recorded. ResultsA total of 40 patients (mean age, 59.7 years; 20 men, 20 women) were evaluated. Twenty-five patients (62.5%) required intensive care unit (ICU) admission and 15 patients (37.5%) were treated in the medical ward. Hemorrhagic complications were detected in 19 patients (47.5%), the most common was intramuscular hematoma diagnosed in 17 patients; It involved the iliopsoas compartment unilaterally in 10 patients, bilaterally in 2 patients and the rectus sheath in 5 cases. Pelvic extraperitoneal hemorrhage was found in 3 patients, and mesenteric hematoma in one patient. Thromboembolic events were diagnosed in 8 patients (20%) including; arterial thrombosis (n = 2), venous thrombosis (n = 2), splenic infarct (n = 1), bowel ischemia (n = 1) and multiple sites of thromboembolism (n = 2). ConclusionOur study highlights that both hemorrhagic and thromboembolic complications can be seen in hospitalized patients with COVID-19. It is important that radiologists maintain a high index of suspicion for early diagnosis of these complications.

The appearance of canine insulinoma on dual phase computed tomographic angiography.

To further evaluate the appearance of insulinoma in dogs on dual-phase CT angiography, given the disparity of findings in recent publications. To establish whether CT angiographic localisation of insulinoma correlates with surgical findings. Single centre study of dogs with a final diagnosis of insulinoma which underwent abdominal CT angiography. Scans were retrospectively re-evaluated for specific features by two board-certified veterinary radiologists. These findings were also subsequently compared to surgical and histopathological reports to determine the accuracy of lesion localisation on CT. Thirty-five cases were included in final analysis, with pancreatic nodules identified in 33. Twenty-one were confirmed as insulinoma with histopathology. Jack Russell Terriers were over-represented. Twenty of 21 cases with confirmed insulinoma and 27 of 33 overall showed hyperattenuation in the arterial phase. The mean size of pancreatic insulinoma on CT was 15.1 mm, and 18.2% were larger than 20 mm. Eighteen of 21 confirmed and eight of 12 suspected insulinomas caused a deformation of the pancreatic shape, with two only identified as a result of this feature as these lesions were isoattenuating throughout the study. Pancreatic insulinoma location at surgery matched that described on the CT images in 17 of 19 cases where location was described in the surgical report. In contrast to recent publications, this study suggests hyperattenuation of insulinomas in the arterial phase is a predominant feature, and that hypoattenuation or isoattenuation are much less common. CT angiography is accurate in prediction of lesion location before surgery in most cases.

Prevalence of portal vein thrombosis detected by computed tomography angiography in dogs.

To evaluate dogs with computed tomography angiography of the abdomen for overall prevalence of portal vein thrombosis and prevalence of portal vein thrombosis based on different disease categories. To evaluate dogs with and without portal vein thrombosis for differences in outcome. To compare ultrasound to computed tomographic angiography for identification of portal vein thrombosis. Abdominal computed tomography angiography of 223 client-owned animals was reviewed for evidence of portal vein thrombosis. Based on medical records, dogs were assigned to disease categories: (1) liver disease; (2) non-hepatic neoplasia; (3) pancreatitis; (4) infectious disease; (5) immune-mediated disease; (6) other; (7) multiple diseases. Different categories were compared for the prevalence of portal vein thrombosis. Outcome was evaluated in dogs with and without portal vein thrombosis. Ultrasound reports were reviewed to determine the detection of thrombosis on ultrasound. Twenty-eight dogs (13%) had portal vein thrombosis. The pancreatitis category contained the highest percentage of portal vein thrombosis among different categories (eight of 19; 42%). There was a similar outcome between dogs with and without portal vein thrombosis. Of 21 dogs with portal vein thrombosis that had ultrasound performed, ultrasound detected thrombosis in four of 21 (19%) cases. In this study, portal vein thrombosis prevalence was higher in dogs with pancreatitis compared to dogs with liver disease, non-hepatic neoplasia and other abdominal or systemic disease. The portal system should be carefully evaluated with imaging in dogs with pancreatitis. As compared to ultrasound, CT angiography is the imaging method of choice for detection of portal vein thrombosis in dogs.

Iatrogenic Pseudoaneurysm after Laparoscopic Bilateral Inguinal Hernia Surgery: Treatment with Endovascular Coil Embolization

Although laparoscopic interventions have provided significant achievements in hernia surgery, they may cause complications such as pain, hematoma, intestinal injuries, testicular complications, and sometimes arterial pseudoaneurysms. Arterial pseudoaneurysms are a very rare complication of laparoscopic inguinal hernia surgery. Pseudoaneurysms have serious various causes such as inflammation, trauma, and iatrogenic injury. The patient was diagnosed with bilateral inguinal hernia and a laparoscopic total extra-peritoneal repair was completed. Pelvic bleeding developed on the first postoperative day. A pseudoaneurysm that was 80x70x50 cm was detected in an abdominal computer tomography angiography. In this case because of having high rate morbidity and mortality of open surgery, we selected endovascular angioembolization instead of open surgery in the treatment of pseudoaneurysm which occurred after laparoscopic inguinal hernia surgery

Laparoscopic Pancreaticoduodenectomy with Superior Mesenteric Vein Resection and Artificial Vascular Graft Reconstruction for Borderline Resectable Pancreatic Cancer

BackgroundLaparoscopic pancreaticoduodenectomy (LPD) technique with artificial vascular graft reconstruction for patients with borderline resectable pancreatic cancer has been rarely reported since it is a very challenging technique. However, preliminary experience for the technique has been reported at the Department of Pancreatic Surgery, West China Hospital, Sichuan University.1,2 The rising popularity of neoadjuvant chemotherapy for pancreatic cancer patients may result in the increase of operative difficulty due to tissue edema and many other factors caused by the chemotherapy. The main aim of this study was to demonstrate the feasibility, safety, and key surgical procedure for LPD using video evidence. MethodsA three-dimensional upper abdominal computed tomography angiography (CTA) scan done to a 51-year-old man brought to the center with upper abdominal pain showed a mass in the uncinate process of the pancreas, with over 180-degree involvement of the superior mesenteric vein. Percutaneous transhepatic cholangial drainage (PTCD) was performed to reduce jaundice while endoscopic ultrasound and fine-needle aspiration (EUS-FNA) were done to confirm the diagnosis of adenocarcinoma. The patient underwent two cycles of neoadjuvant chemotherapy using albumin-bound paclitaxel gemcitabine + program. The chemotherapy helped in significantly relieving the symptoms where CA 199 reduced from 586.7 IU/ml to 36.73 IU/ml, and the tumor maximum diameter was reduced from 4.3 cm to 2.2 cm. The violated superior mesenteric vein (SMV) and the tumor were en bloc resected, and a 4.0-cm artificial vascular graft was placed for reconstruction. Bing’s anastomosis was performed using pancreaticojejunostomy3 while cholangiojejunostomy was performed using continuous stitching. The gastroduodenal artery (GDA) stump was wrapped with ligamentum teres hepatis after the completion of gastrointestinal anastomosis. The specimen was then removed through the extended umbilical incision (4 cm) and the operation was completed after the drainage tube was placed. ResultsThe length of intraoperative excisional SMV, duration of artificial vascular graft reconstruction, operation time, and volume of intraoperative blood loss were 4.0 cm, 30 min, 520 min, and 800 mL, respectively. Histopathological examination of ypT2N1 indicated that 1 of the 27 lymph nodes was positive. Pathological results showed a moderately differentiated adenocarcinoma with all margins being negative. ConclusionsThis study demonstrated the feasibility of total laparoscopic pancreaticoduodenectomy combined with vascular resection and artificial vascular graft reconstruction in properly selected cases of pancreatic cancer with vein involvement after neoadjuvant chemotherapy. It is worth noting that skilled laparoscopic technicians and effective teamwork are necessities for safe completion of the procedure.

S2105 Isolated Cecal Varices: A Rare Cause of Hematochezia

INTRODUCTION: Ectopic varices (outside gastro-esophageal region) are uncommon in patients with portal hypertension (PH) and account for 5 % of all variceal bleeding cases. Isolated cecal varices (ICV) without pancolonic varices are extremely rare with only handful of cases reported so far. Here we present a case of bleeding from ICV in patient with alcoholic cirrhosis. CASE DESCRIPTION/METHODS: A 55-year-old male with history of alcoholic cirrhosis (last alcohol use 1 y ago), CKD3 was admitted with 1 day history of hematochezia and dizziness. Hemoglobin on admission was 5.8 gm/dL, platelet 126 b/L and INR 1.4. After initial resuscitation, he underwent EGD which revealed non-bleeding grade 2 esophageal varices which were banded. He continued to have hematochezia. He subsequently underwent colonoscopy which revealed a 4 cm area of granularity in cecum. This area was biopsied following which sudden spurting of blood was seen. He was sent for emergent abdominal CT angiography, which came back negative for active arterial bleeding. Retrospectively, the area of granularity in cecum was thought to represent an ICV. There was spontaneous cessation of bleeding and the patient was discharged in next few days. Two months later, he presented to our hospital for similar episodes of lower GI bleeding. EGD showed non-bleeding grade 1 esophageal varices. Due to suspected bleed from ICV, patient was taken for emergent TIPS. Mesenteric angiogram showed contrast extravasation from a large cecal varix. TIPS and coil embolization of cecal varix was performed resulting in hemostasis. DISCUSSION: Ectopic varices occur in the small intestine, biliary system, colon, rectum, and surgical ostomy sites and can develop in the setting of PH, prior abdominal surgery, vascular thrombosis, or anomalies of the venous outflow vessels. ICV without pancolonic involvement are extremely rare as less than 20 cases have been reported so far in English literature. Almost all the reported cases have presented with massive lower GI bleeding. Usually EGD is performed to rule out more common upper GI bleeding from esophageal varices. CT angiography may be obtained but extravasation may only be seen in the venous phase. No- bleeding ICV can be missed on colonoscopy as over-insufflation can cause the collapse of such varices. Exsanguinating ICV are usually treated by performing emergent TIPS with or without adjunctive variceal embolization.Figure 1.: Colonoscopy showing area of granularity in cecum representing cecal varix (left). Active bleeding seen when this area was mistakenly biopsied (right).Figure 2.: Abdominal angiogram showing large isolated cecal varix with extravasation of contrast.Figure 3.: Fluoroscopic image showing coil embolization of the cecal varix.

A CASE OF RUPTURED MYCOTIC ANEURYSM AFTER DISSEMINATED MYCOBACTERIUM BOVIS INFECTION

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Dissemination is a rare complication of intravesical bacille Calmette-Guerin (BCG) therapy for bladder malignancy. CASE PRESENTATION: An 86 year-old male with medical history of atrial fibrillation, cerebrovascular accident, and bladder carcinoma treated with intravesical BCG who initially presented with worsening lower back pain. A contrast CT showed left psoas abscess abutting posterior and left lateral wall of the infrarenal abdominal aorta without evidence of aneurysm formation or contrast extravasation. Culture from the left psoas abscess aspirate returned positive for mycobacterium tuberculosis complex with a monoresistance pattern for Pyrazinamide consistent with the diagnosis of Mycobacterium Bovis(M.Bovis). He was started on a multidrug antitubercular regimen with a plan for close-follow up with serial imaging. After 3 months, he developed worsening back pain and was brought to the emergency room with increasing somnolence. Vitals were remarkable for hypotension and tachycardia. On physical examination, the patient was disoriented and had mild abdominal tenderness. Rest of the exam was unremarkable. His blood work revealed hemoglobin 6.2mg/dl and creatinine 2.2mg/dl. Abdominal CT angiography showed large left retroperitoneal hematoma and contained rupture of the infrarenal aortic aneurysm. He was resuscitated with blood products and anticoagulation was held. He underwent emergent endovascular aneurysm repair. His postoperative period was complicated by the deterioration of renal functions resulting in anuric renal failure. He was transitioned to hospice as hemodialysis was not consistent with his goals of care. DISCUSSION: BCG contains a weak strain of M. Bovis which is used as a vaccination against mycobacterium tuberculosis infection in some parts of the world and also as intravesical immunotherapy for the treatment of bladder cancer. Common side effects of intravesical BCG treatment include transient fever, fatigue, dysuria, or hematuria. Rarely, it can lead to disseminated infection leading to pneumonitis, prostatitis, hepatitis, or endovascular involvement. The pathogenesis of endovascular invasion by BCG is unclear but it is postulated to be associated with instrumentation of the bladder. Presentation of endovascular involvement may be subtle and is usually discovered after the development of complications like a ruptured aneurysm. Mycotic aneurysm related to disseminated BCG infection should be suspected based on relevant history. Diagnosis requires imaging as well as a specimen collection for microscopic analysis and culture. Mycobacterium Bovis isolates are inherently resistant to pyrazinamide. On biopsy, there is usually evidence of granulomatous inflammation. Management involves multidrug antitubercular regimen and surgical repair of the aneurysm. CONCLUSIONS: Physicians should be aware of late complications of intravesicular BCG administration. Reference #1: A. Steg, S. Adjiman, B. Debre BCG therapy in superficial bladder tumors—complications and precautions Eur Urol, 21 (suppl 2) (1992), pp. 35-40 Reference #2: J.M. LaBerge, R.K. Kerlan Jr, L.M. Reilly, T.A. Chuter Diagnosis please: Case 9: mycotic pseudoaneurysm of the abdominal aorta in association with mycobacterial psoas abscess—a complication of BCG therapy Radiology, 211 (1999), pp. 81-85 Reference #3: D.L. Lamm, P.M. van der Meijden, A. Morales, S.A. Brosman, W.J. Catalona, H.W. Herr, et al. Incidence and treatment of complications of bacillus Calmette-Guerin intravesical therapy in superficial bladder cancer J Urol, 147 (1992), pp. 596-600 DISCLOSURES: No relevant relationships by Shahrukh Arif, source=Web Response No relevant relationships by Firas Jafri, source=Web Response

S1441 Emphysematous Pancreatitis Complicated by Gastroduodenal Artery Pseudoaneurysm and Extra-Pancreatic Involvement

INTRODUCTION: Emphysematous pancreatitis (EP) is a rare form of necrotizing pancreatitis associated with gas-forming bacteria and a high mortality rate. Extra-pancreatic complications include pleural effusion, ascites, vascular and gastrointestinal involvement. Disruption of the pancreatic duct can cause pancreatic ascites and pleural effusion. Gastroduodenal artery (GDA) pseudoaneurysms are rare complications of EP caused by release of proteolytic enzymes leading to weakening and ballooning of the vessel wall. CASE DESCRIPTION/METHODS: We present a case of an 82-year-old male ex-smoker with a history of hyperlipidemia, peptic ulcer disease, and noninsulin-dependent diabetes mellitus, who presented with postprandial epigastric pain. During the first 24 hours of onset, he met three out of the five Ranson criteria: age greater than 55, LDH above 350, glucose of 393 mg/dl, with additional findings of AST 46 IU/L, WBC 14.64, amylase 2,378, and lipase greater than 600. CT revealed pancreatic gas, bilateral pleural effusions, and cholelithiasis, the latter of which was determined to be the cause of acute EP (Figure 1). The patient required surgical debridement and ERCP with stenting of biliary and pancreatic ducts (Figure 2). Intraoperative cultures were negative for enteric, fungal, or anaerobic organisms. One month later, the patient presented with septic shock and leukocytosis. Abdominal CT revealed sequelae of necrotizing pancreatitis with increased extent of fluid collection. Upper endoscopic ultrasound identified a 35 mm fluid-filled lesion in the pancreatic head positive for gram-negative rods and Streptococcus anginosus. The following week, the patient presented with melena and painless bleeding from his Davol drain. Abdominal CT angiography showed a pseudoaneurysm arising from the distal GDA and endovascular coil embolization was performed (Figure 3). One year later, the patient presented with weight loss. Abdominal CT identified a 7.0 cm pancreatic pseudocyst causing extrinsic compression in the gastric body and antrum leading to LA Grade C stasis esophagitis. A 15 mm cystgastrostomy metal stent was placed across the posterior gastric wall to relieve gastric outlet obstruction. DISCUSSION: Our case offers a unique sequela of EP causing GDA pseudoaneurysm with delayed formation of a pancreatic pseudocyst leading to severe esophagitis and gastric outlet obstruction. Effective diagnostic and therapeutic management helped this patient survive his multiple, life-threatening complications associated with EP.Figure 1.: Figure 1. Abdominal CTs in coronal view performed 6 hours apart. (A) Initial abdominal CT without contrast showed extensive inflammatory and air (white arrow) around the pancreatic head concerning for emphysematous pancreatitis versus duodenal perforation. (B) Subsequent same-day CT examination with oral contrast only demonstrated marked increase in pancreatic gas and inflammatory changes (white arrow) concerning for rapid progression. There was no extravasation of oral contrast (dashed white arrows) thereby ruling out perforated viscus as a cause for the air.Figure 2.: Figure 2. ERCP and sphincterotomy were performed given the known pancreatic head necrosis. The main pancreatic duct (A) and common bile duct (B) were cannulated, and temporary pancreatic and biliary stents were placed.Figure 3.: Figure 3. (A) Abdominal CT angiography showed pseudoaneurysm (white arrow) arising from a branch of the gastroduodenal artery in the region of peripancreatic inflammatory changes. (B) The gastroduodenal artery was embolized with multiple coils (dashed white arrow) endovascularly to treat the pseudoaneurysm.

Feasibility of near-infrared fluorescence imaging in assisting with the determination of the resection range of radiation intestinal injury

Objective: To investigate the feasibility of near-infrared fluorescence imaging (NIRFI) to assist in determining the resection range of radiation intestinal injury (RII). Methods: A descriptive cohort study was conducted. Clinical data of 10 RII patients who presented intestinal obstruction and received operation with more than 100 cm of small intestine had been resected atGeneral Department of Jinling Hospital from October 2014 to January 2015 were retrospectively analyzed. The Novadaq SPY Intra-operative Imaging System was used in capturing and viewing fluorescent images. Firstly, the dense adhesion was mobilized and the obstructive intestine was fully freed under laparoscopy, then entering into abdomen from the corresponding incision. The surgeon determined the resection range according to the color of the intestinal serous layer of the diseased intestinal wall, the thickness of the intestinal wall, and the degree of swelling of the mesentery. Afterwards, intra-operative NIRFI was performed by intravenous injection of 2 ml indocyanine green (ICG) and the imaging results of the diseased intestinal arteriovenous phase were observed and recorded. The evaluation criteria for the final resection range were mainly based on the changes in mesenteric arterial phase imaging. In RII lesions, mesenteric vessels in mesenteric artery phase were disordered, and the comb-like distribution of normal mesenteric vessels completely disappeared. Only the clouded appearance in the intestinal wall was observed. Imaging results of the diseased intestinal tissue during the development phase and mesenteric vein phase were not significantly different from normal intestinal tissue. Intraoperative and postoperative conditions under NIRFI-assisted positioning, including the resection range, anastomosis site, operation-related complications, hospitalization time and cost were recorded. Data of abdominal contrast-enhanced CT and gastrointestinal angiography during 5 years of follow-up were collected to evaluate whether there was anastomotic stenosis or insufficient resection of diseased bowel. Results: Based on the imaging of mesenteric arterial phase of NIRFI, the median resection length of the small intestine was 185 (120-260) cm. After NIRFI imaging, only local lesion of ileum was excised in 6 patients, and jejunum-ileum anastomosis was performed to preserve ileocecal flap. No serious complications such as anastomotic leakage and anastomotic hemorrhage, or chronic intestinal failure such as short bowel syndrome occurred. The median hospitalization time was 32 (22-51) days, and the median hospitalization cost was 142 000 (90 000-175 000) RMB. The hospitalization time and cost were mainly used for the enteral and parenteral nutrition support treatment during the perioperative period. All the patients had normal oral diet and/or oral enteral nutrient. After 5 years of follow-up, no recurrence was found. Abdominal contrast-enhanced CT and gastrointestinal angiography showed no thickening of the intestinal wall or stenosis of the lumen. Conclusion: Mesenteric arterial phase imagingof NIRFI can help surgeons to determine the site and range of resection of RII lesions.

Dense biased networks with deep priori anatomy and hard region adaptation: Semi-supervised learning for fine renal artery segmentation.

Fine renal artery segmentation on abdominal CT angiography (CTA) image is one of the most important tasks for kidney disease diagnosis and pre-operative planning. It will help clinicians locate each interlobar artery's blood-feeding region via providing the complete 3D renal artery tree masks. However, it is still a task of great challenges due to the large intra-scale changes, large inter-anatomy variation, thin structures, small volume ratio and small labeled dataset of the fine renal artery. In this paper, we propose the first semi-supervised 3D fine renal artery segmentation framework, DPA-DenseBiasNet, which combines deep prior anatomy (DPA), dense biased network (DenseBiasNet) and hard region adaptation loss (HRA): 1) Based on our proposed dense biased connection, the DenseBiasNet fuses multi-receptive field and multi-resolution feature maps for large intra-scale changes. This dense biased connection also obtains a dense information flow and dense gradient flow so that the training is accelerated and the accuracy is enhanced. 2) DPA features extracted from an autoencoder (AE) are embedded in DenseBiasNet to cope with the challenge of large inter-anatomy variation and thin structures. The AE is pre-trained (unsupervised) by numerous unlabeled data to achieve the representation ability of anatomy features and these features are embedded in DenseBiasNet. This process will not introduce incorrect labels as optimization targets and thus contributes to a stable semi-supervised training strategy that is suitable for sensitive thin structures. 3) The HRA selects the loss value calculation region dynamically according to the segmentation quality so the network will pay attention to the hard regions in the training process and keep the class balanced. Experiments demonstrated that DPA-DenseBiasNet had high predictive accuracy and generalization with the Dice coefficient of 0.884 which increased by 0.083 compared with 3D U-Net (Çiçek etal., 2016). This revealed our framework with great potential for the 3D fine renal artery segmentation in clinical practice.

Weakly-supervised convolutional neural networks of renal tumor segmentation in abdominal CTA images

BackgroundRenal cancer is one of the 10 most common cancers in human beings. The laparoscopic partial nephrectomy (LPN) is an effective way to treat renal cancer. Localization and delineation of the renal tumor from pre-operative CT Angiography (CTA) is an important step for LPN surgery planning. Recently, with the development of the technique of deep learning, deep neural networks can be trained to provide accurate pixel-wise renal tumor segmentation in CTA images. However, constructing the training dataset with a large amount of pixel-wise annotations is a time-consuming task for the radiologists. Therefore, weakly-supervised approaches attract more interest in research.MethodsIn this paper, we proposed a novel weakly-supervised convolutional neural network (CNN) for renal tumor segmentation. A three-stage framework was introduced to train the CNN with the weak annotations of renal tumors, i.e. the bounding boxes of renal tumors. The framework includes pseudo masks generation, group and weighted training phases. Clinical abdominal CT angiographic images of 200 patients were applied to perform the evaluation.ResultsExtensive experimental results show that the proposed method achieves a higher dice coefficient (DSC) of 0.826 than the other two existing weakly-supervised deep neural networks. Furthermore, the segmentation performance is close to the fully supervised deep CNN.ConclusionsThe proposed strategy improves not only the efficiency of network training but also the precision of the segmentation.

Afebrile and Leukopenic Sweet's Syndrome Following Partial Ileectomy in an Elderly Woman

Afebrile and Leukopenic Sweet's Syndrome Following Partial Ileectomy in an Elderly Woman