Acute Onset Of Abdominal Pain Research Articles

Circulating monocytes in acute pancreatitis.

Acute pancreatitis is a common gastrointestinal disease characterized by inflammation of the exocrine pancreas and manifesting itself through acute onset of abdominal pain. It is frequently associated with organ failure, pancreatic necrosis, and death. Mounting evidence describes monocytes - phagocytic, antigen presenting, and regulatory cells of the innate immune system - as key contributors and regulators of the inflammatory response and subsequent organ failure in acute pancreatitis. This review highlights the recent advances of dynamic change of numbers, phenotypes, and functions of circulating monocytes as well as their underling regulatory mechanisms with a special focus on the role of lipid modulation during acute pancreatitis.

ODP135 A New Life-Saving Treatment not yet Included in Guidelines for Recurrent Severe Hypertriglyceridemia-Induced Pancreatitis

Abstract Severe hypertriglyceridemia is a rare cause of acute pancreatitis especially in non-alcoholic, non- gallstones, non-obese, non-diabetic patients and has a few options for its management. Hypertriglyceridemia-induced pancreatitis causes 1 to 14 percent of all cases of acute pancreatitis. The risk of developing acute pancreatitis is approximately 5 percent with serum triglycerides >1000 mg/dL and 10 to 20 percent with triglycerides >2000 mg/dL. This is the case of a 63-year-old female who came to the Emergency Department with acute onset of abdominal pain, located at the mid-epigastric region, radiating to back, 10/10 in a scale of severity, no alleviating or aggravating factor, accompanied by nausea, 5 episodes of bilious emesis. Past medical history includes recurrent acute pancreatitis induced by hypertriglyceridemia (3 episodes last year), arterial hypertension, and dyslipidemia treated with Fenofibrate and Atorvastatin. Denies toxic habits. Physical examination showed abdominal tenderness with positive bowel sounds. Laboratories report cholesterol: 44mg/dl, triglycerides: 5,831mg/dl, LDL: -735 mg/dl, and HDL: 13 mg/dl. The patient condition warranted admission to the intensive care unit with the diagnosis of severe hypertriglyceridemia induced pancreatitis. Initially managed with insulin drip, bowel rest, and conservative management, which did not result in any improvement in her symptoms. A successful method of treatment relies on plasmapheresis for the lowering of triglyceride levels. This was first reported in 1978 by Betteridge and can result in a rapid decrease in triglyceride levels over a short period of time compared to the other treatment options. In this case, vascular surgery was consulted for apheresis catheter placement, with triglyceride improvement from 5,831mg/dl to 973 mg/dl after initial and single apheresis intervention, as the patient's symptoms resolved. Triglyceride levels decreased to 113 mg/dl after a week of therapy with plasmapheresis. The patient continues evaluation at the outpatient clinic and currently has been without recurrence of pancreatitis for the last year. Finally, the use of insulin infusion in conjunction with plasmapheresis has been demonstrated to be a viable option for rapid improvement in symptoms associated with acute pancreatitis associated with elevated triglycerides. Plasmapheresis rapidly removes triglycerides from the circulation removing the inciting factor, decreasing inflammation, and damage to the pancreas. The patient's triglyceride level decreased to 973 mg/dl the next day from 5,831mg/dl initially and the patient's symptoms resolved. Plasmapheresis is not an established guideline for the management of hypertriglyceridemia -induced pancreatitis. Plasmapheresis lowers the lipid levels drastically within hours compared to conservative therapy that usually takes several days to achieve the same reduction in triglycerides levels. Presentation: No date and time listed

PSAT006 Two Cases of Pheochromocytoma Associated Takotsubo Syndrome- Importance of Early Recognition and Treatment

Abstract Introduction Pheochromocytoma is a rare catecholamine producing adrenal medullary tumor that classically presents with hypertension. Takutsubo cardiomyopathy (TC) is a rare but increasingly recognized presentation of pheochromocytoma. We present two cases of TC likely caused by pheochromocytoma. Case 1 A 60 y/o male who presented with acute onset nausea, vomiting and abdominal pain. Systolic BP was 150-160 mm Hg, and diastolic BP was 100 mmHg. Troponin was elevated (4.15 ng/ml; nl = 0-0.04). An echocardiogram showed a reduced left ventricular ejection fraction (LVEF) of 15-20% (nl = 50-75%), a mildly dilated left ventricle, and apical ballooning suggestive of TC. Coronary arteries were normal on cardiac catheterization. CT scan identified a 5.3×5.6×5.7 cm adrenal mass of 50 HU pre-contrast. Further evaluation revealed markedly elevated plasma metanephrine concentration of 858 pg/ml (nl<57) and normetanpehrine concentration of 1729 pg/ml (<148). His presentation was strongly suggestive of pheochromocytoma associated TC. He was prepared for surgery with doxazosin 2 mg twice daily followed by metoprolol succinate and metyrosine up to 500 mg/d. Final pathology revealed a 5.3 cm left pheochromocytoma with negative surgical margins. Germline genetic testing was negative for pheochromocytoma/paraganglioma pathogenic gene mutations, and an MIBG scan did not reveal metastatic disease. Echocardiogram one month after adrenalectomy showed a marked improvement in LVEF to 55-60% with no regional wall motion abnormalities, and plasma metanephrine concentrations normalized. Case 2 A 61 y/o female smoker with type 2 diabetes mellitus, hypertension, Graves disease and obesity presented with sudden onset of nausea followed by chest discomfort, bilateral shoulder discomfort and shortness of breath. Troponin was 0.6 ng/ml (nl = 0-0.04), EKG showed ST elevations in leads I, 2, V5 V6 with hyperacute T waves. Coronary arteries were normal on catheterization. She required intubation, and systolic BP ranged from 110 to 200 mm Hg. On echocardiogram the LVEF was 35% to 40% (nl = 50-75), and there was diffuse hypokinesis of the mid to apical LV myocardium with hypercontractility of the LV base, suggestive of TC. The plasma metanephrine concentration was 3.31 nmol/l (nl= 0-0.49), and normetanephrine concentration was 5.02 nmol/l (nl= 0-0.89). CT imaging revealed a 2.9 cm left adrenal mass. She underwent successful left adrenalectomy after preparation with alpha, beta blockade and metyrosine. Germline genetic testing was negative for pheochromocytoma/paraganglioma pathogenic gene mutations . Echocardiogram nine months post-adrenalectomy showed normal EF of 50-55% and resolution of apical hypokinesis. Discussion We present two pheochromocytoma patients presenting with TC that reversed following appropriate pheochromocytoma management. Few case series report the association of pheochromocytoma and TC. These patients usually present acutely without prodromal stressors commonly found with classic TC. Conclusion In the setting of TC, pheochromocytoma should be considered. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

S2793 Adrenal Crisis in a Patient With Crohn’s Disease: A Legacy of the Corticosteroid Treatment Era

Introduction: Before the era of biologic agents, corticosteroids were the most effective therapy available for inflammatory bowel disease (IBD) as well as other inflammatory and immune-mediated disorders, and treatment often was prolonged. As a result, many patients developed secondary adrenal insufficiency, in which the normal circadian rhythm of cortisol secretion was maintained but a defect in the cortisol response to stress persisted, as was the risk of adrenal crisis in response to severe physiologic stress. As corticosteroids are no longer used chronically in IBD, adrenal crisis has become a rare complication, and many gastroenterologists have no personal experience with it. We recently saw such a case which we are presenting as a reminder of its continued existence. Case Description/Methods: A 73-year-old female with Crohn’s disease diagnosed at the age of 18, complicated by short bowel syndrome and esophageal involvement, who had been steroid dependent for 15 years though stable on ustekinumab and no steroids for more than 8 years, presented to the emergency department with an acute onset of abdominal pain, diarrhea with incontinence, profound weakness, disorientation, and possible syncope, one hour after IV iron sucrose therapy. Initial physical exam was notable for pallor and edema of hands and feet. Laboratory exams showed hemoconcentration, leukocytosis, hyponatremia, plus elevated serum lactate concentration and anion gap. Because of the severity of this response, the possibility of adrenal crisis was raised: serum cortisol was 15.5 ug/dL (nl 6.2-29) despite the stressful situation and the patient responded clinically to 100 mg of hydrocortisone IV. She was discharged within 24 hours and all laboratory abnormalities reversed within 72 hours. Discussion: Adrenal crisis can present with a wide variety of nonspecific symptoms and should be in the differential diagnosis when a patient presents after a significant physiologic stress and has a history of chronic oral corticosteroid use. Electrolyte disturbances are less common in secondary adrenal insufficiency as the zona glomerulosa of the adrenal gland is not affected. Secondary adrenal insufficiency may persist for many years after chronic steroid use and may be permanent. In patients with secondary adrenal insufficiency. Important hints are the patient’s age and GI history, which includes extent of exposure to corticosteroids. Effective diagnosis requires maintaining a high index of suspicion.

S2716 CMV in IBD: An Innocent Bystander, or Active Pathogen?

Introduction: Ulcerative Colitis (UC) is a gastrointestinal inflammatory disease that affects over 6 million people worldwide. Clinical manifestations of UC such as bloody diarrhea and abdominal pain can often mimic an infectious colitis, such as cytomegalovirus (CMV) colitis. Often a silent infection, CMV has a worldwide seroprevalence of 83%. We present an interesting case of a UC patient with biopsy positive CMV colitis, who symptomatically improved on steroids and mesalamine alone. Case Description/Methods: A 66 year old African American female with a history of well-controlled UC was evaluated for acute onset bloody diarrhea and abdominal pain. Following negative stool studies for infection, the patient underwent colonoscopic evaluation. Preliminary imaging and results demonstrated a left-sided UC flare extending from the rectum to the splenic flexure. The patient was started on pulse dose steroids with instructions to taper as an outpatient and experienced resolution of symptoms. Biopsy revealed CMV with subsequent serologic testing showing a CMV viral load of < 390 cpy/mL, IgM level of 45.4 AU/mL and negative IgG levels. Interestingly, the patient's acute gastrointestinal symptoms resolved with glucocorticoid treatment. Discussion: CMV reactivation is common in patients with moderate to severe UC. Symptoms of diarrhea, bloody stool, abdominal pain and complications such as megacolon, fulminant colitis and perforation often overlap in both CMV and UC. Endoscopic evaluation can provide a more definitive means of differentiating CMV colitis from an acute exacerbation of UC, however, may not be able to be quickly performed before complications arise. There has been much debate on the role of CMV in UC and whether it is an active pathogen contributing to the inflammatory state or simply a surrogate marker for disease severity. Multiple studies have demonstrated an association of CMV antigenemia with endoscopically significant severe UC. In such patients, after detection of CMV in the colon with biopsy, treatment with antiviral therapy and withdrawal of immunosuppressive agents would be expected to induce clinical response. Continuation of immunosuppressive therapies was associated with adverse events such as fulminant colitis and colectomy. (Figure) Differentiating an active CMV infection versus a UC flare can be challenging given the wide overlap of symptoms. Colonoscopic evaluation is important in supplementing a diagnosis with histopathological confirmation of CMV and can help guide treatment.Figure 1.: Inflammation characterized by friability, loss of vascularity, mucous, pseudopolyps and deep ulcerations was found in a continuous and circumferential pattern in the terminal ileum (1,2), hepatic flexure (3), transverse colon (4,5,6), descending colon (7,8), sigmoid colon (9,10,11), and rectum (12,13,14). This was graded as Mayo Score 3 (severe, with spontaneous bleeding, ulcerations).

S3216 When to Start Anticoagulation? A Case of Portal Vein Thrombosis in a Post-Partum Cirrhosis Patient With Variceal Bleeding

Introduction: While portal vein thrombosis (PVT) is a relatively rare disease in the general population, the prevalence of PVT in cirrhosis increases in parallel with the severity of cirrhosis. The pathogenesis of PVT in cirrhosis is thought to be multifactorial resulting mainly from alterations in the different components of Virchow’s triad. Case Description/Methods: Here we report a case of a 36-year-old woman with history of alcoholic cirrhosis who presented 2 weeks status post c-section complaining of acute onset abdominal pain, bloating, and nausea with two episodes of hematemesis. Her initial vital signs were unremarkable and hemoglobin was 7.4 gm/dL. Her model for end-stage liver disease (MELD) score was 16. She underwent upper endoscopy (EGD) with successful banding of 3 columns of large varices which showed stigmata of recent bleeding. Patient also underwent diagnostic and therapeutic paracentesis which did not show signs of spontaneous bacterial peritonitis (SBP). However, she did have history of wound dehiscence of her cesarean incision with persistent leakage of serous fluid despite prior negative pressure wound therapy. Therefore, CT abdomen/pelvis was obtained which demonstrated nonocclusive thrombus in the main portal vein extending into both the right and left branches. Due to finding of PVT, MRI was also obtained which showed no evidence of malignancy. As her hemoglobin remained stable ( >7 gm/dL) during hospitalization, she was started on therapeutic low molecular weight heparin (LMWH). Unfortunately, patient was re-admitted five days later for hematemesis and drop in her hemoglobin to 5.6 gm/dL. She received blood products, and repeat EGD showed cratered and superficial esophageal ulcers at the site of prior variceal treatment. Ultimately LMWH was held and resumed after hemoglobin stabilized. Discussion: This case demonstrates the conundrum of if/when to treat PVT in patients with cirrhosis. Current guidelines recommend anticoagulation as the mainstay of PVT treatment. However, this is can be complicated by other sequelae of decompensated cirrhosis such as variceal bleeding. Consequences of non-treatment include further increase in resistance to portal blood thus worsening portal hypertension. In this case, patient’s post-partum status also favors anticoagulation as other society guidelines have recommended anticoagulation with LMWH for postpartum patients with vascular disease of the liver. Therefore, individualized treatment algorithms should be developed and used to guide management.

S2686 A Rare but Potentially Fatal Cause of Abdominal Pain: Segmental Arterial Mediolysis

Introduction: Segmental arterial mediolysis (SAM) is a rare disease, defined as a nonatherosclerotic, noninflammatory disruption of the arterial medial layer of a medium- to large-sized artery. We describe a case of a healthy woman with acute onset abdominal pain subsequently found to have spontaneous peritoneal hemorrhage from SAM. Case Description/Methods: A 52-year-old former professional female athlete developed abrupt onset lower abdominal pain with nausea and vomiting. Pain was 10/10 in severity with a sharp and crampy quality. She denied fevers, diarrhea, melena, bloody stool, ill contacts, recent travel, or prior episodes. Past medical history was significant for endometrial polyp, menopause, and iron deficiency. She had no prior surgeries. Family history included colon cancer in her father and ovarian cancer in her mother. Her abdomen was soft with tenderness in the lower quadrants with the remainder of the exam unremarkable. Labs including CBC, BMP, LFT, lipase, beta hCG, troponin, ESR, CRP, serum acetone, urinalysis, and lactic acid were reassuring. CT abdomen and pelvis with and without contrast demonstrated hyperenhancing hepatic lesions suggestive of hemangiomas. Ultrasound of the pelvis with duplex was normal with arterial and venous duplex waveforms to both ovaries. On the second day of hospitalization, she had another episode of abdominal pain with labs demonstrating a hemoglobin drop from 13.7 g/dL to 10.2 g/dL. Repeat CT abdomen pelvis with contrast demonstrated large volume hemorrhagic ascites up to 16 cm in size with concerns for active hemorrhage in the left upper quadrant. Diagnostic angiography was performed by Interventional radiology which did not show active arterial hemorrhage although demonstrated fusiform dilatation of the distal middle colic artery and short segment focal fusiform dilatation of the left colic artery at the splenic flexure suggestive of SAM. She subsequently underwent diagnostic laparoscopy and evacuation of hemoperitoneum with over 1L of unclotted blood evacuated with a mesenteric hematoma noted in the distal transverse and proximal descending mesocolon. The spontaneous peritoneal hemorrhage was thought to be secondary to underlying arterial abnormalities triggered by minor trauma. (Figure) Discussion: Vascular causes of abdominal pain such as segmental arterial mediolysis are uncommon. Awareness of noninflammatory and nonatherosclerotic artery diseases such as SAM need to be recognized since they can be fatal if not treated promptly.Figure 1.: Fig 1 demonstrates a bleeding artery as seen on CT abdomen and pelvis with intravenous contrast. Fig 2 demonstrates the large hemoperitoneum in the left upper quadrant seen on CT abdomen and pelvis.

54-Year-Old Woman With Altered Mental Status and Abdominal Pain

54-Year-Old Woman With Altered Mental Status and Abdominal Pain

Midgut volvulus due to congenital malrotion in adults: A case report

Intestinal malrotation is a rare congenital anomaly. It may occurs in adult but it is very rare. Our case is 20 year old male from Khartoum (Sudan) presented to emergency department with acute onset abdominal pain, vomiting and abdominal distension diagnosed as having intestinal obstruction due to congenital malrotation complicated by Midgut volvulus. Midgut volvulus secondary to congenital malrotation in adults is a very rare condition, abdominal CT scan with IV contrast, are helpful for preoperative diagnosis, treatment is by Ladd procedure.

Spontaneous small bowel perforation: a rare GI manifestation of type IV Ehlers-Danlos syndrome

Isolated small bowel perforation is low in the differential diagnosis of abdominal pain in the young, relatively healthy patient. It is, however, a rare manifestation of type IV (vascular) Ehlers-Danlos syndrome (EDS). In addition, there is no general consensus on the management of GI manifestations in patients with type IV EDS. We present the case of a 31-year-old male with history of type IV EDS, presenting with acute onset abdominal pain. Imaging was notable for intra-abdominal free air and thickened loops of small bowel in the pelvis. The patient underwent exploratory laparotomy with resection of the small bowel perforation with enteroenteric anastomosis. In our literature review, we evaluated gastrointestinal manifestations observed in patients with type IV EDS, management recommendations and potential complications to be mindful of in this population.

Recurrent right hepatic artery pseudoaneurysm after robotic-assisted cholecystectomy in a patient with Mirizzi syndrome: a case report

BackgroundIatrogenic hepatic artery pseudoaneurysm is a rare complication following laparoscopic cholecystectomy. Trans-arterial embolization (TAE) is an effective way to control bleeding after a ruptured aneurysm. But uncommonly, rebleeding may occur which will require a second embolization or even laparotomy.Case presentationWe report a case of a 45-year-old woman who underwent robotic-assisted cholecystectomy after the diagnosis of type II Mirizzi syndrome. During the operation, the anterior branch of the right hepatic artery was damaged and Hem-o-lok clips were applied to control the bleeding. The postoperative course was smooth, and the patient was discharged 6 days after the procedure. However, one week after hospital discharge, she presented to the emergency department with right upper abdominal tenderness, melena, and jaundice. After examination, the computed tomography angiography (CTA) revealed a 3 cm pseudoaneurysm at the distal stump of the right hepatic artery anterior branch. TAE with gelfoam material was performed. Three days later, the patient had an acute onset of abdominal pain. A recurrent pseudoaneurysm was found at the same location. She underwent TAE again but this time with a steel coil. No further complication was noted, and she was discharged one week later.ConclusionsEven with the assistance of modern technologies such as the robotic surgery system, one should still take extra caution while handling the vessels. Also, embolization of the pseudoaneurysm with steel coils may be suitable for preventing recurrence.

Giant umbilical cord with impending heart failure—Prognostic significance of prenatal ultrasound

Detection of giant umbilical cord prenatally should lead to vigilant monitoring particularly at term as fetal demise is a possibility, as noted in the present case because of altered hemodynamics and related vascular complications such as compromised fetal circulation. A case of prenatally diagnosed, giant umbilical cord with fetoplacental insufficiency and impending heart failure is reported. An 18-year-old primigravida, presented at 34 weeks of gestational age with complaints of acute onset abdominal pain. Fetal umbilical artery obstetric Doppler examination demonstrated reversal of diastolic flow. 2D echocardiography demonstrated dilated all 4 chambers of the heart with reduced contractility suggesting impending heart failure. Subsequently, fetal demise was noted after 2 days, and labour was induced followed by vaginal delivery of the dead fetus. A giant umbilical cord was seen at delivery with absent knots or strictures. This case report deserves a special mention as there were no earlier reported cases of giant umbilical cord in literature presenting with impending heart failure and fetal demise. We have presented the detailed clinical course of the fetus with giant umbilical cord along with a review of the related literature.

Concomitant ileocecal intussusception due to cecal lipoma and paraduodenal hernia

We present a healthy adolescent male with no past surgical history who presented with acute onset abdominal pain. Cross-sectional imaging was concerning for possible ileocecal intussusception, and repeat imaging demonstrated an internal hernia. The patient was taken to the operating room for exploration. He was discovered to have an ileocecal intussusception with a large cecal mass, as well as a left paraduodenal hernia. Closure of the mesenteric defect and ileocecectomy with primary anastomosis were performed. Pathology of the mass was consistent with colonic lipoma. Postoperatively, he had slow return of bowel function, but his recovery was otherwise uncomplicated. This case reports a rare presentation of concomitant ileocecal intussusception due to a cecal lipoma and congenital internal hernia. Intussusception in the pediatric population is typically idiopathic, and intussusception with a pathologic lead point is far more common in adults. Gastrointestinal lipomas are also uncommon in pediatric patients, and when discovered are generally small and asymptomatic. Internal hernias most commonly are due to acquired mesenteric defects or adhesive disease, though may present congenitally as seen in this patient. This case is unique because of the simultaneous occurrence of two separate surgical problems, both with atypical etiologies based on patient history and demographics.

Risk Factors Associated with Adnexal Torsion after Hysterectomy

<h3>Study Objective</h3> To identify preoperative and intraoperative risk factors for adnexal torsion after hysterectomy, and to estimate the incidence of the disease in the modern-day era of laparoscopic surgery. <h3>Design</h3> Retrospective nested case-control study. <h3>Setting</h3> Large urban medical system. <h3>Patients or Participants</h3> Eighty-nine female patients ages 17-51. <h3>Interventions</h3> Patients underwent ovarian-sparing hysterectomy. <h3>Measurements and Main Results</h3> The estimated incidence of ovarian torsion after hysterectomy was 0.5% (46/8,538 ovarian-sparing hysterectomies). The following variables were found to be associated with adnexal torsion after hysterectomy in an adjusted logistic regression: laparoscopic approach to hysterectomy vs any other approach (OR 3.73 [95% CI: 0.95, 14.59]); younger age at the time of hysterectomy (17-40 years) vs older age (41-51 years) (OR 3.78 [95% CI: 1.39, 10.27]); and a gynecologic history significant for endometriosis (OR 4.46 [95% CI: 1.07, 18.67]). <h3>Conclusion</h3> There is an association between laparoscopic approach to hysterectomy and risk of subsequent adnexal torsion. Providers should have a heightened index of suspicion for adnexal torsion after hysterectomy in patients presenting with acute-onset abdominal pain who underwent laparoscopic hysterectomy at a younger age.

905 Inferior Mesenteric Artery Branch Aneurysm Causing Ischemic Colitis – A Sequela of Anabolic Steroid Use

Abstract An inferior mesenteric artery (IMA) aneurysm comprises less than 1% of all reported visceral artery aneurysms. A 34-year-old bodybuilder with a history of anabolic steroid (AS) use of unknown duration, dose and frequency initially presented to the hospital with recurrent bouts of acute onset abdominal pain and alternating episodes of watery-mucous diarrhoea and constipation. Patient’s medical history was otherwise unremarkable with no stigmata of any connective tissue disorders. A diagnosis of ischemic colitis secondary to a distal IMA branch aneurysm measuring 6mm x 5mm x 10mm on CT was made three years after first presentation. Flexible sigmoidoscopy confirmed mucosal changes consistent with sigmoid ischemic colitis. A robotic anterior resection was performed due to two failed attempts at coiling the aneurysm. The histology was consistent with a secondary fibromuscular dysplasia in the IMA and its branches. There was a resolution of symptoms and return to normal stool and bowel function post-operatively. The commonest cause of an IMA aneurysm is the “jet disorder” phenomenon caused by incomplete atherosclerotic occlusion of the superior mesenteric (SMA) and celiac arteries (CA). While the link between AS use and dyslipidaemia is established, the patient’s lipid profile was normal. We believe this case lends valuable insight into atypical causes of ischemic colitis and adds to the literature on AS use and vascular pathology.

PHLEGMASIA CERULEA DOLENS ASSOCIATED WITH OBSTRUCTIVE SHOCK

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Phlegmasia cerulea dolens (PCD) is a rare, fulminant condition caused by massive venous thrombosis associated with a high morbidity (amputation rates 20-50%) and mortality (25-40%)1. PCD often presents as a triad of limb swelling, acute ischemic pain, and reddish purple to blue skin discoloration1. This case presents a patient who developed PCD involving complete obstruction of the inferior vena cava (IVC) leading to obstructive shock. CASE PRESENTATION: Shortly after admission a 67 year old female with a relevant past medical history of metastatic tonsillar cancer on chemotherapy, Sjogren's disease, and previous venous thromboembolism (no longer on anticoagulation) developed acute onset of abdominal pain and hypotension associated with significant mottling and edema in her bilateral lower extremities. Six months prior to presentation she had an IVC filter placed. She developed worsening shock, acute kidney injury, and metabolic academia. A CT abdomen/pelvis revealed an extensive clot burden distal to the IVC filter with extension down through the bilateral iliac veins (img 1). Bilateral lower extremity venous duplex ultrasound scans showed extensive bilateral acute deep vein thromboses (img 2). Vascular surgery took the patient to the operating room for mechanical thrombectomy of the IVC and left iliac vein (img 3) and right above-the-knee amputation due to the severity of injury to right lower extremity. After returning from the operating room she developed worsening shock despite continued resuscitative measures, and after discussion with the patient's family her goals of care were transitioned to comfort-focused. DISCUSSION: Similar to DVT risk, factors associated with the development of PCD include congestive heart failure, immobility post-operatively, and malignancy1,2. Chemotherapy may increase the risk by up to six to seven times3. Initial management of PCD includes elevation of affected limbs, judicious fluid resuscitation, and anticoagulation1. Definitive therapeutic interventions include catheter-directed thrombolysis and surgical thrombectomy1. IVC filter presence is also a rare but important risk factor for the development of PCD associated with up to 3.2% of cases in one review1. The presence of an IVC filter may lead to the development of inferior vena cava syndrome which is often mistaken for other conditions. Complications associated with IVC filter presence also highlights the value of bedside ultrasound which could help to identify non-collapsible femoral veins. CONCLUSIONS: The clinical triad of PCD includes limb swelling, acute ischemic pain, and reddish purple to blue skin discoloration. Early recognition and treatment is critical to improved outcomes.Risk factors for the development of PCD are the same as those associated with DVT or PE IVC filter presence can be a nidus for thrombus development which can progress to the point of filter occlusion REFERENCE #1: Chinsakchai K, Ten Duis K, Moll FL, de Borst GJ. Trends in management of phlegmasia cerulea dolens. Vasc Endovascular Surg. 2011;45(1):5-14. doi:10.1177/1538574410388309 REFERENCE #2: Mohammed, M., Elhamdani, S., Abusnina, W., Majdi, A., & Yousef, S. (2018). Inferior Vena Cava Obstruction and Shock. Journal of emergencies, trauma, and shock, 11(2), 146–148. https://doi.org/10.4103/JETS.JETS_22_17 REFERENCE #3: Söderman, M., & Grimm, P. (2020). Phlegmasia cerulea dolens in a patient treated with carboplatin. BMJ case reports, 13(4), e233760. https://doi.org/10.1136/bcr-2019-233760 DISCLOSURES: No relevant relationships by Avraham Cooper, source=Web Response No relevant relationships by Sarah MacDowell, source=Web Response

S2817 Glycopenic Hepatopathy in a Patient With Recurrent Diabetic Ketoacidosis: A Rare Complication of Poorly Controlled Type 1 Diabetes Mellitus

Introduction: Glycogenic hepatopathy (GH) is a rare condition predominately seen in patients with poorly controlled type 1 diabetes mellitus. This condition develops due to excessive accumulation of glycogen in the hepatocytes, leading to significant hepatomegaly and transient liver dysfunction with elevated liver enzymes. Case Description/Methods: A 24-year-old female with a history of poorly controlled type 1 diabetes mellitus complicated by multiple admissions for diabetic ketoacidosis (DKA) presented with acute onset abdominal pain, nausea and vomiting. Physical exam was significant for tender hepatomegaly. Admission laboratory results were significant for serum glucose 189 mg/dL, bicarbonate 5 mmol/L, anion gap 35 mmol/L, beta-hydroxybutyrate 6.5 mmol/L, and HbA1c 11.4%. Admission hepatic panel was significant for alanine aminotransferase 31 U/L, aspartate aminotransferase 56 U/L, alkaline phosphatase 138 U/L with normal bilirubin and prothrombin time. Patient was treated with insulin and intravenous fluids with resolution of her DKA. However, her clinical course was complicated by persistent abdominal pain with an acute rise in liver enzymes (alanine aminotransferase 216 U/L, aspartate aminotransferase 249 U/L, alkaline phosphatase 116 U/L with normal bilirubin and prothrombin time). Triglyceride level was elevated at 214mg/dL. Abdominal computed tomography was notable for hepatomegaly with liver size of 24 cm. Workup for hepatitis, HIV, COVID-19, autoimmune hepatitis, hemochromatosis, and Wilson's disease were negative. Patient underwent liver biopsy that demonstrated diffuse hepatocyte cytoplasmic clearing, consistent with GH. The patient was medically managed with strict glycemic control, diabetic diet and endocrinology input throughout admission. One week after hospital discharge, the patient remained asymptomatic and liver function tests returned to normal limits. Discussion: GH is a rare condition that should be considered in patients with poorly controlled diabetes mellitus who present with hepatomegaly and acute liver injury. While GH presents similarly to NAFLD, it can only be differentiated and definitely diagnosed by liver biopsy. This condition should not be overlooked as it is a favorable diagnosis with a good prognosis compared to other liver disease associated with diabetes mellitus. Further studies are needed to better understand the characteristics of this disease, and future development of non-invasive, rapid diagnostic testing could help avoid extensive and costly workups. (Figure Presented).

Celiac artery dissection in polycystic kidney disease.

Autosomal‐dominant polycystic kidney disease (ADPKD) is rarely complicated by celiac artery dissection. Dissection of the aorta and its major branches should be carefully differentiated in ADPKD patients with acute‐onset abdominal pain.

Treatment of Symptomatic Paravisceral Aortic Thrombus Using Percutaneous Suction Thrombectomy

Paravisceral aortic thrombus in an otherwise normal aorta is rare. A hemodynamically significant thrombus burden in such patients can result in visceral malperfusion and bilateral lower extremity ischemia, both of which, historically, have a high mortality rate. Open thrombectomy via a thoracoabdominal approach is associated with high mortality. Other endovascular alternatives, including Fogerty embolectomy and mechanical thrombectomy, are associated with visceral embolization. The Penumbra CAT-12 lightning device (Penumbra Inc, Alameda, Calif) most commonly used to treat ileofemoral deep vein thrombosis is a 12F suction catheter with the ability to remove large amounts of clot burden with minimal blood loss owing to its sensor mechanism. The ability to suction thrombectomy-focused areas in the aorta reduces the likelihood of embolization. We have presented the cases of two patients with acute symptomatic paravisceral aortic thrombus who were treated with this device and their outcomes. Two patients had presented to the emergency room with acute onset abdominal pain and bilateral lower extremity rest pain and numbness. Patient 1 was a 46-year-old woman with antithrombin III and protein C deficiency (Fig 1). Patient 2 was a 78-year-old woman with recent coronavirus disease 2019 infection, chronic obstructive pulmonary disease, and congestive heart failure (Fig 2). Computed tomography angiography of patients demonstrated aortic thrombus in the paravisceral aorta extending from the supraceliac to the infrarenal aorta. Both patients underwent percutaneous suction thrombectomy of the aorta using the Penumbra CAT-12 lightning device. Patient 2 also underwent bilateral femoral cutdown, thrombectomy, and kissing iliac stents, followed by diagnostic laparoscopy without any further intervention. The intraoperative angiographic images demonstrated the initial aortic thrombus in the paravisceral aorta with resolution of thrombus after suction thrombectomy (Figs 1 and 2). The abdominal pain and bilateral lower extremity rest pain had resolved in both patients postoperatively and did not require any further surgical intervention. Patient 1 was discharged home on postoperative day 3. Patient 2 was discharged to a rehabilitation facility on postoperative day 10. Percutaneous suction thrombectomy devices such as the Penumbra CAT-12 lightning device is effective in removing a large paravisceral aortic clot burden without any embolization to the visceral vessels. This is a newly available alternative to consider for such patients with symptomatic paravisceral aortic thrombus considered to have a high mortality risk with open intervention.Fig 2a, Angiogram demonstrating aortic thrombus at the level of the superior mesenteric artery. b, Coronal view of paravisceral aortic thrombus. c, Abdominal aortogram demonstrating improvement in paravisceral thrombus burden with embolization of thrombus to the aortic bifurcation. d, Lateral aortogram demonstrating patent and disease-free celiac and superior mesenteric artery. e, Aortogram after bilateral femoral embolectomy and bilateral kissing iliac stents showing flow to the lower extremity and pelvis restored with no further thrombus burden. f, Post-op CTA demonstrating aortic lumen patency at the SMA take-off.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

COVID-19 gastrointestinal manifestation presenting as acute surgical like abdomen

COVID-19 disease is caused by severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) which can cause respiratory symptoms more. It can cause gastrointestinal symptoms also due to this RNA virus protein binding to the angiotensin converting enzyme 2 (ACE2) receptors which are abundantly present in stomach, small intestine, large intestine and liver. The gastrointestinal manifestations of COVID-19 disease can present as acute surgical abdomen which can create diagnostic dilemma. We presented a case of COVID-19 disease, admitted in our hospital. Later he had symptoms of acute surgical abdomen symptoms like sudden onset abdominal pain, nausea, vomiting and loose stool without blood. He was properly evaluated and conservatively managed. The gastrointestinal manifestations of COVID-19 disease can present as acute surgical abdomen. So, these patients properly evaluated and then only surgical plan will be made according pathology.