Aggressive Intravenous Fluid Resuscitation Research Articles

A rare case of IgA lambda multiple myeloma in a 32-year-old woman with t(14;16) translocation associated with kidney injury and non-albumin proteinuria

BackgroundMultiple myeloma (MM) is a malignant disorder characterized by monoclonal differentiated plasma cells. While it is more commonly diagnosed in elderly individuals, it can also affect younger populations, though with a lower incidence.Case presentationHere, we present the case of a 32-year-old woman diagnosed with IgA lambda MM. She presented with fatigue, nausea, acute kidney injury (AKI) with a rapid increase in creatinine, and anemia. A kidney biopsy was done to rule out a rapidly progressive glomerular disease and a diagnosis was thus reached. A genetic workup revealed t(14;16) translocation and an extra copy of TP53. The patient received aggressive intravenous steroids and intravenous fluid resuscitation, resulting in an improvement in renal function. Treatment with daratumumab in combination with bortezomib, thalidomide, and dexamethasone was initiated and well tolerated. Despite the generally poor prognosis of IgA MM, our case emphasizes the importance of considering MM in young patients with unexplained kidney injury.ConclusionEarly recognition and prompt intervention are essential in managing MM patients, especially in those with high-risk cytogenetic abnormalities. This case serves as a reminder for clinicians to maintain a high index of suspicion for MM, even in younger populations, when presented with unexplained kidney injury.

Case Report on a Cocktail Drug Abuser Developing Rhabdomyolysis

Rhabdomyolysis is a medical emergency characterized by the break down of skeletal muscle leading to the release of intracellular contents into the blood stream, which can lead to acute kidney injury and even death. Drug abuse is one of the potential causes of rhabdomyolysis. This case report describes a 18-year-old male with a history of drug abuse who presented to the emergency department with severe muscle pain, weakness, dark and reduced amount of urine. The patient was diagnosed with rhabdomyolysis, which was likely due to a combination of high doses Marijuana, Chlorpheniramine, Dextromethorphan (Corex Syrup), Dicyclomine, Tramadol, Acetaminophen and cigarette smoking over period of 4-5 years, landed up in rhabdomyolysis after joining gym. The patient was immediately started on aggressive intravenous fluid resuscitation, and his urine output and electrolyte levels were closely monitored. Patient required initiation of Hemodialysis over period of 15 days. Patient's muscle pain and weakness gradually improved over the next few days, and he was discharged with a diagnosis of AKI due to Rhabdomyolysis due to drug abuse. Prompt recognition and treatment of rhabdomyolysis are crucial to prevent serious complications, and addiction treatment should be pursued to prevent future episodes of rhabdomyolysis and other drugrelated complications.

A Nationwide Analysis of Fluid Resuscitation Outcomes in Patients With Acute Pancreatitis.

Traditionally, fluid resuscitation has been the foundation of effective acute pancreatitis (AP) treatment. Experts advocate for aggressive intravenous fluid (IVF) resuscitation, especially within the first 24 hours.Research suggests limited efficacy of this approach; in fact, some studies show there may be a risk of increased complications. The aim of this study was to assess outcomes of aggressive IVF resuscitation in patients with AP. We queried the TriNetX Research Network (Cambridge, Massachusetts, United States) for patients admitted between January 1, 2010, and December 31, 2020, with a diagnosis of AP and who had received IVF on admission for at least 24 hours.We compared two cohorts; cohort 1 consisted of patients receiving aggressive IVF resuscitation (>3 ml/kg/hr), and cohort 2 was comprised of patients receiving non-aggressive (≤1.5 ml/kg/hr) IVF resuscitation. We compared mortality during index hospitalization, hospital length of stay (HLS), mechanical ventilation rates, acute kidney injury (AKI), and severe sepsis between the cohorts with propensity scoring matched (PSM) pairs of patients. A sub-analysis of patients with severe AP was performed. After comparing the two well-matched PSM cohorts (3,680/3,680), we found no significant differences in mortality, HLS, mechanical ventilation rates, AKI, or severe sepsis.We found similar results after conducting the sub-analysis of patients with severe pancreatitis. We found no significant differences in mortality and HLS when comparing rates of IVF resuscitation.

S108 The Effect of Aggressive Intravenous Fluid Resuscitation on the Mortality Outcome in Patients With Acute Pancreatitis: A Systematic Review and Meta-Analysis

S108 The Effect of Aggressive Intravenous Fluid Resuscitation on the Mortality Outcome in Patients With Acute Pancreatitis: A Systematic Review and Meta-Analysis

Aggressive intravenous fluid resuscitation for acute pancreatitis.

Academic Emergency MedicineAccepted Articles THE BRASS TACKS: CONCISE REVIEWS OF PUBLISHED EVIDENCE Aggressive Intravenous Fluid Resuscitation for Acute Pancreatitis Brit Long MD, Corresponding Author Brit Long MD [email protected] orcid.org/0000-0003-4770-8869 Brooke Army Medical Center, Department of Emergency Medicine, 3551 Roger Brooke Dr, Fort Sam Houston, TX, United States Correspondence Brit Long, MD, Present Address: 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234. Email: [email protected]Search for more papers by this authorMichael Gottlieb MD, Michael Gottlieb MD orcid.org/0000-0003-3276-8375 Department of Emergency Medicine, Rush University Medical CenterSearch for more papers by this author Brit Long MD, Corresponding Author Brit Long MD [email protected] orcid.org/0000-0003-4770-8869 Brooke Army Medical Center, Department of Emergency Medicine, 3551 Roger Brooke Dr, Fort Sam Houston, TX, United States Correspondence Brit Long, MD, Present Address: 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234. Email: [email protected]Search for more papers by this authorMichael Gottlieb MD, Michael Gottlieb MD orcid.org/0000-0003-3276-8375 Department of Emergency Medicine, Rush University Medical CenterSearch for more papers by this author First published: 20 April 2023 https://doi.org/10.1111/acem.14741 Supervising Editor: Shahriar Zehtabchi This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi:10.1111/acem.14741. AboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Accepted ArticlesAccepted, unedited articles published online and citable. The final edited and typeset version of record will appear in the future. RelatedInformation

Effect of Aggressive Intravenous Fluid Resuscitation Versus Nonaggressive Fluid Resuscitation in the Treatment of Acute Pancreatitis: A Systematic Review and Meta-Analysis.

Despite the need for active fluid therapy, fluid management of most acute pancreatitis (AP) cases is still supportive. The aim of this review is to compare the effect of aggressive versus nonaggressive intravenous (IV) fluid resuscitation in the treatment of acute pancreatitis. A systematic search of medical databases, such as Medline, Google Scholar, Science Direct, Cochrane Central, was conducted for publication until April 2022. We included randomized controlled trials or cohort (prospective and retrospective) studies reporting the outcomes of AP in patients that were managed with aggressive and nonaggressive IV fluid resuscitation. The primary outcome of interest was in-hospital mortality. Fourteen trials involving 3423 acute pancreatitis patients were included in the review. We did not observe any differences in the risk of mortality, persistent organ failure, and systemic inflammatory response syndrome in both study groups. However, there was an increased risk of development of pancreatic necrosis, renal failure, and respiratory failure in the aggressive fluid therapy group compared with nonaggressive therapy. The funnel plot showed no publication bias. Aggressive fluid therapy did not improve mortality rates in acute AP patients and was associated with an increased risk of acute renal failure, and respiratory failure.

Comparison of early aggressive versus nonaggressive fluid resuscitation in acute pancreatitis: a meta-analysis.

Early fluid resuscitation is one of the main therapeutic strategies for acute pancreatitis (AP). This study investigated the effects of early aggressive and nonaggressive hydration on AP. The aim of this meta-analysis is to investigate the differences between aggressive and nonaggressive intravenous fluid resuscitation in AP. This study was based on publicly available data, all of which have been extracted from previous ethically approved studies. Two authors systematically searched PubMed, Embase (via OVID), Web of Science, and Cochrane Library to find all published research before February 2023. In-hospital mortality were set as primary endpoints. This meta-analysis included seven randomized controlled trials (RCTs) and eight cohort studies with 4072 individuals in nonaggressive (n = 2419) and aggressive (n = 1653) hydration groups. The results showed that patients in the nonaggressive group had a lower mortality rate than those in the aggressive hydration group [relative risks (RR), 0.66; p = 0.02]. Subgroup analysis results showed that patients in the nonaggressive hydration group had lower mortality rates in RCTs (RR, 0.39; p = 0.001), studies conducted in Eastern countries (RR, 0.63; p = 0.002), and studies with severe pancreatitis (RR, 0.65; p = 0.02). In addition, the nonaggressive hydration group had lower rates of infection (RR, 0.62; p < 0.001), organ failure (RR, 0.65; p = 0.02), and shock (RR, 0.21; p = 0.02), as well as a shorter hospital stay (weighted mean difference, -1.63; p = 0.001) than the aggressive hydration group. Early nonaggressive fluid resuscitation is associated with lower mortality, lower risk of organ failure and infection, and shorter hospital stays than aggressive fluid resuscitation. CRD42023396388.

S1905 A Rare Case of Acute Pancreatitis With Normal Lipase

Introduction: Acute pancreatitis (AP) is an inflammatory disease of the pancreas that usually presents with epigastric pain radiating to the back. AP is a critical condition that can lead to multi-organ failure if not diagnosed early. It is diagnosed with 2 of the following: characteristic abdominal pain, imaging consistent with acute pancreatitis, and lipase levels greater than 3 times the upper limit of normal. The negative predictive value of lipase for diagnosing acute pancreatitis is between 94% and 100%. We present a rare case of acute pancreatitis with normal serum lipase levels. Our findings highlight the vital utility of imaging for diagnosing acute pancreatitis in the setting of normal lipase levels. Case Description/Methods: An 80-year-old female presented with a 1-day history of epigastric pain radiating to her back associated with nausea, vomiting, and loss of appetite. Her past medical history was significant for hypertension, NIDDM II, and atrial fibrillation. She had no recent medication changes and took amlodipine, metformin, metoprolol, and apixaban. Previous surgeries included cholecystectomy and appendectomy. She abstained from alcohol, tobacco, or recreational drug use. She reported abdominal trauma from bicycle collision one week prior to arrival. Vital signs were remarkable for T 101.2 F. She did not appear in acute distress. Her physical exam was remarkable for epigastric tenderness on palpation. Murphy, Cullen, and Grey-Turner signs were absent. Laboratory evaluation revealed WBC 12.8 k/uL, lipase 29 U/L, amylase 52 U/L, AST 13 U/L, ALT 21 U/L, ALP 58 U/L (Table). Lipid profile and EtOH levels were within normal limits. CT of the abdomen and pelvis revealed interstitial edematous pancreatitis (Figure). She was started on aggressive intravenous fluid resuscitation, metoclopramide for nausea, and intravenous acetaminophen for pain. Her abdominal pain progressively resolved, and she tolerated a full diet by day 3. Discussion: AP is a critical condition that requires early diagnosis. The negative predictive value of elevated lipase levels for diagnosing AP ranges from 94% to 100%. Our patient was diagnosed with acute pancreatitis due to trauma in the setting of normal lipase levels. We demonstrate the utility of imaging in diagnosing acute pancreatitis in the setting of normal serum lipase levels.Figure 1.: CT scan of the abdomen revealed peripancreatic fat stranding and interstitial edema consistent with findings of pancreatitis. Table 1. - Laboratory trends are displayed here. Lipase remained within normal limits through the 4 days measured. Admission Day 1 Day 2 Day 3 Day 4 Normal Range Hemoglobin 8.8 7.8 9.3 8.6 9.0 12.0 - 15.0 g/dL WBC 12.8 7.4 5.9 5.7 6.2 3.4 - 11.0 10*3/uL Amylase 52 39 29 - 103 U/L Lipase 29 12 13 - 60 U/L Calcium 8.9 8.1 8.9 8.8 8.4 8.4 - 10.2 mg/dL Alkaline Phosphatase 58 44 46 59 54 40 - 129 U/L ALT 21 16 29 17 11 10 - 50 U/L AST 13 10 14 12 16 13 - 39 U/L

S1720 Diabetic Ketoacidosis as a Rare Complication of Alcoholic Pancreatitis in a Previously Euglycemic Patient

Introduction: Acute alcoholic pancreatitis is an acute inflammation of the pancreas secondary to alcohol intake due to autodigestion from an increase in pancreatic enzyme release. Most commonly due to gallstones, alcohol intake, and hypertriglyceridemia, pancreatitis commonly presents with severe epigastric abdominal pain, nausea and vomiting and is managed with aggressive intravenous (IV) fluid resuscitation. Some complications include acute respiratory distress syndrome and compartment syndrome. A very rare complication of acute pancreatitis is diabetic ketoacidosis (DKA), especially in patients without a history of diabetes mellitus. Case Description/Methods: A 25-year-old female with a medical history significant for alcohol abuse presented with nausea, vomiting, and abdominal pain for 2 days. The patient reported drinking one pint of liquor per day. She was tachycardic with a heart rate of 115 and other vitals were normal. Significant laboratory studies showed a lipase of 1715, aspartate transaminase of 292, alanine transaminase of 155, glucose of 540, venous pH of 7.277, bicarbonate of 9, anion gap of 21, and beta-hydroxybutyrate of 5.1. A computed tomography scan of her abdomen and pelvis without IV contrast showed edematous and inflammatory changes in the tail of the pancreas and severe hepatic steatosis (Figure). The patient was managed with aggressive IV fluids and IV insulin infusion. Her abdominal pain and anion gap resolved on day 2 of admission and she was able to tolerate a diet. Glycated hemoglobin (HbA1c) returned a value of 4.7 and C-peptide was low at < 0.10; the subsequent pancreatic antibody panel was negative. The patient was seen in the clinic 6 months later and HbA1c at that time was 4.8. Discussion: This case illustrates DKA as a rare complication of acute pancreatitis. It provides an example of why a high level of suspicion for DKA should be present in patients presenting with alcoholic pancreatitis even in the absence of any diabetic history. Though there is no definitive mechanism of action for this presentation, it is likely from a combination of pancreatic beta-cell destruction and counter-regulatory hormone effects. Pancreatic beta-cell destruction causes impaired insulin production, leading to acute hyperglycemia. Furthermore, as acute pancreatitis can lead to severe intravascular depletion, increased secretion of counter-regulatory hormones such as cortisol and glucagon, in combination with impaired insulin secretion, can precipitate DKA in such a scenario.Figure 1.: CT abdomen without contrast demonstrating edematous and inflammatory changes in the tail of the pancreas.

FATAL ABDOMINAL WALL HEMATOMA AFTER ENOXAPARIN IN A PATIENT WITH MULTIPLE RISK FACTORS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Rectus sheath hematoma is an accumulation of blood within the rectus sheath, is not usually fatal and can be similar to intra abdominal pathologies. Multiple risk factors are associated with this type of bleeding of the inferior epigastric artery. CASE PRESENTATION: Case of 82 years old female that went to the ER due to chest pain, 6/10 in severity, pounding, non-radiating associated with elevated blood pressure of 270/150mmHg. The patient was admitted with a diagnosis of acute coronary syndrome for which dual-antiplatelet therapy of clopidogrel and aspirin at loading doses and full anticoagulation with subcutaneous enoxaparin 1 mg/kg were given. After a few hours after admission, the patient developed sudden right side abdominal pain but due to the severity of pain she was unable to provide a precise description of the pain. Physical examination was remarkable for right sided abdominal tenderness and a palpable induration of approximately 15cm by 15cm. Carnett's sign and Fothergill's signs were also positive. An abdominopelvic CT scan with PO contrast described a large right sided anterolateral abdominal and pelvic wall hematoma measuring 21.5cm anterior-posterior, 15cm in transverse and 26cm in the craniocaudal direction. The patient developed hemorrhagic shock despite multiple blood product transfusions, aggressive intravenous fluid resuscitation and IV vasopressor therapy. The hypovolemic shock persisted for which emergent exploratory OR was indicated in which evacuation of the hematoma and ligation of inferior epigastric artery were performed. However, the patient subsequently developed multiple organ failure due to persistent hypotension that ultimately caused her death. DISCUSSION: This case resulted in a rare rectus sheath hematoma fatality most likely propagated by the patient's underlying risk factors such as arterial hypertension, asthma, being female gender, advanced age, and receiving a full dose of anticoagulation along with dual antiplatelet therapy. Due to the lack of interventional radiology services in our facility, this patient had an emergent surgical intervention without the expected results as the patient had a prolonged period of hypotension causing multiorgan damage. CONCLUSIONS: Hemodynamically unstable rectus sheath hematoma in a setting where interventional radiology is unavailable, exploratory surgical intervention for ligation or embolization of bleeding vessels and evacuation of hematoma must be performed as soon as possible to avoid fatalities associated with delayed treatment. Reference #1: Nourbakhsh E, Anvari R, Nugent K. (2011) Abdominal wall hematomas associated with low-molecular-weight-heparins: an important complication in older adults, J Am Geriatr Soc, vol. 59 (pg. 1543-5) https://doi.org/10.1111/j.1532-5415.2011.03529.x Reference #2: Peng, Wang B., Luo B. (2014): Spontaneous Abdominal Wall Hematoma Caused By Abdominal exercise as a complication of warfarin therapy. Chinese Medical Journal, Volume 127 - Issue 9 - p 1796 https://https://doi.org/10.3760/cma.j.issn.0366-6999.20132338 Reference #3: Goldstein J., Sebire D. (2013): Abdominal wall haematoma in the obese: a dangerous phenomenon. Journal of Surgical Case Reports, Volume 2013, Issue 7 https://doi.org/10.1093/jscr/rjt060 DISCLOSURES: No relevant relationships by Greisha Gonzalez Santiago, source=Web Response No relevant relationships by Paola Lopez, source=Web Response No relevant relationships by Hiram Maldonado Rivera, source=Web Response No relevant relationships by Carlos Ramos Encarnacion, source=Web Response No relevant relationships by Joel Rodriguez Ramos, source=Web Response

Gender-Specific Outcomes In Patients With Heart Failure And Sepsis Who Received Aggressive Intravenous Fluid Resuscitation

Background Limited data exist about the impact of gender-specific outcomes in patients with heart failure (HF) who develop concomitant sepsis. Methods This is a retrospective cohort study of patients with HF who developed sepsis. Clinical outcomes, including in-hospital mortality, development of cardiogenic shock (CS), volume overload requiring urgent intravenous diuretics (IVD), acute kidney injury (AKI), length of stay (LOS), and 30-day HF-related readmission were evaluated amongst men vs. women. Results This cohort of 618 patients includes 272 (44%) women with a mean age of 75±14 years. Coronary artery disease (p Conclusion Women with HF who developed sepsis receive a more aggressive implementation of the surviving sepsis campaign than men, leading to more volume overload events in women with HFpEF and more cardiogenic shock in women with HFrEF. A cautiously tailored approach is desperately needed for patients with HF who develop sepsis.

Is aggressive intravenous fluid resuscitation beneficial in acute pancreatitis? A meta-analysis of randomized control trials and cohort studies.

BACKGROUNDThere is conflincting evidence on the intravenous fluid (IVF) strategy for acute pancreatitis (AP). We perform a metaanalysis of the available evidence.AIMTo investigate if aggressive IVF therapy in AP patients is beneficial to decrease mortality and improve outcomes.METHODSMetaanalysis of available randomized controlled trials and cohort studies comparing aggressive IVF vs non-aggressive IVF resuscitation.RESULTSThere was no significant difference in mortality between the aggressive (n = 1229) and non-aggressive IVF (n = 1397) patients. Patients receiving aggressive IVF therapy had higher risk for acute kidney injury and acute respiratory distress syndrome. There also was no significant difference in the overall incidence of systemic inflammatory response syndrome, persistent organ failure, pancreatic necrosis when comparing both study groups.CONCLUSIONEarly aggressive IVF therapy did not improve mortality. Moreover, aggressive IVF therapy could potentially increase the risk for acute kidney injury and pulmonary edema leading to respiratory failure and mechanical ventilation. Studies are needed to investigate which subset of AP patients could benefit from aggressive IVF therapy.

Cardiac Arrest Due to Severe Dynamic Left Ventricular Outflow Obstruction and Hypertrophy Following Anesthesia Induction

Cardiac arrest following induction of general anesthesia is a rare event. A 47-year-old woman with a history of chronic neck pain secondary to spinal stenosis presented for elective cervical laminectomy. Induction of general anesthesia induced cardiac arrest and emergency insertion of the transesophageal echocardiogram probe identified severe, undiagnosed left ventricular hypertrophy with dynamic outflow obstruction. Resuscitative treatment was immediately implemented to include aggressive intravenous fluid resuscitation, intravenous esmolol and phenylephrine to augment preload, afterload, and reflex bradycardia effect. Return of spontaneous circulation was achieved and the patient was admitted to the ICU, where she was extubated with preserved neurocognitive function on the same day. Our case describes the risk presented by undiagnosed cardiac abnormalities in what was accepted as a low-to-intermediate risk patient undergoing an elective procedure. The increasing popularity and use of pocket-sized handheld ultrasound devices may help reduce the risk of occurrences such as this in the future.

Impact of oral resuscitation on circulating and splenic leukocytes after burns.

Hemodynamic aberrations after severe burns are treated with aggressive intravenous (IV) fluid resuscitation however, oral resuscitation has been proposed in resource poor scenarios. Previously we have shown that animals receiving oral fluid following burns were able to recover kidney function. However, immune function such as circulating and splenic immune cell populations after oral or intravenous fluid administration was not examined. Herein, we perform a follow up analysis of splenic tissue and plasma from the previous animal study to examine the splenic response following these resuscitation strategies after burn injury. Eighteen anesthetized Yorkshire swine receiving 40%TBSA contact burns were randomized to receive either: (1) no fluids (Fluid Restricted; negative control), (2) 70 mL/kg/d Oral Rehydration Salt solution (Oral), or (3) 2 mL/kg/%TBSA/d of lactated Ringer's solution IV. Blood was drawn for blood cell analysis, and CT scans were performed before and 48 h post-burn, at which point spleens were harvested for histological, Western blot, and RT-PCR analyses. Splenic artery diameter decreased by -0.97 ± 0.14 mm in fluid-restricted animals, while IV led to an increase of 0.68 ± 0.30 mm. No significant differences were detected in white and red pulp. IV fluids reduced the population of splenic monocytes (CD163; P = 0.001) and neutrophils (MPO protein; P = 0.13), as well as cytokines IL-8 (P = 0.003), IFN-γ (P = 0.11) and TNFα (P = 0.05). Additionally, withholding IV fluids consistently decreased the expression of FoxP3, CCR6, and IL17β in spleen, suggesting a shift in T-cell phenotype with IV resuscitation. The route of fluid administration has a minor influence on the changes in circulating and splenic leukocytes post-burn in the acute phase. Further research is needed to help guide resuscitation approaches using immunologic markers of splenic function following burns.

The Effect of Burn Resuscitation Volumes on the Gut Microbiome in a Swine Model.

While recent reports underscore the significance of the gut microbiome (GM) in health and disease, its importance in burn outcomes remains unclear. Moreover, aggressive intravenous (IV) fluid resuscitation of patients may alter intestinal flora. Herein, we describe GM changes following a large burn in swine randomized to different volumes of IV Lactated Ringers' (LR). Anesthetized Yorkshire swine sustained 40% total body surface area full-thickness burns and were randomized to different volumes of IV LR: none (n = 5), 15 mL/kg/d (low; n = 6), or 80 mL/kg/d (high; n = 6). At baseline and days 1 and 2, fecal swabs were collected for 16s rDNA sequencing. Proximal jejunum was collected immediately after euthanasia (day 2) for western blot, histopathology, and cytokine analyses. Burns produced significant shifts in β-diversity and non-significant reductions in α-diversity that did not recover regardless of treatment group. Burn-induced increases in Proteobacteria and decreases in Firmicutes were attenuated by IV fluids in a dose-dependent manner, and also correlated with α-diversity. IV fluids caused a dose-dependent increase in Bacteroides and prevented a transient increase in the opportunistic pathogen Haemophilus parainfluenzae. While high volumes of IV fluids increased intestinal Hsp70 levels (P = 0.0464), they reduced SGLT1 (P = 0.0213) and caspase3 (P = 0.0139) levels. IV fluids elicited a non-specific cytokine response; however, Bacteroidetes levels correlated with intestinal IL18 levels (P = 0.0166, R = 0.4201). We present the first report on the gut microbiome in a porcine burn model, and present data to suggest that IV fluids may influence GM and gut functional proteins following a burn. Overall, burn-induced GM diversity shifts may expose diagnostic and/or therapeutic targets to improve outcomes.

1411 A Rare Cause of Acute Pancreatitis in a Transgender Female

INTRODUCTION: While hypertriglyceridemia and certain medications are known causes of acute pancreatitis, estrogen resulting in secondary hypertriglyceridemic acute pancreatitis (HTG-AP) is rare. To our knowledge, this is only the third case of a transgender female presenting with acute pancreatitis secondary to estrogen-induced hypertriglyceridemia. CASE DESCRIPTION/METHODS: A 31-year-old transgender female presented to the hospital with epigastric pain, fever, chills and decreased appetite. Laboratory work-up was significant for lipase &gt;7,500 u/L, triglycerides &gt;7,000 mg/dL and calcium of &lt;4 mg/dL. The patient denied alcohol use, diabetes, hypothyroidism or family history of pancreatitis. Initial management included aggressive intravenous fluid resuscitation. CT scan of the abdomen was performed and was notable for a large peripancreatic fluid collection most consistent with walled off necrosis (Figures 1 and 2). Three retroperitoneal drains were placed into the fluid collections with clinical improvement. Upon further questioning, it was discovered that several months prior to admission, the patient had started taking oral estrogen therapy obtained via an online store to transition from male to female, which was ultimately felt to be the most likely cause of her very severe hypertriglyceridemia. Two weeks after discharge, patient had IR drain exchange and repeat CT scan showed almost complete resolution of the fluid collections and her drains were removed. DISCUSSION: Medications are often described as the etiology for why people develop pancreatitis. However, to clearly prove a medication as the inciting factor, reinitiation of that medication needs to occur in order to establish a temporal relationship. Estrogen is a rare cause of drug-induced pancreatitis with approximately 40 cases reported worldwide. It is one of the few medications that has a described mechanism, hypertriglyceridemia, for the development of pancreatitis. Of the 40 cases described only 2 published case reports involve transgender females (7) (Table 1). The number of transgender patients presenting to the healthcare system for care is growing (9.2 per 100 000). Importantly, transgender females require supraphysiologic doses of estrogen therapy to maintain secondary sexual characteristics. Accounting for these factors, it is important for healthcare providers to understand their risk for and ways to prevent acute pancreatitis from occurring in their transgender patient population (8).

Tumor Lysis Syndrome after Hepatic Artery Embolization in a Patient with Neuroendocrine Tumor of Unknown Primary.

While tumor lysis syndrome is a relatively common oncologic emergency that may occur spontaneously or resulting from cancer directed therapy, it is relatively unusual occurrence in solid tumors, especially neuroendocrine tumors. It is also particularly rare after hepatic trans-arterial embolization. We report a case of a 60-year-old man who had hepatic trans-arterial embolization for metastatic neuroendocrine tumor of the liver of unknown primary, who developed tumor lysis along with post-embolization syndrome. He received aggressive intravenous fluid resuscitation, allopurinol and rasburicase for his tumor lysis syndrome but subsequently had acute renal failure for which he underwent renal replacement therapy. The patient responded well to treatment with complete resolution of his post-embolization syndrome, tumor lysis syndrome and acute renal failure. Our case report highlights the need to consider tumor lysis syndrome in solid tumors. It should be readily recognized and treated given the associated high risk of morbidity and mortality.

Dieulafoyʼs Lesion in the Esophagus: A Rare Cause of Upper Gastrointestinal Bleed

Dieulafoy's lesions account for about 1.5% of acute upper gastrointestinal (GI) bleeding and have a propensity to cause massive hemorrhage with a high mortality rate of about 80%. A Dieulafoy's lesion is a dilated, aberrant, submucosal artery eroding the overlying mucosa with no underlying ulcer, aneurysm, or intrinsic mural abnormality. The lesion is most commonly located in lesser curvature of the stomach, with rare occurrences in the esophagus. There have been about 280 published case reports in literature, but only 2 of these reports describe Dieulafoy's lesions in the esophagus. A 55-year-old male presented to the emergency department with a three-day history of melena and a near-syncopal episode. Upon presentation, he had a large amount of hematemesis followed by a syncopal episode. The patient required two units of packed red blood cells (PRBC) and aggressive intravenous fluid resuscitation. He was subsequently transferred to the intensive care unit (ICU) for close monitoring. Emergent endoscopy was performed at the bedside which revealed a visible submucosal vessel in distal esophagus suggestive of a Dieulafoy's lesion. It was sclerosed using an injection of epinephrine and complete obliteration of the vessel was achieved using gold probe cautery. Patient's symptoms of GI bleeding resolved and was discharged home. He was recommended to follow up outpatient for subsequent endoscopy in 8 weeks. Dieulafoy's lesions were first reported by Gallard in 1884, and were more precisely reviewed by Georges Dieulafoy. These lesions are commonly called caliber-persistent arteries. They are most commonly found in the stomach (prevalence 75-90%), but are exceedingly rare in the esophagus (prevalence 8%). Patients most commonly present with hematemesis and melena. Endoscopy has become the mainstay of diagnosis and treatment. The endoscopist may choose to use clipping, thermocoagulation, or to inject epinephrine into the lesion like in our case. Endoscopy has a 70% sensitivity, and if it fails to diagnose the lesion, angiography may be employed and the lesion may be embolized. If minimally invasive approaches fail, surgery is reserved as a last resort. Although Dieulafoy's lesions are exceedingly rare in the esophagus, the high mortality associated with it goes undiscovered and its amenability to life-saving endoscopic therapy prompts us to keep this as a possible differential diagnosis for an upper GI bleed.

Comparative effectiveness of aggressive intravenous fluid resuscitation with lactated Ringer's solution and rectal indomethacin therapy in the prevention of pancreatitis after endoscopic retrograde cholangiopancreatography: a double blind randomised controlled clinical trial.

IntroductionThere is growing evidence indicating the aggressive intravenous fluid resuscitation (IVFR) can decrease the rate of pancreatitis; however, to the best of our knowledge it has not been well studied in a post-endoscopic retrograde cholangiopancreatography (post-ERCP) setting.AimTo compare the effects of aggressive IVFR and rectal indomethacin (RI) in preventing pancreatitis after ERCP.Material and methodsThis is a double blind randomised controlled clinical trial on 186 patients undergoing ERCP in Ahvaz, Iran. The inclusion criteria were ERCP for standard clinical indications such as choledocholithiasis, bile duct leak, and biliary obstruction. The IVFR group (n = 62) received a bolus of 20 ml/kg of body weight lactated Ringer’s solution (LRS) immediately after ERCP, followed by 3 ml/kg/h maintenance for 8 h. The RI group (n = 62) received 50 mg rectal indomethacin immediately before procedure and 12 h after ERCP. The control group (n = 62) did not receive any treatment.ResultsPost-ERCP pancreatitis in IVFR, rectal indomethacin, and control groups occurred in 8 (12.9%), 16 (25.8%), and 20 (32.3%) patients (p = 0.036). Pancreatic pain was reported in 13 (21%), 21 (33.9%), and 27 (43.5%) patients in the IVFR, RI, and control group (p = 0.046). The serum amylase level increased over 24 h after intervention in all three groups. The mean serum amylase level 8 h after intervention in the IVFR patients was lower than the RI and control groups.ConclusionsIntravenous fluid resuscitation with LRS was more effective in preventing post-ERCP pancreatitis in comparison to the rectal indomethacin and control group.

Preventing Post-ERCP Pancreatitis: IV Fluids to the Rescue?

Pilot study data suggest a possible role for aggressive intravenous (IV) fluid resuscitation in preventing post–endoscopic retrograde