Cases Of Jaundice Research Articles

Ayurvedic management of Ruddhapatha Kamala (Obstructive Jaundice) - A Case Study

Biliary obstruction[1] refers to blockage of any duct that carries bile from the liver to the gallbladder or from the gallbladder to the small intestine. The clinical setting of the failure of biliary flow may be due to obstruction by mechanical means or by metabolic factors in the hepatic cells. The discussion of metabolic causes of biliary obstruction is very complex; the pathogenesis is not always clearly defined. While on the other hand, the condition Ruddha Patha Kamala in Ayurveda is the nearest possible clinical correlation to biliary obstruction wherein the flow of Pitta is obstructed by Kapha.[2] A structural / physical complete blockage of biliary flow needs a surgical intervention while if the cause is due to metabolic compromise or a partial block, the condition can be reversed effectively through Ayurvedic medications. Here is a case of obstructive jaundice, with a h/o cholecystectomy 20y back and H/O ERCP 5y back, treated successfully with Ayurvedic medications and some diet modifications for about 42 days. A combination of Avipatthikara Churna, Shweta Parpati, Yava Kshara and Katuki Churna was the intervention given. Mulaka Yusha twice a day along with bland diet was advised as Pathya. By the end of 42 days, the LFT report turned completely normal and the patient felt very healthy subjectively. There exists a need in the current times to critically understand the treatment techniques and principles of traditional medicine systems and to make use of them in treating certain conditions where the other conventional medicine systems fail.

Role of Subcutaneous Bilirubinometre in the Evaluation of Bilirubin Level in Neonatal Jaundice

Objectives: To record the demographic features of neonates presenting with jaundice, identify their cause, and co-relate bilirubin levels obtained by subcutaneous bilirubinometre with a standard biochemical method.
 Study Design: Cross-sectional study
 Place and Duration of Study: Nursery of Combined Military Hospital, Malir Cantt Karachi, from Jul to Dec 2020.
 Methodology: A total of 100 cases of neonatal jaundice were enrolled using a systematic random sampling technique. The demographic data of enrolled neonates and risk factors for jaundice were recorded. Their bilirubin levels were recorded using transcutaneous bilirubinometre (TCB) JH-2. Serum bilirubin levels were analyzed at the same time and recorded.
 Results: Out of 100 neonates, 61(61 %) were male. Risk factors for jaundice included exaggerated physiological 70(70%), prematurity 11(11%), Rh incompatibility 9(9%), G6PD deficiency 5(5%). For all weight ranges, mean TCB values significantly correlated with mean serum bilirubin level (p-value <0.001) with a co-relation coefficient of 0.683 and device reliability of 74%.
 Conclusion: Transcutaneous bilirubinometre can be considered a reliable tool to assess bilirubin for screening neonatal jaundice in term and pre-term neonates.

235 A case of Painless Palpable Gall bladder - a rare Exception of the Courvoisier's Law

Abstract Introduction The Courvoisier's law states that a painless palpable enlarged gallbladder with jaundice is unlikely to be caused by gallstones. There are however various exceptions to the law. We report a rare case of such an exception to make us aware of the clinical condition. Case Description 72-year-old male, otherwise fit and healthy, presented to the Emergency department with epigastric discomfort, along with dark urine and pale-coloured stool. He was clinically examined to have jaundice, and a painless globular palpable gall bladder, with blood results confirming obstructive picture i.e. raised bilirubin (70 μmol/L), ALT (103 U/L) and Alkaline Phosphatase (590 IU/L). Ultrasound abdomen showed acute cholecystitis. CT chest-abdomen-pelvis showed cholelithiasis and choledocolithiasis with dilated common bile duct (CBD), as well as asymmetric gallbladder wall thickening. The MRCP showed concentric and uniform thickening of the entire gallbladder wall, with minimal pericholecystic fluid reflecting acute inflammation. Multiple calculi were noted to be present within the CBD and gall bladder, resulting in dilation of CBD (15.8mm). The patient had ERCP with sphincterotomy and retrieval of multiple stones by balloon trawl. He was discharged the following day and is planned to undergo laparoscopic cholecystectomy as an elective procedure. His liver function test markedly improved at discharge bilirubin of 18 μmol/L and ALP of 364 IU/L. Conclusion This is an unusual case of painless jaundice with palpable gall bladder due to stones impacted in the CBD and not due to periampullary carcinoma, which is an exception to the Courvoisier's Law.

Hubungan Kelahiran Prematur dengan Kejadian Ikterus Neonatorum pada Bayi Baru Lahir di RSUD

According to data from the World Health Organization (WHO), the infant mortality rate (IMR) in the world in 2012 was 49 per 1000 live births, high risk infant or infant factors that increase the risk of perinatal or neonatal death is one of them is jaundice neonatorum or jaundice. neonatorum is the cause of neonatal death about 20-40% of all deliveries. Based on the results of a preliminary study conducted at the hospital, from 120 cases of premature birth there were 32 cases of neonatal jaundice. This study was to determine the relationship between premature birth and the incidence of neonatal jaundice in newborns. This type of research is correlational analytic with a case control design. The number of samples used in this study is 55 people in the case group and 55 people in the control group. The analysis used is univariate analysis and bivariate analysis. based on the results of statistical test analysis, it was found that in the case group or mothers who experienced premature birth, there were 32 babies (58.2%) who had neonatal jaundice and in the control group or the group of mothers who did not experience premature birth, they got 14.infants or (25.5%) who had neonatal jaundice. the results of the chi square test obtained a p-value of 0.001, it can be concluded that there is a significant relationship between premature birth and the incidence of neonatal jaundice. it is hoped that pregnant women will continue to routinely carry out antenatal care to prevent premature birth, for further researchers to be able to look for other variables related to the incidence of neonatal jaundice.

Cholestatic Jaundice during Epstein-Barr Virus Primary Infection: A Rare Manifestation

Infectious mononucleosis, induced by the Epstein-Barr virus (EBV), is a very frequent infection, affecting mostly young adults. Although liver damage is often mild and self-limiting, only a few cases of severe EBV-induced cholestatic hepatitis and jaundice have been reported in the literature. EBV infection should be considered as part of the differential diagnosis in patients with an obstructive pattern on liver function tests without evidence of biliary obstruction demonstrated on advanced imaging. The diagnosis is usually confirmed only by serology and the evolution is generally favorable. We report the observation of an 16 year old female with no particular medical history, who developed a febrile cholestatic jaundice without signs of hemolysis and without biliary obsruction on imagery.

ABO/Rh incompatibility in neonatal jaundice: a tertiary hospital based cross sectional study

Background: Neonatal hyperbilirubinemia, defined as a total serum bilirubin level above 5 mg/dl (86 μmol/l). Haemolytic disease of the newborn due to blood group incompatibilities between mother and foetus is one of the commonest cause of hyperbilirubinemia in the newborn. Methods: A Hospital based cross sectional study was conducted among newborns admitted with jaundice. Results: In our study 51 cases of neonatal jaundice were due to ABO incompatibility and among them 24 were having O-A incompatibility and 27 were having O-B incompatibility. The mean serum bilirubin in patients with ABO incompatibility were higher (24.8) than those without ABO incompatibility. Conclusions: In the present study, one third of newborns with neonatal jaundice were having ABO incompatibility. The mean serum bilirubin in patients with ABO incompatibility were higher than those without ABO incompatibility. This highlights the importance of recognizing ABO Rh incompatibility in neonatal jaundice.

Clinical and genetic diagnosis for 26 paitents with hereditary spherocytosis.

Hereditary spherocytosis (HS) is the most common hereditary defect of the red cell membrane, mainly characterized by anemia, jaundice, and splenomegaly. Due to the atypical clinical manifestations and negative family history of some patients, as well as the low sensitivity and specificity of traditional laboratory examinations, it is easy for it to escape diagnosis or be misdiagnosed. At present, it has been confirmed that the mutation of ANK1, SPTB, SPTA1, SLC4A1 and EPB42 genes can cause the deletion of their corresponding coding proteins, and thus lead to the defect of erythrocyte membrane. This study aims to analyze the feasibility and clinical application value of HS gene diagnosis. Data of 26 patients from Hunan, China with HS admitted to the Department of Hematology, Second Xiangya Hospital of Central South University from January 2018 to September 2021 were retrospectively collected, and their clinical manifestations and results of laboratory examinations were analyzed. Next-generation sequencing (NGS) combined with Sanger sequencing were applied. The mutation of HS pathogenic gene and the variation of uridine diphosphate-glucuronosyl transferase 1 family polypeptide A1 (UGT1A1), a key enzyme in the regulation of bilirubin metabolism, were detected. The results of pathogenic gene variations were interpreted pathogenic gene variations in accordance with the Standards and guidelines for the interpretation of sequence variants published by the American College of Medical Genetics and Genomics (ACMG). The clinical characteristics of patients with different gene variants were analyzed, and the clinical diagnosis and genetic diagnosis were compared. Among the 26 patients with HS, there were 23 cases of anemia, 25 cases of jaundice, 24 cases of splenomegaly, and 14 cases of cholelithiasis. There were 16 cases with family history and 10 cases without family history. The results of HS mutation test were positive in 25 cases and negative in 1 case. A total of 18 heterozygous mutations of HS pathogenic genes were detected in 19 families, among which 14 were pathogenic, 1 was likely pathogenic and 3 were of unknown significance. SPTB mutations (12) and ANK1 mutations (4) were the most common. The main variation types were nonsense mutation (9). There were no significant differences in peripheral blood cell parameters and hemolysis indicators between the SPTB mutant group and the ANK1 mutant group (all P>0.05). The rate of splenectomy in ANK1 mutation group was higher than that in SPTB mutation group, and the difference was statistically significant (χ2=6.970, P=0.014). There were no significant differences in peripheral blood cell parameters and hemolysis indicators among different mutation types (nonsense mutation, frameshift mutation, splice site mutation and missense mutation) (all P>0.05). Among the 18 clinically confirmedpatients, there were 17 cases whose diagnosis is consistent with the genetic diagnosis. Eight patients were clinically suspected, and all of them were confirmed by detection of HS gene mutation. Twenty-four patients with HS underwent UGT1A1 mutation detection, among which 5 patients carried UGT1A1 mutation resulting in a decrease in enzyme activity, and 19 patients had normal enzyme activity. The level of total bilirubin (TBIL) in the group with reduced enzyme activity was higher than that in the group with normal enzyme activity, and the difference was statistically significant (U=22, P=0.038). Most patients with HS have anemia, jaundice and splenomegaly, often accompanied by cholelithiasis. SPTB and ANK1 mutations are the most common mutations in HS pathogenic genes among patients in Hunan, China, and there was no significant correlation between genotype and clinical phenotype. Genetic diagnosis is highly consistent with clinical diagnosis. The decrease of UGT1A1 enzyme activity can lead to the aggravation of jaundice in HS patients. Clinical combined gene diagnosis is beneficial for the rapid and precision diagnosis of HS. The detection of UGT1A1 enzyme activity related gene variation plays an important role in evaluation of HS jaundice.

Computer-Aid System for Automated Jaundice Detection

At the beginning of their lives, newborns may have a widespread condition known as Jaundice or Hyperbilirubinemia. High levels of bilirubin in the blood are the primary cause of jaundice. Severe cases of jaundice may cause acute bilirubin encephalopathy due to the toxicity of bilirubin to the cells of the brain, which may lead to kernicterus. Kernicterus causes several symptoms, including a permanent upward look, loss of hearing, and repetitive and uncontrolled movements. Therefore, diagnosing this condition at the appropriate time helps to prevent chronic effects. In this study, jaundice or hyperbilirubinemia is diagnosed using a computer vision system based on a random forest algorithm. The system comprises a digital HD camera, a computer device with a Matlab application installed to analyze and detect the skin color changes of the infant, and an Arduino Uno microcontroller to control an LED ultraviolet light. A set of neonate images were collected to train the random forest algorithm, including 374 for normal and 137 for jaundiced infants. |The experimental results using the random forest algorithm for classification reached an accuracy of 98.4375%. The results of this study are promising and open doors for new monitoring applications in various medical diseases detection with a high degree of accuracy.

Carbimazole-Induced Cholestatic Jaundice with Heterozygous Mutant of H63D for Hemochromatosis

Carbimazole belongs to thionamide group of drugs and inhibits thyroid hormone synthesis by preventing organification of iodine to tyrosine residue in thyroglobulin as well as coupling of iodotyrosines. Although most of the side effects are minor such as rash, serious side effects such as hepatotoxicity and agranulocytosis have also been reported. The occurrence of carbimazole-induced hepatotoxicity has overall risk of <0.5%. Before confirming the diagnosis of cholestatic jaundice secondary to carbimazole, other causes has to be excluded as well. We report an interesting as well as rare case of cholestatic jaundice in a 50-year-old female who is a known case of hyperthyroidism who presented with icterus, generalized itching for 15 days duration and later on found to have hyperferritinemia, increased transferrin saturation, heterozygous mutant for H63D gene for hemochromatosis.

A CLINICAL STUDY ON OBSTRUCTIVE JAUNDICE DUE TO PERIAMPULLARY CARCINOMA WITH SPECIAL REFERENCE TO ITS MANAGEMENT

Background Periampullary carcinoma includes a group of malignant neoplasm arising in the pancreas or in or near the ampulla of vater. Main modalities of treatment in patients with obstructive jaundice due to periampullary carcinoma: resection of the tumor with bilioenteric anastomosis, palliative surgical bypass and stent insertion. Aims and objectives To nd out results, morbidity and mortality to various modalities of treatment to all operable and non operable case of obstructive jaundice due to periampullary carcinoma following proper diagnosis by clinical, radiological and other investigation procedures Materials and methods This is a prospective study on patients presented with obstructive jaundice due to periampullary carcinoma with special reference to its management, admitted in different surgical units of Nootan Medical College &amp; Research Centre, Visnagar from the month of August 2019 to July 2022 suspected due to peri-ampullary carcinoma. Results and discussion Twenty eight cases studied in regard to their incidence of age, sex, religion, occupation, their clinical features, investigations different etiological factors of obstructive jaundice due to periampullary carcinoma and their management. Maximum numbers of obstructive jaundice due to periampullary carcinoma were found to be due to carcinoma head of pancreas, Most of the patients present late and curative resection was not possible in them 24 out of 30 patients were operated out of which 10 had denitive surgery and in 14 palliative surgeries were done. Conclusions Most of the patients' present late and curative resection was not possible in them. Surgical palliation is a better alternative in those patients when nonsurgical palliation is not available

Investigation of an outbreak of jaundice in a rural area of District Srinagar in Kashmir

: A team of doctors visited the Gasoo area of Batpora on 20-02-2020 to investigate the suspected outbreak of jaundice.1. To verify the occurrence of an outbreak of jaundice, 2. To identify etiology of this outbreak and 3.To identify the population affected.Two teams started from the center of village in two opposite directions and undertook house to house survey. Any person having the history of one or more of 5 symptoms/signs: yellowish discoloration of eyes or body, pain abdomen, vomiting, fever or history of hospitalization within past 1 month was considered for inclusion into investigation. Blood samples were taken for hepatitis serology.A totalof16 cases were examined with 9 of them males. History of Yellowish discoloration of eyes or body was the most common symptom (87%) followed by fever (81%). Mean Serum bilirubin was 3.4 mg/dl. Hepatitis A serology was positive in 7 cases out of 8 tested cases while as hepatitis B and C serology was negative in all the tested cases.: As there was clustering of cases of jaundice in the area clearly in excess of expected, so the outbreak of Juandice was confirmed. The time, place and person distribution of jaundice pointed towards a water-borne hepatitis which was confirmed by laboratory tests to be Hepatitis A outbreak. Most commonly affected age group was 10 to 15 years.An outbreak of jaundice was confirmed and it was found to be due to Hepatitis A Virus.

An Implicit Cause of Prolonged Neonatal Jaundice: Vitamin B12 Deficiency

Abstract Objective Prolonged jaundice is defined as a serum bilirubin level of more than 5 mg/dL, which persists at postnatal 14 days in term infants and 21 days following birth in preterm infants. Although the underlying causes cannot be found in the majority of prolonged jaundice cases, this may be the first sign of a serious issue. Therefore, this study aimed to evaluate the association between vitamin B12 deficiency and prolonged jaundice in newborns. Material and Methods This descriptive cross-sectional study was performed in a university hospital between January 1, 2015 and October 1, 2020. All participants consisted of infants who were admitted to the pediatric outpatient clinics. Infants &gt; 35 weeks of gestation and with prolonged jaundice of unknown etiology were included in the study group. The control group consisted of infants &gt; 35 weeks of gestation without prolonged jaundice. Demographic and clinical characteristics and serum vitamin B12 levels were evaluated comparatively. Results A total of 126 infants, 66 of whom had prolonged jaundice, were included. The mean gestational week of the study group was 38.4 ± 1.8, and the control group was 38.6 ± 1.9 weeks. There was no difference between the groups in terms of demographics and laboratory data. The vitamin B12 level of the study group was significantly lower (median = 170 pg/mL) than the control (median = 268 pg/mL). Conclusion Based on the findings of this study, vitamin B12 deficiency was thought to be an important cause of prolonged jaundice, and further studies are needed to explain the role of vitamin B12 deficiency in the etiology of prolonged jaundice.

Intrahepatic Stone in Post Liver Transplanted Patient

BACKGROUND: The complication of the bile duct is quite a typical case of indisposition after liver transplant from a deceased or a live donor. The morbidity rates of the patients that underwent orthotopic liver transplantation were reported. In this case report, the intrahepatic stone formation was studied in post liver transplanted patients. CASE REPORT: This report presents a sporadic case of 53-year-old male patient in post-operative liver transplant. The initial post-transplant course of the patient was quite favorable, but after a week post-surgery, the patient developed the case of jaundice and came on with yellow discoloration in the skin. The endoscopic retrograde cholangiopancreatography (ERCP) was initially performed and the common bile duct (CBD) stent was inserted. Routine post-operative examination and follow-ups showed that the onset of jaundice. Further investigations with ERCP and the magnetic resonance cholangiopancreatography (MRCP) to determine the complete mapping of the biliary region showed the presence the presence of biliary stones in the CBD. In short, this is a rare finding that presents a sporadic case of post-operative liver transplant complications of biliary stones. The patient underwent a liver transplant but came back with post-surgery complications. MRCP and ERCP techniques were used for the imaging and providing an accurate diagnosis, indicating the presence of biliary stones in the CBD. CONCLUSION: Intrahepatic stone was found in patients with post liver transplanted patient.

Obstructive Jaundice: A Clinical Analysis with it’s Management

Jaundice is a frequent manifestation of biliary tract disorders and the evaluation and management of obstructive jaundice is a common problem faced by the general surgeon. Obstructive jaundice of varied etiology is one of the causes of admission to hospitals across Guwahati Medical College &amp; Hospital. To diagnose the cause, site of obstruction and management of a case of surgical jaundice is indeed a challenging task for the surgeon. Hence, a comprehensive study of the etiology, clinical presentation and management of obstructive jaundice is of paramount importance in the appropriate management of these patients. This study evaluates the age and sex distribution, clinical presentation, aetiology, and the different modalities of treatment of obstructive jaundice. Stone extraction and CBD exploration with cholecystectomy and drainage procedure was done by T tube or choledochoduodenostomy.

Relationship between the expression levels of CD4+ T cells, IL-6, IL-8 and IL-33 in the liver of biliary atresia and postoperative cholangitis, operative age and earlyjaundice clearance.

To investigate the expression levels of CD4+ T cells, IL-6, IL-8 and IL-33 in liver tissue of BA, and the relationship with postoperative cholangitis, operative age and early jaundice clearance. 45 cases of jaundice treated in the hospital from June 2018 to May 2020 were analyzed retrospectively. The expression and distribution of these factors were detected by HE staining and immunohistochemistry, the total bilirubin level and the incidence of cholangitis were recorded, and the relationship between liver inflammation level and the postoperative incidence of cholangitis, age of operation and early jaundice clearance were compared. Immunohistochemistry showed that the expression of CD4+ T cells, IL-6, IL-8 and IL-33 in the BA group were higher than those in the CBD group. ROC curve analysis showed the AUC of CD4+ T cells, IL-6 and IL-8 were 0.869, 0.886 and 0.838, respectively. The expression level of CD4+ T cells was negatively correlated with the decline rate of TBIL 3months after operation, and the expressions of IL-8 and IL-33 were negatively correlated with the decline rate of TBIL 1week after operation. The high expression of CD4+ T cells, IL-6, IL-8 and IL-33 in the BA liver tissue may lead to cholangitis and can be used as a predictor of early jaundice clearance. The degree of liver inflammation infiltration had nothing to do with the age of operation and is not a risk factor for postoperative cholangitis.

S1779 A Peculiar Case of Jaundice and Renal Failure After Hurricane Ida

Introduction: Leptospirosis is a zoonotic disease seen in tropical and temperate regions, with roughly 1.03 million cases worldwide and 58,900 deaths annually. Humans are infected when exposed to the tissue or urine of colonized rodents, cattle, swine, dogs, or sheep. The symptoms are nonspecific but include fever, myalgia, and rigors. Laboratory findings in severe cases include hyponatremia, elevated hepatic enzymes, renal failure, and thrombocytopenia. Transaminases are typically mildly elevated, but total bilirubin can increase to as high as 80 mg/dL. The associated jaundice is thought to be due to hepatocellular necrosis, intrahepatic cholestasis, and absorption of tissue hemorrhage. In severe cases of jaundice and renal failure, “Weil's Disease” is diagnosed. Case Description/Methods: Hurricane Ida produced record rainfall in the northeastern US over an 18 hour period. Five days following the storm, a 52 year old male with no significant past medical history, presented to our ER complaining of fever, night sweats, chills, fatigue, and generalized weakness. For work, he had been tasked to clear pools of stagnant water from normally dry areas of urban parks. On presentation, his blood pressure was 136/68 mmHg, heart rate 159 bpm, temperature 36.4 degrees C, and oxygen saturation of 95% on room air. His exam was notable for scleral icterus, jaundice, and tachycardia. The abdomen was soft, non-tender and non-distended, and without hepatomegaly. Laboratory values are given in the Table. The patient’s renal failure subsequently worsened with BUN/creatinine reaching 114/7.48 mg/dL. Abdominal ultrasound and MRCP demonstrated no abnormalities. On day 4 urine DNA for Leptospira was positive, though serum Leptospira PCR was negative. He was started on doxycycline and ceftriaxone with improvement in his symptoms, jaundice and renal failure. Discussion: Leptospira is endemic in mostly southern and Pacific coastal areas of the US, as well as Hawaii. In developed countries, leptospirosis is commonly seen after heavy rainfall and floods. Over the past 5 years, locally acquired cases of leptospirosis have surpassed travel associated infection in our local jurisdiction. Climate studies have pointed to a positive correlation between cases of leptospirosis and significant changes in climate and associated flooding. Given the potential severity of leptospirosis, community education to avoid stagnant water and barrier coverage in emerging Leptospirosis hotspots could be beneficial in the prevention of disease. Table 1. - Relevant Labs from Admission Hemoglobin 14.3 g/dL Platelets 68,000 u/L MCV 84 fL ESR 58 ml/Hr BUN / Cr 54 mg/dL / 2.9 mg/dL Sodium 129 mmol/L Total Bilirubin 6.7 mg/dL Direct Bilirubin 5.08 mg/dl ALT 78 unit/L AST 191 unit/L Alkaline Phosphatase 102 unit/L CPK 3,600 unit/L Lipase 2.3 unit/L Hepatitis A,B,C serology evidence of prior HBV vaccination Ds-DNA within normal limits Immunoglobin A,G,E,M within normal limits

S1953 An Unexpected Diagnosis in an Elderly Patient Presenting With Jaundice

Introduction: Cholangioscopy is an important tool in the evaluation of indeterminate biliary strictures allowing for direct visualization of strictures and targeted biopsies. We present an unusual case of painless jaundice where cholangioscopy played a crucial role in making the diagnosis. Case Description/Methods: A 76-year-old male with a past medical history of hypertension and diabetes mellitus, and a past surgical history of a laparoscopic cholecystectomy ten years prior to presentation was referred for one week of painless jaundice, darkening of urine, and pruritus. He denied any weight loss, abdominal pain, nausea, or vomiting. Laboratory evaluation was significant for a total bilirubin of 14.8, direct bilirubin of 7.6, AST 40, ALT 56, and alkaline phosphatase of 128. Magnetic resonance cholangiopancreatography was obtained, which revealed a poorly defined soft tissue lesion at the junction of the intrahepatic and extrahepatic common hepatic duct (CHD) with intrahepatic ductal dilation (IHD). Multiple small filling defects within the dilated ducts were also noted, suggestive of choleliths. The patient was referred for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). EUS revealed IHD and a benign appearing porta hepatis lymph node with no endosonographic evidence of pancreatic mass or cysts. The lymph node at the porta hepatis was sampled using fine needle aspiration (FNA). ERCP was then performed, revealing a single stenosis at the level of the CHD with IHD. Cholagioscopy was performed, which revealed an inflammatory-appearing stenosis of the CHD with embedded suture material and a cholelith proximal to the stenosis (Figure). The stenosis was biopsied and dilated with a 4 mm balloon dilator. An 8.5 x 10 cm plastic biliary stent was placed with subsequent flow of bile. FNA cytology and pathology of the CHD stricture were both negative for malignancy. Discussion: Our patient likely sustained a bile duct injury during his prior cholecystectomy, which was repaired with suture, leading to an inflammatory stricture and obstructive jaundice. We had a high suspicion pre-procedure for malignancy given this patient’s presentation, and as such cholangioscopy was crucial in determining the etiology of this patient’s stricture. Our case highlights the importance of cholangioscopy in the evaluation of indeterminate biliary strictures, particularly in patients whom have undergone biliary surgery.Figure 1.: Left: Cholangiogram revealing hilar stricture. Right: Cholangioscopy revealing inflammatory stricture with embedded suture material.

S1792 Painless Obstructive Jaundice: Pancreatic Adenocarcinoma Cannot Be Excluded

Introduction: Autoimmune pancreatitis (AIP) is a chronic inflammatory condition typically presenting with abdominal pain, jaundice and weight loss. AIP is an uncommon cause of pancreatitis and diagnosis may be challenging, but it is highly responsive to corticosteroids. We present a case of painless obstructive jaundice complicated by a mass on the pancreatic head. Case Description/Methods: A 57-year-old Indian male with no past medical history presented with vague abdominal pain, pruritus, and clay colored stools. Vital signs were unremarkable and laboratory investigations revealed alkaline phosphatase 515 U/L, alanine transaminase 732 IU/L, and total bilirubin 7.6 mg/dL. The patient underwent a right upper quadrant ultrasound which showed an enlarged gallbladder and dilated common bile duct (1.9 cm) down to the level of the pancreatic head. An endoscopic ultrasound (EUS) revealed a 3.2 x 3.7 cm hypoechoic mass in the head of the pancreas obstructing the bile duct, 2 enlarged lymph nodes in the area near the bile duct, marked bile duct dilation, and an enlarged sludge-filled gallbladder. Of note, unlike most ductal tumors the pancreatic duct upstream of the mass was not dilated. Fine needle aspiration (FNA) was unsuccessful due to the obstruction by the lymph nodes. Endoscopic retrograde cholangiopancreatography (ERCP) showed stricture of bile duct consistent with a pancreatic head mass, and was stented. Abdominal and pelvic computed tomography (CT) confirmed a 3 cm pancreatic head mass. Pathology result from the attempted FNA was inconclusive. Further labs revealed normal IgG4 and CA 19-9 level of 194; indicative of possible pancreatic malignancy. The patient developed jaundice, scleral icterus and rapid weight loss. EUS with FNA with repeat biopsies revealed rare degenerated epithelial cells. The patient was treated with high dose steroids, with planned pancreaticoduodenectomy. Follow-up CT revealed resolution of the pancreatic mass and was confirmed by repeat EUS/ERCP and normal CA 19-9 level. Discussion: Although painless obstructive jaundice with a pancreatic mass is a typical presentation for a pancreatic neoplasm; it is not the only possible diagnosis. Despite biochemical and radiographic evidence suggesting a malignancy; if AIP remains in the differential, a trial of steroids may be warranted to avoid unnecessary surgical intervention and associated morbidity.

S3114 Painless Jaundice With a Significantly Elevated CA 19-9: It Is Not Always Pancreaticobiliary Cancer

Introduction: Carbohydrate antigen 19-9 (CA 19-9) is often very high in pancreaticobiliary cancers but can be substantially elevated in benign diseases too. We present a case of painless jaundice with a significantly elevated CA 19-9 from vanishing bile duct syndrome (VBDS). Case Description/Methods: 65-year-old white male with history of obesity, hypertension, hyperlipidemia, prior cholecystectomy and no family history of pancreatic cancer presented with two weeks of painless jaundice and 10 pounds unintentional weight loss. Physical exam noted scleral icterus and jaundice with a T.Bili of 23 mg/dL (Table 1). CT scan showed intrahepatic bile duct dilation and a 10 mm common bile duct without a discrete mass. CA 19-9 was elevated to 1,480 U/mL, concerning for malignancy. ERCP found a low-grade main bile duct stricture which was stented. Bile duct brushings and fine needle aspiration of the pancreas were negative for malignancy. Biliary dilation was resolved on follow-up MRCP but his bilirubin remained high. Infectious and autoimmune workup was unremarkable. Repeat cholangiography and brushings confirmed no obstruction or malignancy (Fig. 1a). An infiltrative versus drug induced liver injury was suspected. EUS-guided liver biopsies revealed cholestasis with dilated bile canaliculi, hepatocytes with ballooning degeneration and a paucity of bile ductules. Cytokeratin-7 immunostaining demonstrated >50% ductopenia, confirming VBDS (Fig. 1b and c). Follow up at hepatology clinic determined triamterene-HCTZ, atorvastatin or omeprazole stopped during hospitalization to be the likely culprit. His CA 19-9, LFTs and symptoms improved over the following weeks (Table 1). Discussion: VBDS is an acquired cholestatic liver disease that may mimic the presentation of pancreatic cancer. CA 19-9 can be substantially elevated through T-cell mediated destruction of small bile ducts causing impaired excretion, inflammatory production, and decreased clearance. Severity of liver damage depends on the duration of injury and degree of bile duct loss at the time of diagnosis. Prompt diagnosis is important to prevent cirrhotic progression, improve outcomes, and avoid unnecessary treatments. Recognizing its association with an elevated CA 19-9 may help with this, but is scarcely reported in the literature. CA 19-9 is not typically checked in cases of VBDS but is likely commonly elevated. Providers should be aware of this association when faced with a patient with painless jaundice and a significantly elevated CA 19-9 but no obvious malignancy. Table 1. - LFT Trends During the Course of Presentation Normal Range Hospital Admission * 2 weeks 3 weeks ** 4 weeks *** 7 weeks 13 weeks Total bilirubin 0.2-1.3 mg/dL 23 22.7 22 19.7 4.7 1.3 Direct bilirubin 0.0-0.2 mg/dL >13 n/a 14.9 14.6 4.2 0.6 AST 0-45 U/L 107 134 172 200 121 27 ALT 0-50 U/L 190 130 163 182 120 35 ALP 40-150 U/L 267 179 187 168 132 109 CA 19-9 0-35 U/mL 1480 n/a n/a 85 49 n/a AST, aspartate aminotransferase; ALT, alanine aminotransferase; ALP, alkaline phosphatase; CA19-9, carbohydrate antigen 19-9; n/a, not available. * ANA, anti-AMA, anti-SMA, anti-mitochondrial, anti-TTG, anti-LKM 1/2 IgG, and EBV IgG antibodies were negative. Serum IgA, A1AT, ceruloplasmin, TSH, iron levels, hepatitis panel, serum protein electrophoresis and acetaminophen levels were normal. Acetaminophen, multivitamin, iron, triamterene- HCTZ, omeprazole and atorvastatin were stopped on discharge. ** Three weeks post hospitalization. Repeat EUS/ERCP showed biliary decompression. VBDS diagnosed on liver biopsies. *** Seen in liver clinic. Started ursodiol 2000mg daily. Figure 1.: (A) ERCP with cholangiogram showing a low-grade distal biliary stricture without significant upstream dilation. (B) Liver biopsy with H&E stain, 500 μm magnification showing small portal tracts with no bile ducts (red circle); note marked cholestasis (arrows) in dilated canaliculi and lack of ductular reaction. Also visible at this magnification is the ballooning degeneration of hepatocytes. (C) Liver biopsy with cytokeratin 7 immunostain, 500 μm magnification. Small portal tracts with no terminal/small bile ducts. Early signs of ductular reaction seen by hepatocytes taking up CK7 stain (arrows).

The study of frequency of malignancy and its types in surgical jaundice; a tertiary care experience.

To determine the frequency of malignancy and its types in patients presenting with surgical jaundice in a tertiary care setting. The cross-sectional study was conducted at the North Surgical Ward, Mayo Hospital, Lahore, Pakistan, from May 8 to November 8, 2020, and comprised patients of either gender with a diagnosis of surgical jaundice made on the basis of history, clinical examination, haematological and biochemical reports and radiological investigations. All patients were managed as per the guidelines for surgical jaundice with injection vitamin K intramuscular, hydration with intravenous fluids, avoidance of constipation by lactulose or neomycin, vitals and urine output monitoring and prophylactic antibiotics. Demographic data as well frequency of malignancy were noted using a predesigned proforma. Data was analysed using SPSS 21. Of the 95 patients, 51(53.7%) were male and 44(46.3%) were female. The overall mean age was 49.96±16.54 years (range: 18-80 years). A total of 19(20%) cases had body mass index <30. Malignancy was identified in 50(52.6%) cases; 14(28%) gallbladder, 4(8%) head of pancreas, 9(18%) peri-ampullary carcinoma, 7(14%) cholangiocarcinoma, 6(12%) Klastkin tumour, 5(10%) hepatocellular carcinoma, and 5(10%) metastatic tumour. More than half of the surgical jaundice cases had malignancy, gallbladder being the most affected site.