Computed Tomography Of Abdomen Research Articles

A Rare Presentation of Vesicocutaneous Fistula as Groin Abscess after 8 Years of Laparoscopic Mesh Repair of Inguinal Hernia

Laparoscopic mesh repair of inguinal hernia is common but rarely associated with vesicocutaneous fistula as a complication. The most common implications are mesh erosion and migration due to inappropriate strategies in the selection of the mesh type, size, and placement of mesh. This case study reports a 74-year-old man who suffered immense physical, mental, and cosmetic hardship due to a vesicocutaneous fistula postlaparoscopic mesh repair of an inguinal hernia performed 8 years ago. He presented with groin abscess secondary to vesicocutaneous fistula, diagnosed with high inflammatory markers and computed tomography abdomen pelvis. Groin abscess was drained and identified vesicocutaneous fistula which was managed conservatively.

Abdomen CT multi-organ segmentation using token-based MLP-Mixer.

Manual contouring is very labor-intensive, time-consuming, and subject to intra- and inter-observer variability. An automated deep learning approach to fast and accurate contouring and segmentation is desirable during radiotherapy treatment planning. This work investigates an efficient deep-learning-based segmentation algorithm in abdomen computed tomography (CT) to facilitate radiation treatment planning. In this work, we propose a novel deep-learning model utilizing U-shaped multi-layer perceptron mixer (MLP-Mixer) and convolutional neural network (CNN) for multi-organ segmentation in abdomen CT images. The proposed model has a similar structure to V-net, while a proposed MLP-Convolutional block replaces each convolutional block. The MLP-Convolutional block consists of three components: an early convolutional block for local features extraction and feature resampling, a token-based MLP-Mixer layer for capturing global features with high efficiency, and a token projector for pixel-level detail recovery. We evaluate our proposed network using: (1) an institutional dataset with 60 patient cases and (2) a public dataset (BCTV) with 30 patient cases. The network performance was quantitatively evaluated in three domains: (1) volume similarity between the ground truth contours and the network predictions using the Dice score coefficient (DSC), sensitivity, and precision; (2) surface similarity using Hausdorff distance (HD), mean surface distance (MSD) and residual mean square distance (RMS); and (3) the computational complexity reported by the number of network parameters, training time, and inference time. The performance of the proposed network is compared with other state-of-the-art networks. In the institutional dataset, the proposed network achieved the following volume similarity measures when averaged over all organs: DSC = 0.912, sensitivity = 0.917, precision = 0.917, average surface similarities were HD = 11.95 mm, MSD = 1.90 mm, RMS = 3.86 mm. The proposed network achieved DSC = 0.786 and HD = 9.04 mm on the public dataset. The network also shows statistically significant improvement, which is evaluated by a two-tailed Wilcoxon Mann-Whitney U test, on right lung (MSD where the maximum p-value is 0.001), spinal cord (sensitivity, precision, HD, RMSD where p-value ranges from 0.001 to 0.039), and stomach (DSC where the maximum p-value is 0.01) over all other competing networks. On the public dataset, the network report statistically significant improvement, which is shown by the Wilcoxon Mann-Whitney test, on pancreas (HD where the maximum p-value is 0.006), left (HD where the maximum p-value is 0.022) and right adrenal glands (DSC where the maximum p-value is 0.026). In both datasets, the proposed method can generate contours in less than 5 s. Overall, the proposed MLP-Vnet demonstrates comparable or better performance than competing methods with much lower memory complexity and higher speed. The proposed MLP-Vnet demonstrates superior segmentation performance, in terms of accuracy and efficiency, relative to state-of-the-art methods. This reliable and efficient method demonstrates potential to streamline clinical workflows in abdominal radiotherapy, which may be especially important for online adaptive treatments.

A case of blunt abdominal trauma resulting in significant bladder injury (AAST grade IV)

Introduction: Bladder injuries are uncommon and its diagnosis is often missed. However, in patients presenting with blunt abdominal trauma, bladder, and other lower urinary tract injuries must be ruled out using adequate investigations. Case Report: A 33-year-old male presented to the Emergency Department 24 hours after a fall, complaining of lower abdominal pain and inability to void. Examination revealed a mildly distended abdomen with no signs of peritonism. A random bladder scan showed a volume of 583 mL. Basic investigations showed the patient to be in acute kidney injury (AKI) stage III with a creatinine of 350 mmol/L. Clinical findings were suggestive of a bladder injury. However, due to the rarity of such cases, clinicians reviewing the patient did not think of a bladder injury as one of the differential diagnoses. Instead of also requesting for a computed tomography (CT) cystography, only a trauma CT abdomen and pelvis with contrast was requested which demonstrated an intraperitoneal bladder injury. The patient was taken to theater for an emergency laparotomy and repair of a 4 cm bladder laceration. According to the American Association for the Surgery of Trauma (AAST) classification, the patient had a Grade IV bladder injury. A cystogram performed 4 weeks after the surgery showed no urine leak and the urethral catheter was removed. Fortunately, no harm was brought to the patient. Conclusion: Intraperitoneal bladder injuries, if missed, can be associated with serious morbidities and even increase the risk of mortality.

Abdominal Imaging Findings on Computed Tomography as a Tool for COVID-19 Mortality Risk Assessment: Comparison With Chest Radiograph Severity Scores.

To quantify the association between computed tomography abdomen and pelvis with contrast (CTAP) findings and chest radiograph (CXR) severity score, and the incremental effect of incorporating CTAP findings into predictive models of COVID-19 mortality. This retrospective study was performed at a large quaternary care medical center. All adult patients who presented to our institution between March and June 2020 with the diagnosis of COVID-19 and had a CXR up to 48 hours before a CTAP were included. Primary outcomes were the severity of lung disease before CTAP and mortality within 14 and 30 days. Logistic regression models were constructed to quantify the association between CXR score and CTAP findings. Penalized logistic regression models and random forests were constructed to identify key predictors (demographics, CTAP findings, and CXR score) of mortality. The discriminatory performance of these models, with and without CTAP findings, was summarized using area under the characteristic (AUC) curves. One hundred ninety-five patients (median age, 63 years; 119 men) were included. The odds of having CTAP findings was 3.89 times greater when a CXR score was classified as severe compared with mild (P = 0.002). When CTAP findings were included in the feature set, the AUCs for 14-day mortality were 0.67 (penalized logistic regression) and 0.71 (random forests). Similar values for 30-day mortality were 0.76 and 0.75. When CTAP findings were omitted, all AUC values were attenuated. The CTAP findings were associated with more severe CXR score and may serve as predictors of COVID-19 mortality.

Role of computed tomography in non-traumatic acute abdomen in adults

Background: The objective of this study was to study, assess, and diagnose causes of acute abdomen accurately, to determine the accuracy of multidetector computed tomography (CT) for confirmation of negative, diagnosed, or equivocal ultrasonography (USG) cases, and to establish role of CT as the primary imaging modality. Aims and Objective: To study, assess and diagnose causes of acute abdomen accurately, To determine the accuracy of MDCT for confirmation of Negative, diagnosed or equivocal USG cases & To establish role of CT as the primary imaging modality. Materials and Methods: One hundred and twenty random patients were included in this prospective study. USG and CT were done in all patients. Axial, coronal, and sagittal reformatted images were studied. Intravenous and oral contrast were also used depending on the clinical condition. All these patients were followed up diagnosis obtained before and after CT were compared with intraoperative findings or final clinical diagnosis at discharge. Results: Among 120 patients, confirmative CT diagnosis was made in 111 cases and was discordant in seven cases, while two cases could not be followed up. Forty-five cases underwent surgical management and rest of them were managed medically. Conclusion: CT abdomen done in patients presenting with non-traumatic acute abdominal pain which helps to make accurate diagnosis and planning the appropriate treatment.

PSAT030 A Clinically Dormant Adrenal Incidentaloma Evolving to A Cortisol Secreting Adenoma, A Ten Year Follow Up Experience

Abstract Intro Adrenal incidentalomas (AIs) are found in approximately 3–4% of abdominal computed tomography (CT) scans performed for other reasons. Most of these masses are found to be nonfunctioning. Studies showed that subtle cortisol secretion in AIs and disruption in the hypothalamic-pituitary-adrenal axis are more frequent than expected. Here we report a case of a small AI progressing to a hormone-secreting adrenal mass causing Cushing's syndrome (CS) after a period of a decade, in which dexamethasone suppression test was the confirmatory diagnostic procedure. Case 66-year-old woman was referred to Endocrinology in 2007 for assessment of abnormal abdominal CT finding indicating minimal nodularity of the right adrenal gland followed by an MRI performed 2 years later with suspicion of a small adenoma measuring 1.4 cm. Patient's past medical history included coronary artery disease, impaired glucose tolerance controlled by diet. No reported family history of relevant endocrine tumors. At time of initial assessment, functional hormonal baseline workup was normal including ACTH: 23 pg/mL [5-27 pg/mL], AM Cortisol level: 13.6 mcg/dL [4-22 mcg/dL], 24h U-Cortisol: 16.4 mcg/24h/1g Cr [4-50 mcg/24h/1g], and DHEAS: 30 mcg/dL [<185 mcg/dL] Patient was re-evaluated annually. Over the course of the follow-up, she was found to have poor healing after surgical repair of ankle fracture in 2012, as well as depression necessitating medical therapy in 2015. Her previously diet-controlled diabetes significantly progressed, requiring combination therapy and ultimately basal/bolus insulin. Moreover, patient developed hypertension with antihypertensive medication doses increased from Valsartan 40mg to Valsartan/HCT 80/12.5 in a 5-year period. The patient was found to have normal ACTH, serum, and urine cortisol levels throughout her follow-up period. Annual CT imaging demonstrated no change in right adrenal mass. In 2017, overnight low dose dexamethasone suppression test was found to be 16.2 mcg/dL[<1.8 mcg/dL], which is significantly increased from 0.9 mcg/dL in 2011. In 2018, CT abdomen showed a marked increase in the adrenal mass size to 2.8 cm. In 2020, she underwent right-sided adrenalectomy with no complications. Both blood pressure and glucose levels improved postoperatively. The preoperative use of mifepristone therapy controlled her blood sugar and pressure and eliminated the need for postoperative glucocorticoid replacement. She is currently controlled on diet and lifestyle modifications alone. Discussion Our case highlights the limitations of current guidelines in the management of AIs that recommend discontinuing annual follow-up if no significant growth occurs after 5 years. Careful long-term follow-up of AIs provides an opportunity to detect the subclinical hormonal alterations, development of new hormonal abnormalities, or any change in mass size. These findings indicate the need for good communication between radiology, primary care, and endocrine providers to assure periodic hormonal and morphological evaluation. This case also suggests that the dexamethasone suppression test may be useful in the evaluation of CS in patients without significant hypercortisolemia. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

PSAT032 Metoclopramide Induced Pheochromocytoma Multisystem Crisis: An Unusual Initial Presentation of Pheochromocytoma

Abstract Introduction Pheochromocytoma is a rare catecholamine secreting tumor arising from the adrenal medulla. It presents with hypertension and symptoms of catecholamine excess (episodic headache, sweating, palpitations). Pheochromocytoma crisis (PC) can encompass multiple organ failure, lactic acidosis, elevated temperature, encephalopathy, and hypertension and/or hypotension. Metoclopramide is a D2 receptor blocker and is known to precipitate pheochromocytoma crisis. It is commonly used in the emergency department (ED) for nausea and is often used as part of the "migraine cocktail". Case presentation 41-year-old female with primary hypothyroidism and hypertension diagnosed 5 months prior on two anti-hypertensive agents, presented to the ED with a severe headache. She recently had been placed on a Holter monitor for evaluation of episodes of palpitation/tachycardia. She was hemodynamically stable. Intravenous metoclopramide was administered as part of a "migraine cocktail". Shortly thereafter, she developed tachycardia with heart rate (HR) in the 130s, hypertension with blood pressure (BP) in the 180s/120s and proceeded to have generalized tonic-colonic seizures that lasted for 3 minutes. She was treated with lorazepam and was intubated for airway protection. Initial labs were only significant for mild leukocytosis. The urine drug screen was unrevealing. Due to the unexpected rapid clinical deterioration, computed tomography (CT) of the head, chest, abdomen, and pelvis were obtained. CT abdomen revealed a large 6.4×5.7×5.2 cm right adrenal mass. HR and BP remained elevated in the 170s and 200s/100s respectively. Given CT findings, a PC was suspected. She was started on doxazosin and labetalol. Phenoxybenzamine was later started. Biochemical testing was consistent with pheochromocytoma with elevated normetanephrine (NE) >20,000 pg/mL (<=148 pg/mL), metanephrine (M)>20,000 pg/mL (<=60 pg/mL), and total urinary metanephrines (TM) >40,000 pg/mL (<=205 pg/mL). HR and BP stabilized with treatment and the patient was subsequently extubated. She was noted to have new dysarthria and visual field deficits. Magnetic resonance imaging and CT angiography revealed findings consistent with posterior reversible encephalopathy syndrome (PRES) and acute cerebellar infarct. Dotatate scan was negative for metastasis. She later underwent right adrenalectomy; pathology report confirmed the diagnosis of nonmalignant pheochromocytoma. Repeat NE, M, and TM 10 days post-op were unremarkable. The patient follows with endocrinology clinic outpatient and has been doing well. Conclusion Multiple cases of metoclopramide-induced pheochromocytoma crisis have been reported in the literature. These accounts indicate that the empiric use of metoclopramide for individuals presenting with headaches/nausea is not without risk especially for those with a history of hypertension and other symptoms of catecholamine excess. This case also highlights the importance of suspecting pheochromocytoma crisis in patients who develop rapid onset hypertensive crisis and other symptoms of catecholamine excess immediately after administering metoclopramide. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Abdomen and pelvis computed tomography procedure: Effective dose assessment and establishment of a local diagnostic reference level

Exposure to ionizing radiation may induce cancer risk to the patients proportional to the radiation absorbed dose and the organ sensitivity. Therefore protection of radiation exposure is essential to minimize the radiation cancer risk and prevent the deterministic effects. The International Atomic Energy Agency (IAEA) encourages member countries to establish national diagnostic reference levels (DRLs) to reduce unjustified radiation exposure. This study establishes a local DRL for computed tomography (CT) abdomen and pelvis procedures. In total, 1444 CT abdomen procedures were carried out during nine months. CT abdomen procedures were carried out at King Faisal Specialist Hospital and research center using six CT machines from different vendors. The mean and range of patients' weight (kg) are 50 (42–120). The recommended DRLs values in DLP (mGy.cm) and CTDIvol (mGy) were 900 and 15 per CT abdomen and pelvis procedure, respectively. 3% (41 cases) were higher than the national DRL for CT abdomen and pelvis. The proposed DRL values are slightly higher than the European and the American College of Radiologists (ACR) DRL values in DLP. The purpose of DRL in terms of CTDIvol (mGy) is comparable with the international guidelines. Thus reducing the scan length, is recommended ensuring that patients receive a minimal possible radiation dose while maintaining the image quality.

Trainable joint bilateral filters for enhanced prediction stability in low-dose CT

Low-dose computed tomography (CT) denoising algorithms aim to enable reduced patient dose in routine CT acquisitions while maintaining high image quality. Recently, deep learning (DL)-based methods were introduced, outperforming conventional denoising algorithms on this task due to their high model capacity. However, for the transition of DL-based denoising to clinical practice, these data-driven approaches must generalize robustly beyond the seen training data. We, therefore, propose a hybrid denoising approach consisting of a set of trainable joint bilateral filters (JBFs) combined with a convolutional DL-based denoising network to predict the guidance image. Our proposed denoising pipeline combines the high model capacity enabled by DL-based feature extraction with the reliability of the conventional JBF. The pipeline’s ability to generalize is demonstrated by training on abdomen CT scans without metal implants and testing on abdomen scans with metal implants as well as on head CT data. When embedding RED-CNN/QAE, two well-established DL-based denoisers in our pipeline, the denoising performance is improved by 10%/82% (RMSE) and 3%/81% (PSNR) in regions containing metal and by 6%/78% (RMSE) and 2%/4% (PSNR) on head CT data, compared to the respective vanilla model. Concluding, the proposed trainable JBFs limit the error bound of deep neural networks to facilitate the applicability of DL-based denoisers in low-dose CT pipelines.

A rare case of severe anaemia due to pancreatic pseudoaneurysm complicated by COVID-19

Pancreatitis in children is now diagnosed more frequently with an incidence of acute pancreatitis turning to chronic being 20–25%. Pancreatic pseudoaneurysm is a rare and life-threatening complication of chronic pancreatitis. An adolescent a known case of chronic pancreatitis for 3 years, presented with a history of recurrent black-coloured stools for 1 month and haematemesis, fever and cough for 2 days. The child was pale and febrile with tachypnoea and tachycardia with severe tenderness in the epigastric and umbilical regions. Investigations showed severe anaemia (Hb-1.4 g/dL) with positive COVID-19 Reverse transcription-polymerase chain reaction. Computed tomography abdomen showed pancreatitis with a pseudocyst, pseudoaneurysm from the gastroduodenal artery and consolidation in lung COVID 19 Reporting and data system. The child was treated symptomatically along with multiple packed red blood cells transfusions. Selective catheterisation and stent grafting of the gastroduodenal artery was performed. This case report highlights an unusual complication of pancreatitis with concurrent COVID infection.

“All-in-one” window/level whole-body computed tomography scan – A faster way to evaluate trauma cases

PurposeTo investigate the accuracy and total assessment time (TAT) of the “All-in-one” (AIO)-window/level setting for whole-body computed tomography (CT) image compared to multiple tissue-specific window/level settings conventionally used for detection of traumatic injuries. MethodContrast-enhanced chest, abdomen, and pelvic CT scans of 50 patients who presented to our emergency department (ED) for major trauma were retrospectively selected. In a simulation of a “wet read” performed at the CT scanner console, 6 readers with different levels of experience had up to 3 min to describe any traumatic finding identified on the CTs. The readers reviewed each patient in two different sessions separated by a washout period to suppress any recall bias from one session to the next. Each scan was reviewed once using the AIO-window/level setting and another time using the conventional bone, lung, and soft tissue window/level display settings, in a randomized order. The CT reports were used as reference standard. ResultsOverall, there was no statistically significant difference in the assessment accuracy of the review based on the AIO or the conventional window/level settings (0.89 ± 0.09 vs 0.90 ± 0.08). Using the AIO-window/level settings, TAT was 14.3 s faster when compared with the conventional window/level settings (2.33 ± 0.63 vs 2.57 ± 0.51 min; p < 0.001). ConclusionsIn a time-delimited image review, similar diagnostic accuracy was reached faster using the AIO vs the conventional window/level settings. When providing a “wet read” at the CT console, the ability to identify traumatic injury using a single AIO-window/level may help expedite patient management.

CYSTIC LUNG DISEASE IN A YOUNG MALE WITH SYSTEMIC LUPUS ERYTHEMATOSUS

CYSTIC LUNG DISEASE IN A YOUNG MALE WITH SYSTEMIC LUPUS ERYTHEMATOSUS

S2168 The Use of Rituximab for IgG4–Related Sclerosing Mesenteritis

Introduction: Sclerosing mesenteritis (SM) is an uncommon fibro-inflammatory disease affecting the abdominal mesentery. Although some patients are asymptomatic or have minimal symptoms, SM can present with complications such as bowel obstruction, chylous ascites, and mesenteric ischemia. First-line therapy includes glucocorticoids in combination with tamoxifen in those who are symptomatic. Case Description/Methods: An 82-year-old man with a history of prostate cancer and melanoma in remission and lymphocytic colitis presented with 4-months of poor appetite and 40-pound unintentional weight loss. Computed tomography (CT) abdomen showed an irregular 8.6 cm mesenteric mass with surrounding misty mesentery (Figure, Panel 1). CT-guided biopsy demonstrated fibro-adipose tissue with increased IgG4-positive plasma cells, supporting a diagnosis of IgG4-related SM. Follow-up CT abdomen 6 months later demonstrated enlargement of the mass with new encasement of the jejunal and ileal branches of the superior mesenteric artery and vein. Given impending mesenteric ischemia, he was treated with rituximab, a monoclonal anti-CD20 antibody, with 2 infusions 2 weeks apart without side-effects. He had contraindications to first-line therapy with glucocorticoids given prior suicidal ideation while on budesonide for microscopic colitis. Three months following treatment, his erythrocyte sedimentation rate improved from 52 to 25 (reference range, 3-28 mm/h) and IgG4 level from 851 to 267 (2.4-121 mg/dL). CT abdomen demonstrated a 50% decrease in the volume of the mesenteric mass without significant vascular involvement (Figure, Panel 2) and he had regained 30 pounds. Discussion: Although rituximab has been studied for IgG4-related disease in general, the use of rituximab specifically for IgG4-related SM is not well-known. We report a case of a patient with IgG4-related SM treated effectively with rituximab, suggesting this may be a suitable medication for those who have contraindications or do not respond to current first-line therapy, especially if IgG4-related. Whether this drug would also work in patients with SM not related to IgG4 disease is unknown. Patients treated with rituximab should be closely monitored for infections, as well as allergic and infusion-related reactions.Figure 1.: CT abdomen pelvis of sclerosing mesenteritis before (1) and after (2) rituximab treatment.

CATASTROPHIC ANTIPHOSPHOLIPID SYNDROME: A VICIOUS CIRCLE OF CLOTTING AND BLEEDING

CATASTROPHIC ANTIPHOSPHOLIPID SYNDROME: A VICIOUS CIRCLE OF CLOTTING AND BLEEDING

S1721 Doxycycline-Induced Pancreatitis: An Uncommon Complication of a Common Drug

Introduction: Drug induced pancreatitis (DIP) is rare but potential cause of acute pancreatitis and accounts for 0.1-5.3% of all cases. In this case series, we report 2 cases of patients with doxycycline induced pancreatitis. Case Description/Methods: A 60-year-old woman with cervical osteomyelitis on iv ceftriaxone and doxycycline presented with 2-day history of severe nausea, vomiting, and epigastric pain. On exam, she had epigastric and right upper quadrant tenderness. Laboratory evaluation was significant for serum lipase 6,699 u/l , creatinine of 1.94 mg/dl. Liver function tests and lipid panel were within normal limits. Computerized tomography (CT) of the abdomen and pelvis confirmed acute interstitial pancreatitis (Figure). Triglyceride, IgG subclasses and calcium levels were normal. Thorough review of her medications revealed doxycycline induced pancreatitis was suspected. Her symptoms gradually improved and lipase returned to 85 u/l with discontinuation of doxycycline. A 91year-old woman with recent history of left elbow fracture complicated by wound dehiscence on doxycycline therapy, presented for hospital admission with several days of increased confusion, malaise, and generalized, severe abdominal pain. She appeared ill, with dry mucous membranes and diffuse abdominal tenderness. Laboratory test results were notable for blood urea nitrogen (BUN) 56 mg/dl, creatinine 2.35 mg/dl, ALP 223 u/l, total bilirubin 1.1 mg/dl, wbc count 26.7 k/ul, calcium 6.4 mg/dl, lipase 301 u/l, AST, ALT, triglycerides and IgG subclass levels were within normal limits. CT abdomen showed extensive intrapancreatic and peripancreatic edema, the patient was diagnosed with severe pancreatitis. With careful exclusion of other etiologies, she was diagnosed with doxycycline induced pancreatitis. Her symptoms improved with aggressive hydration and discontinuation of doxycycline. Discussion: Onset of symptoms with relation to starting the offending drug is key in identifying the causative agent of DIP. The severity, onset of symptoms, dosage of doxycycline and latency have been reported as variable as in our cases. Symptom onset was at 14 days of doxycycline therapy in the first vs 22 in the second case. Treatment includes cessation of doxycycline and aggressive IV fluid resuscitation. This case series emphasizes the importance of considering doxycycline as a cause of acute pancreatitis especially with its increased use in recent years.Figure 1.: CT abdomen with extensive intrapancreatic and peripancreatic edema (second case presented).

S3641 Not Where You Want It! A Very Odd Occurrence of Fishbone Firmly Lodged in the Stomach

Introduction: Inadvertently ingesting fish bones is frequent, and most fish bones pass through the gastrointestinal tract without causing any symptoms or complications within a week. Only about 10% to 20% of foreign bodies necessitate an endoscopic procedure, and less than 1% necessitate surgery. Here, we present a case of fish bone impaction in the stomach and its delayed consequences Case Description/Methods: A 44-year-old female presented with an insidious onset of dull, aching left sided abdominal pain for the past 3 days with nausea and vomiting. She denies NSAIDs, no blood in stools or vomitus. She had eaten Tilapia for Christmas dinner 4 months prior and at that time felt a slight irritation in her throat that had passed, and no other symptoms until now. CT abdomen and pelvis showed a curvilinear foreign body in the pyloric region about 3cm in size. Subsequent EGD showed fishbone securely lodged in the posterior wall of gastric antrum, removed with snare through an overtube, to repair the defect the tissue edges were approximated and two hemostatic clips placed successfully. She was continued on Protonix orally for 4 weeks with complete resolution of symptoms (Figure) Discussion: Fish bones make up about two-thirds of foreign bodies, and 75 percent of ingested foreign bodies get impacted in the oral cavity and laryngopharynx. Moreover, fish bone ingestion might present with a variety of clinical symptoms, including upper GI impaction, dysphagia, bowel obstruction, and silent perforation, as well as frank peritonitis. In our case, it’s quite improbable that a fishbone was stuck in the pylorus for four months without any symptoms. Furthermore, foreign bodies lodged in the stomach are relatively unusual, as peristalsis normally drives them out. Complications have been reported in up to 35% of patients when sharp items pass through the stomach. Also, anything larger than 2 to 2.5 cm in diameter or longer than 5 to 6 cm in length should be removed immediately from the stomach since they will not pass through the pylorus, duodenum, or ileocecal valve. In conclusion, given its vague presentation and difficulties obtaining medical history (as only a small percentage of people recall eating them by mistake), we recommend through this case that clinicians must keep this possibility in mind and conduct timely investigations, as delayed intervention could result in bowel perforation.Figure 1.: A-C : Coronal view of a computed tomography (CT) image showing a linear, hyperdense, foreign body (arrow) which appeared to lodge in posterior wall of gastric antrum. Figure D-F: Endoscopy images of impacted fishbone and its retrieval. Figure G: Photograph of the removed fish bone.

S1889 A Case of Ruptured Gastroduodenal Artery Pseudoaneurysms in a Patient With Chronic Pancreatitis

Introduction: Pancreatic pseudoaneurysm is a rare vascular complication of pancreatitis, with an estimated prevalence of 10%. Pseudoaneurysm can result from trauma, inflammation, infection, and iatrogenic causes. Due to its weak structural support, the risk of rupture is higher for pseudoaneurysm than that of a true aneurysm of similar size. Pancreatic pseudoaneurysms can lead to life-threatening complications such as rupture and bleeding, with increased morbidity and mortality up to 90% in untreated patients and 12.5% despite treatment. Due to its high mortality rate with rupture, pseudoaneurysms should be treated immediately once it is identified, regardless of their size or whether it is symptomatic or not Case Description/Methods: We present a case of a 68-year-old male patient with a past medical history significant for chronic pancreatitis who presented with altered mental status and hypovolemic shock secondary to unexplained gastrointestinal and retroperitoneal hemorrhage (Table). Computed tomography (CT) Angiography was done which showed an enlarging retroperitoneal and right-sided intraperitoneal hematoma with suspicion for active arterial extravasation or punctate pseudoaneurysms in the pancreatic head (Figure). Celiac angiogram was done under fluoroscopic guidance, which showed gastroduodenal and superior pancreaticoduodenal artery pseudoaneurysms. He underwent successful endovascular coil embolization of the gastroduodenal artery. Post procedure he was monitored in intensive care unit. His clinical condition continued to improve and was discharged to a skilled nursing facility in stable condition. Discussion: Physicians should be aware of pancreatic pseudoaneurysms as rare vascular complication associated with chronic pancreatitis that may lead to fatal gastrointestinal or retroperitoneal bleeding with a high mortality rate. Our case highlights the importance of early diagnosis and prompt treatment in these patients.Figure 1.: A: CT abdomen and pelvis without intravenous contrast showing peripancreatic inflammation surrounding the pancreatic body and head along with retroperitoneal bleed (red arrow). Pancreatic calcifications present (yellow arrow) signifying radiologic evidence of chronic pancreatitis B: CT Angiography showing retroperitoneal and right-sided intraperitoneal hematoma with active arterial extravasation or punctate pseudoaneurysms in the pancreatic head. Table 1. - Laboratory Investigation Investigation Day 1 of Hospitalization Day 5 At Time of Discharge Reference Range White Blood Cell count 24.3 14.3 k/uL 7 k/uL 4.8-10.8 k/uL Red Blood Cell Count 4.77 2.69 MIL/uL 3.19 MIL/uL 4.50-5.90 MIL/uL Hemoglobin 15.8 8.5 mg/dl 10.2 mg/dl 12.0-16.0 g/dL Hematocrit 47.6 25.7 % 30.5% 42-51 % Platelet count 171 155 k/uL 215 k/uL 150-400 k/uL Sodium, Serum 132 139 mEq/L 140 mEq/L 135-145 mEq/L Potassium, Serum 3.0 3.2 mEq/L 3.9 mEq/L 3.5-5.0 mEq/L Blood Urea Nitrogen, Serum 41 17 mg/ml 10 mg/ml 8-26 mg/dL Creatinine, Serum 1.2 0.5 mg/dl 0.6 mg/dl 0.5-1.5 mg/dL Bilirubin, Serum total 0.5 0.7 mg/dl 0.3 mg/dl 0.2-1.1 mg/dL Serum Direct Bilirubin 0.3 0.3 mg/dl < 0.2 mg/dl 0.0-0.3 mg/dL Alkaline Phosphatase 51 48 units/L 73 units/L 56-155 unit/L Aspartate Transaminase 125 21 units/L 18 units/L 9-48 unit/L Alanine Aminotransferase 81 30 units /L 12 units /L 5-40 unit/L Lactic acid Level 8.2 0.8 mmoles/L 1.1 mmoles/L 0.5-1.6 mmoles/L Prothrombin Time 15.2 13.9 sec 10.5 sec 9.9-13.3 seconds International Normalized Ratio 1.31 1.20 0.92 0.85-1.14 Serum Calcium 6.6mg/dl 7.6 mg/dl 9.2 3 mg/dl 8.5-10.5 mg/dl Serum Lipase 24 U/L < =61U/L Serum Triglyceride 163mg/gl 55-150 mg/dl Serum Ethanol < 10 < = 10mg/dl Urine Toxicology Cocaine and methadone Negative

S2283 Aspiration Pneumonia: An Atypical Case Presentation of Esophageal Malignancy

Introduction: Esophageal malignancy is the most common cause of tracheoesophageal fistula (TEF) in adults. TEFs develops in 5-15% of patients with esophageal malignancy, often being found late in the disease course. TEFs are often a result of cellular damage from radiation therapy. Patients often present with symptoms including coughing, pneumonia, hemoptysis, hypoxic respiratory distress, and aspiration. The symptoms of cough, aspiration, and pneumonia remain consistent with expected symptoms of esophageal radiation, and thus, can lead to delay in diagnosis of tracheoesophageal fistula. Case Description/Methods: The patient was a 75-year-old male with a history of non-Hodgkin’s lymphoma status post radiation, and chronic dysphagia was admitted to the medical intensive care unit for acute hypoxic respiratory failure requiring non-invasive mechanical ventilation. Labs were remarkable for white blood cell count of 17.9, hemoglobin 10.5, platelets 400, and all electrolytes were within normal limits. Total bilirubin, transaminases, alkaline phosphatase, and lipase were unremarkable. Computed tomography (CT) chest w/o contrast noted multifocal aspiration pneumonia, most severe at the left lung base. CT abdomen w/o contrast showed irregular thickening of the mid to distal esophagus suspicious for a neoplastic etiology, for which GI was consulted for an esophagogastroduodenoscopy (EGD). Subsequently he developed pulseless electrical activity-arrest requiring intubation. At this point, it was conducive for the patient to undergo EGD, which found invasive squamous cell carcinoma of the esophagus with tracheal fistulation. Due to poor prognosis, the palliative care team was consulted at which point the patient elected for hospice with comfort measures only (Figure). Discussion: Despite improvement in detection techniques, the incidence of esophageal malignancy in the United States continues to rise. Esophageal cancer is the 6th leading cause of cancer related death in men with a 5-year survival rate of 15-25%. It is important that these patients are diagnosed early in the disease course. Unfortunately, due to the rapidly progressive nature of the disease and the frequent lack of clinical symptoms during early stages, esophageal carcinoma is especially difficult to detect. Although TEFs are typically found late in the disease course, it is critical to recognize that complications associated with esophageal fistulas can be the presenting findings of esophageal malignancy.Figure 1.: Upper left: Proximal esophagus with evidence of necrosis Upper right: TEF of mid esophagus Lower left: partially obstructive squamous cell carcinoma of the mid esophagus Lower right: CT scan revealing advanced multifocal aspiration pneumonia of the left lung.

S1733 Exceedingly Rare Coexistence of Metamorphosis of Tubulovillous Adenoma of the Ampulla to Adenocarcinoma with Small Bowel Gastrointestinal Stromal Tumor - Case Report and Review of the Literature

Introduction: This is a unique case of a patient with 3 tumors, which include one benign tumor, tubulo-villous adenoma of the ampulla of Vater (TVAoA), and 2 extremely rare malignant tumors, adenocarcinoma of the ampulla of Vater arising from TVAoA and gastrointestinal stromal tumor (GIST) involving the jejunum. Based on literature review, this is the first case of ampullary adenocarcinoma coexisting with GIST. Distal duodenal polyps are uncommon and have preponderance to occur in and around the ampulla of Vater. We report a case of a 77-year-old male who was admitted for painless obstructive jaundice with a 40-pound weight loss over a 2-month period, and who was subsequently diagnosed with 3 tumors. Case Description/Methods: A 77-year-old man was admitted for generalized weakness with associated weight loss of 40 pounds in the previous 2 months and was noted to have painless obstructive jaundice. Computed tomography (CT) of the abdomen and pelvis and magnetic resonance cholangiopancreatography were consistent with a polypoid mass at the level of the common bile duct (CBD) and ampulla of Vater with CBD dilatation. The same lesions were visualized by endoscopic retrograde cholangiopancreatography. Histopathology of endoscopic forceps biopsy showed tubulo-villous AoA (TVAoA). Histopathology of the surgical specimen of the resected ampulla showed adenocarcinoma arising from the TVAoA. Abdominal and pelvic CT also showed a coexisting heterogeneously enhancing, lobulated mass in the posterior pelvis originating from the jejunum (Figure). The patient underwent resection of the mass and jejunojejunal anastomosis. The histopathology of the resected mass confirmed it as a high-grade GIST. Discussion: AoA can occur sporadically and in a familial inheritance pattern in the setting of FAPS. We emphasize screening and surveillance colonoscopy when one encounters AoA in upper endoscopy to check for FAPS. AoA is a premalignant lesion, particularly in the setting of FAPS, that carries a high risk of metamorphism to ampullary adenocarcinoma. Final diagnosis should be based on a histopathologic study of the surgically resected ampullary specimen, and not on endoscopic forceps biopsy.This case is unique because he had 3 tumors and rare coexistence, which included one premalignant TVAoA and 2 malignant tumors: ampullary adenocarcinoma arising from the TVAoA and coexisting jejunal GIST.Figure 1.: Figure1A: CT abdomen and pelvis with contrast. Obstructed distal common bile duct due to a 9 mm polypoid intraluminal (pointed yellow arrows) lesion in the distal CBD. Figure1B: CT of the abdomen and pelvis with contrast. Heterogeneously enhanced lobulated mass with punctate calcifications (pointed yellow arrows) in the posterior pelvis originating from the serosal surface of the pelvic small bowel. Figure1C: Endoscopic retrograde cholangiopancreatography (ERCP) showed abnormal papilla with polypoid mass. Sphincterotomy and deep cannulation procedures were performed and confirmed by fluoroscopy. It showed common bile duct dilatation, and there was an abrupt cutoff at the distal aspect. Figure1D: High-power photomicrograph showing high-grade glandular dysplasia (hematoxylin and eosin stain, 200 X original magnification) Figure1E: A broad base ampullary mass with red fogerty cath was advanced from the cystic duct down through the ampulla to the duodenum. Figure1F: Pedunculated GIST arising from the small bowel approximately 150 cm proximal to the ileocaecal valve.

S1766 Metastatic Renal Cell Cancer with Pancreatic Mass

Introduction: Pancreas is an uncommon site of metastatic disease. Almost 63% of pancreatic metastasis arise from renal cell cancer. We report a case of metastatic renal cell cancer to pancreas, with contralateral adrenal metastasis 15 years after a radical nephrectomy. Case Description/Methods: 61 years old man with past medical history of renal cell cancer, status post left radical nephrectomy fifteen years ago, presented with dull pain in right lower abdominal for one day. He denied any other abdominal symptoms or weight loss. He smokes up to half a pack of cigarettes daily. His examination was unremarkable but he was noted to have elevated lipase (213U/L) and a bilirubin of 1.1 mg%. On computer tomography abdomen he had bulky, enhancing, soft tissue mass (∼6.7 cm), with dilated pancreatic duct of 1.5 cm with right adrenal mass (Figure). On EUS, the lesion appeared well circumscribed and previously known pancreatic duct dilation was seen. Fine needle biopsy of the mass, which showed numerous atypical cells with round irregular nuclei with prominent nucleoli with clear cytoplasm suggestive of clear cell renal cell carcinoma (Figure). On immune -histochemistry, the tumor was positive for CD10, renal cell carcinoma antigen and PAX 8( Figure) Discussion: Metachronous renal cell cancer to pancreas fifteen years after radial nephrectomy is rare. Our patient had pancreatic metastasis with adrenal involvement and presented with vague abdominal symptoms. .He was noted to have elevated lipase and dilation of main pancreatic duct. Due to a remote history of nephrectomy and the presenting complaints, pancreatic primary was suspected. However, on endoscopic ultrasound the patient was noted to have a well circumscribed lesion in the head of pancreas with dilated pancreatic duct(Figure). Regular borders and absence of pancreatic duct dilation suggested metastatic disease. Our patient had well circumscribed lesion but with a dilated duct. Most pancreatic metastasis are reported to occur within 10 years after treatment of the primary disease but our patient had metastasis fifteen years later without any loco-regional recurrence. Endoscopic ultrasound is extremely important and allows to evaluate the extent of the disease, involvement of portal vein/ superior mesenteric artery, presence of enlarged lymph nodes, which are a must for evaluating the surgical candidature besides providing tissue diagnosis which helped us establish the diagnosis of metastasis.Figure 1.: CT(A,B,C) and EUS(D,E) findings. Image A shows the mass in the Pancreatic head(arrow with red head) with a dilated pancreatic duct seen in imageB( arrow with red head). Adrenal metastasis is seen in image C marked with a red arrow. On EUS, the mass appears well circumscribed( blue arrow, image D) with dilated pancreatic duct seen ( green arrow) in the head of pancreas in E.