Curbside Consultations Research Articles

Pharmacist Interventions in a Palliative PLUS Program at a Veterans Affairs Medical Center.

Background: Palliative PLUS (PP) at the Minneapolis Veterans Affairs Health Care System (MVAHCS) is an interdisciplinary team that seeks to improve veteran access to palliative and hospice resources. Palliative care pharmacists were incorporated to increase patient access to palliative specialties. Objective: To identify and categorize pharmacist interventions within an outpatient PP team at the MVAHCS. Methods: This quality improvement project was a retrospective analysis of the electronic health record. Results: A total of 84 patients were participating in the PP program over 13 months. Among those patients, 25 had pharmacist involvement and a total of 56 interventions were identified. Of those interventions, 29 (51.8%) were direct interventions and 27 (48.2%) were curbside consults. Most interventions involved medication counseling and medication adherence. Conclusion: Pharmacists made an impact on the PP team through direct patient interventions involving medication counseling and aided the interdisciplinary team by facilitating patient medication adherence.

An evaluation of pediatric dermatology curbside consultations in an academic center: A prospective cohort study

An evaluation of pediatric dermatology curbside consultations in an academic center: A prospective cohort study

"Can you help me think this through?" How pediatric hospitalists learn from informal peer consultation.

Informal peer consultation (IPC), also called curbside consultation, is a common practice in medicine. Research has shown that physicians use IPC but how this learning occurs during the process has not been studied. This basic qualitative study describes how pediatric hospitalists learn during IPC, framed by Kolb's (2015) Experiential Learning Theory of Growth and Development. Eleven pediatric hospitalists were interviewed. Deidentified transcripts were coded for key themes using inductive methods. The main prompt for informal peer consultation was the perception of uncertainty. Three themes describe the learning process: "Eliciting Perspectives," "Thinking Aloud Together," and "Experiencing Validation. A fourth theme, "Acknowledging Value," described the importance of IPC for modeling how to manage uncertainty with patients' caregivers and medical trainees. By describing the learning process, the results have implications for physicians who engage in IPC and may inform faculty-level professional development initiatives to improve the IPC process.

(142) Curbside Consults: Practice Considerations in an Evolving Legal Landscape

(142) Curbside Consults: Practice Considerations in an Evolving Legal Landscape

Evaluation of Curbside Consultations Encountered by Emergency Department Physicians during the COVID-19 Pandemic Period

Amaç: Curbside konsültasyon (CK), hem hekimlerin hem de hastaların bilgiye kolay yoldan ulaşmak için yıllardır tercih ettikleri bir yoldur. COVID-19 salgını, CK sıklığını daha da artırmış olabilir. Ancak, CK için herhangi bir kaydın bulunmaması medikolegal riskler oluşturabilir. Bu çalışma, COVID-19 pandemisi sırasında acil hekimlerinin karşılaştığı CK prevalansını ve içeriğini değerlendirmeyi amaçlamıştır. Gereç ve Yöntemler: Araştırmamız AS hekimlerinin COVID-19 pandemisinde karşılaştıkları CK’ları değerlendirmeleri için bir anket çalışması olarak planlandı. Araştırma için katılımcılara Türkiye geneli WhatsApp grupları üzerinden ulaşıldı. Google Formlar ile hazırlanan anket formunu doldurarak araştırmaya katılım sağlandı. Sonuçlar mutlak değerler ve yüzde olarak verildi. Bulgular: Araştırma için ulaşılan 1200 hekimden 256’sı anket formunu doldurarak araştırmaya katıldı. Covid-19 pandemisinde acil servis hekimlerinin 163’üne (%62,5) bir başka hekim tarafından, 220’sine (%85) hekim olmayan kişiler tarafından CK isteminde bulunuldu. Hekimlerin %49,5’ine haftada 4 veya daha fazla kez hekim olmayan kişiler tarafından CK isteminde bulundu. Hekim olmayan kişiler %86 aile bireyleri, %85 yakın arkadaş çevresi ve %79,6 yardımcı sağlık personeliydi. Acil servis hekimlerinin %89,2’si CK sonucunda kişilere faydalı olduğu düşünüyordu. Hekimlerin %98’i CK ile ilgili medikolegal bir problem yaşamamışlardı, %14,8’i CK’ların mevcut şekilde işlerliğinin yeterli olduğunu düşünüyordu. Sonuç: AS hekimleri için oldukça yaygın olan CK kavramı önümüzdeki süreçte medikolegal açıdan bir risk oluşturabilir. CK’lar ile ilgili yasal çerçevenin oluşturulması ve bu konuda teletıp altyapısının sağlanması ile hekimler ve hastalar açısından daha sağlıklı değerlendirmeler yapılabilir.

1290. A Structural Intervention Improves ID Fellow Wellness Amid a Pandemic

Abstract Background Infectious Disease (ID) physicians have historically had higher levels of burnout compared to other medical specialties. Fellows are not immune to the pressures that attendings experience in the course of clinical care. The Accreditation Council for Graduate Medical Education now requires programs to formally promote well-being amongst trainees. We created a structural intervention to improve fellow well-being and conducted a before-and-after study demonstrating effectiveness. Methods We restructured our institution’s inpatient ID clinical services, which increased attending presence on weekends and afternoons to help with clinical volume. A survey including the Maslach Burnout Inventory for Medical Personnel (MBI-HSS(MP)) and wellness metrics was completed by our 5 fellows before and after the intervention. Consult volume and efficiency were assessed before and after the intervention. Descriptive statistics, paired t-tests or Wilcoxon signed-rank tests were utilized as appropriate for data normality. Qualitative survey responses were coded into key domains until saturation was reached for analysis. Results Post-intervention MBI-HSS(MP) mean scores significantly improved for emotional exhaustion (EE) [3.3 to 2.3, p-value .0089]. Personal accomplishment and depersonalization metrics improved but were not significant. Survey items assessing time for education, learning to service balance, satisfaction and wellness all improved but were not significant (Table 1). Consult volume was the most frequent domain associated with dissatisfaction, and was described as the most improved domain since intervention (Table 2). Clinical work volumes were the same, if not higher, in the post intervention period (Table 3). All 5 fellows completed surveys before and after the intervention. The pre and post intervention means with standard errors (SE) or frequency of responses are listed in the table as well as p- values for Wilcoxon-signed rank or paired t-test (depending on normality of that variable). For “education versus service balance” fellows used a visual analogue scale (0-100) to assess their views of balance of education (lower values) to service (higher values) while on General Infectious Disease consults (GID). Fellows were asked to rate their “satisfaction” with GID on a visual analogue scale from 0-100 with lower values as dissatisfaction and higher values as satisfaction. EE, DP, and PA are metrics used in the Maslach Burnout Inventory for Medical Personnel (MBI-SS(MP)). The values of the MBI questions are mean responses across items in their respective inventories, with higher values for EE and DP meaning more frequent negative experiences, and higher values for PA meaning more frequent positive experiences. For MBI, scores indicate how frequently feelings occur: 1, a few times/year; 2, monthly; 3, a few times monthly; 4, weekly; 5, a few times/week. Fellows were also asked to give the frequency at which they were able to teach or complete responsibilities at home (such as childcare, cleaning, cooking, grocery shopping) while on GID. Responses truncated only to frequencies selected by respondents. Responses to the last two questions were numerically coded for statistical analysis. * Indicates statistical significance (p < .05). Free text survey responses were analyzed by authors, resulting in the generation of key conceptual response domains; this process continued until saturation was reached, leading to the coding of text responses as above. Examples from text responses included in parenthesis. Prompt 1 was given to the 5 fellows before and after the intervention leading to 10 responses. Prompt 2 was given to the 5 fellows only following intervention. Variables were assessed pre and post intervention. Max list size is the maximum number of patients on the general infectious disease (GID) consult service, bumped consults is the number of consults not seen until the following work day, curbside consults is the number of consults where recommendations were given without seeing the patient, last rec is the time of delivery of the last recommendation, pages is the raw number of pages received in a day by the GID fellow and COVID-19 census is the total number of patients admitted to our center with COVID-19. *Indicates statistical significance (p < .05) by paired t-test. IQR signifies inter-quartile range. Conclusion We found that an intervention addressing structural contributors to burnout was effective in reducing EE and perception of clinical volume. This finding was significant despite stable to increased clinical volumes and the added stress of the cotemporaneous Omicron outbreak of COVID-19. Disclosures Aniruddha Hazra, MD, Gilead Sciences: Grant/Research Support.

Interprofessional microteaching: An innovation to strengthen the behavioral health competencies of the primary care workforce.

There is significant variability in how residency programs prepare the primary care workforce in behavioral health competencies. One approach that warrants further exploration is to have integrated behavioral health consultants (BHCs) capitalize on in vivo clinical teaching opportunities in the context of team-based care. This article presents preliminary results from the implementation of a pilot program wherein BHCs use warm handoffs and other clinical interactions to provide brief, targeted education to medical residents. Twelve BHCs from five resident training clinics participated in a 1-hr training on "microteaching" skills that could be used in clinical teaching interactions. BHCs were asked to track instances of microteaching using an Excel spreadsheet. After 3 months, BHCs and residents responded to electronic surveys that assessed the acceptability and feasibility of this process. In 3 months, BHCs provided 269 instances of microteaching with 66 residents (66.7%) across five clinics. These microteachings occurred within the context of various interactions, including warm handoffs (n = 138, 51.3%), curbside consultations (n = 78, 29.0%), debriefs (n = 46, 17.1%), and team huddles (n = 7, 2.6%). Roughly half (n = 149, 55.4%) of these encounters involved Level 1 microteaching (i.e., lasting 2 min or less), while half (n = 120, 44.6%) involved Level 2 (i.e., lasting 3-10 min). BHCs and residents rated the microteaching interactions as acceptable and feasible. Leveraging embedded BHCs as clinical educators in integrated care environments may hold value for increasing behavioral health competencies among medical residents. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

New Sections in Gastroenterology—Gastro Curbside Consult and Gastro Grand Rounds

New Sections in Gastroenterology—Gastro Curbside Consult and Gastro Grand Rounds

An Unusual Cause of Acute Gastroenteritis, Ascites, and Eosinophilia in a 29-Year-Old Woman

An Unusual Cause of Acute Gastroenteritis, Ascites, and Eosinophilia in a 29-Year-Old Woman

An Unusual Cause of Acidosis in a Man With Clostridium difficile Colitis

An Unusual Cause of Acidosis in a Man With Clostridium difficile Colitis

A Rare Cause of Abdominal Pain After Transjugular Intrahepatic Portosystemic Shunt

Question: A 77-year-old woman presented with progressive dyspnea for 4 months. The patient was diagnosed with primary biliary cirrhosis more than 1 years ago and was ever since on ursodeoxycholic acid medication. Recurrent ascites occurred at least 6 months before diagnosis and was responsive to diuretics. Beyond these, she did not experience any onset of gastrointestinal bleeding or hepatic encephalopathy. Laboratory examination indicated the decreased hemoglobin (10.7 g/dL, normal value [nv]: 11.5–15 g/dL), leukocyte (2.85 × 103/μL, nv: [3.5–9.5] × 103/μL), and platelet counts (53 × 103/μL, nv: [100–300] × 103 /μL), increased alkaline phosphatase (195 IU/L, nv: 50–135 IU/L) and glutamyl transpeptidase (149 IU/L, nv: <45 IU/L), and normal aminotransferase and total bilirubin levels. Chest computerized tomography showed a large amount of right-sided pleural effusion. Pleural fluid tests revealed an uncomplicated hepatic hydrothorax with serum-pleural fluid albumin gradient >1.1 g/dL and polymorphonuclear cell count <500 cells/μL. However, the patient did not show significant improvement of symptoms with dietary sodium restriction and adequate-dose diuretics. Considering the existence of hepatic hydrothorax refractory, transjugular intrahepatic portosystemic shunt (TIPS) was performed thereafter. The portal pressure gradient decreased from 18 mm Hg–7 mm Hg after stent implantation. The interventional procedure was uneventful and no complication occurred during the processes. Postoperatively, the patient experienced slight dull pain in the right upper abdomen, and the symptom intensified gradually despite giving analgesic medication in the following 36 hours. Abdominal examination showed tenderness in the right upper quadrant and percussion pain in the liver area. Liver function tests revealed obviously elevated alanine aminotransferase (1147 IU/L, nv: <50 IU/L) and aspartate aminotransferase (1582 IU/L, nv: <40 IU/L), mildly elevated total bilirubin (1.73 mg/dL, nv: 0.29–1.64 mg/dL). Blood routine showed the change of hemoglobin (11.4 g/dL) and leukocyte (6.67 × 103 /μL). Abdominal computerized tomography showed multiple strips of low-density shadows along the blood vessels and scattered low-density nodules in the liver parenchyma (Figure A, white arrowheads). What is the most likely diagnosis? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Abdominal contrast-enhanced computerized tomography (CECT) showed diffuse linear hypodensity around portal vein branches and multiple low-density nodules in the liver, but no obvious enhancement was observed (Figures B and C, white arrowheads). These imaging findings were absent from hepatic vein and intrahepatic inferior vena cava (Figure D). According to the history of hepatic invasive procedure, laboratory findings, and CECT presentation, intrahepatic lymphangiectasia was suspected. After a short course of nonsteroidal anti-inflammatory drug therapy, her symptoms completely resolved and transaminases gradually returned to normal levels. Follow-up CECT scans at 30 days showed complete resolution of the periportal low-density areas (Figures E and F). Intrahepatic lymphangiectasia (IHL), manifested as dilated hepatic lymphatics and related lymphedema, is caused by either increased lymph flow or lymphatic obstruction.1Pupulim L.F. Vilgrain V. Ronot M. et al.Hepatic lymphatics: anatomy and related diseases.Abdom Imaging. 2015; 40: 1997-2011Crossref PubMed Scopus (26) Google Scholar Liver transplantation, blunt abdominal trauma, hepatic malignant neoplasms, and congestive hepatomegaly due to cardiac decompensation are the most common underlying etiology of IHL.2Koslin D.B. Stanley R.J. Berland L.L. et al.Hepatic perivascular lymphedema: CT appearance.AJR Am J Roentgenol. 1988; 150: 111-113Crossref PubMed Google Scholar “Periportal halo,” characterized by hypodense appearance on computed tomography and hyperintense appearance on T2-weighted magnetic resonance images, has important clinical significance in the diagnosis of IHL.3Karcaaltincaba M. Haliloglu M. Akpinar E. et al.Multidetector CT and MRI findings in periportal space pathologies.Eur J Radiol. 2007; 61: 3-10Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Presence of hypodense appearance on both sides of the portal venous system can allow differentiation from biliary dilatation.3Karcaaltincaba M. Haliloglu M. Akpinar E. et al.Multidetector CT and MRI findings in periportal space pathologies.Eur J Radiol. 2007; 61: 3-10Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar In fact, IHL could be an overlooked complication of TIPS that has never been previously reported. Iatrogenic injury during a TIPS procedure may interrupt lymphatic vessels and initiate coagulation at the injury site, and thrombus/microthrombus provisionally compresses and blocks the hepatic lymphatic system. Once the thrombus/microthrombus dissolves, the occluded lymphatics are recanalized and IHL could be spontaneously resolved. In conclusion, IHL is a procedure-related complication of TIPS that should not be neglected. Periportal halo by CECT provides valuable evidence for both diagnosis and differential diagnosis. Further studies with a larger sample size are necessary to investigate the morbidity and natural course of IHL after TIPS.

Severe Chronic Rectocolitis Associated With a Characteristic Sunflower Magnetic Resonance Imaging Pattern

Severe Chronic Rectocolitis Associated With a Characteristic Sunflower Magnetic Resonance Imaging Pattern

An Unusual Case of Chest Pain and Pyrexia

Question: A 44-year-old man with tearing retrosternal pain for 2 weeks was admitted to our department. A day before the onset of symptoms, he had pharyngalgia, cough, sputum production, moderate pyrexia, and fatigue, which he thought was due to a common cold. He then had sudden-onset severe chest pain, which lasted 4 to 6 seconds and occurred every 30 seconds, with acid reflux and heartburn. The patient had consumed nothing after the start of the symptoms until this consultation. He denied emesis, hematemesis, melena, dysphagia, odynophagia, history of esophageal disease, eating hurriedly, ingestion of hot or rough food, anticoagulants, or foreign body. His medical history was significant for alcohol consumption (100 g/d) for more than 20 years. He visited a local hospital and underwent chest computer tomography (CT); however, the diagnosis was unclear, and an attempt to insert a nasogastric tube failed. The patient visited another hospital, and a CT scan revealed dilation of the esophageal lumen and thickening of the esophageal wall, with exudation in the periesophageal areas and lung fields. Esophagoscopy revealed a large depressed lesion at 20 cm from the incisors, measuring 1 cm in diameter and covered with pus. The background esophageal mucosa was severely inflamed and edematous. Contrast esophagography performed a week later showed accumulation of contrast medium in the middle and lower esophagus, which formed a sac-like shadow beside the esophagus, without communication with the thoracic or gastric cavity. The patient was treated conservatively, and his symptoms were partially relieved. Because the pathogenesis was still unknown, the patient was referred to our institution for further evaluation. What is the correct diagnosis and management of this condition? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult According to his medical history from other hospitals, normal electrocardiography and cardiac enzyme levels excluded the diagnosis of myocardial infarction; absence of hypertension and no abnormalities in aortic anatomy disclosed by means of contrast CT argued against aortic dissection; absence of emesis and no extravasation of contrast medium demonstrated by contrast esophagography excluded Boerhaave’s syndrome. Then contrast chest CT scan, which revealed thickening and liquid accumulation in the middle and lower esophageal wall, with little extra-esophageal air leakage and pneumonia (Figures A and B), and upper endoscopy (Figures C and D) were performed. A diagnosis of spontaneous intramural esophageal dissection (SIED) complicated by infectious esophagitis and pneumonia was made. SIED is a rare disease entity characterized by transverse and longitudinal separation of the mucosal and submucosal layers from the esophageal wall. Sudden onset of severe retrosternal chest pain, odynophagia, dysphagia, and hematemesis are the most common symptoms. Contrast esophagography and chest CT are the preferred methods to establish the diagnosis, and endoscopy also proved to be safe and useful in this condition. In most cases, conservative treatment has a good prognosis. Endoscopic interventions and surgery are alternative therapies when patients are refractory to conservative management or when complex complications occur.1Khil E.K. Lee H. Her K. Spontaneous intramural full-length dissection of esophagus treated with surgical intervention: multidetector CT diagnosis with multiplanar reformations and virtual endoscopic display.Korean J Radiol. 2014; 15: 173-177Crossref PubMed Scopus (4) Google Scholar,2Jung K.W. Lee O.J. Extensive spontaneous submucosal dissection of the esophagus: long-term sequential endoscopic observation and treatment.Gastrointest Endosc. 2002; 55: 262-265Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar The patient was treated conservatively and discharged on day 35. Seven weeks later, follow-up endoscopy showed complete mucosal healing (Figure E), and he was asymptomatic at the time of writing (August 1, 2022).

A Mysterious Case of Abdominal Pain

A Mysterious Case of Abdominal Pain

Massive Single Lesion in a Patient With Sickle Cell Disease

Massive Single Lesion in a Patient With Sickle Cell Disease

An Atypical Complication of Chronic Pancreatitis

An Atypical Complication of Chronic Pancreatitis

A Curious Case of Severe Proctitis

Question: A 40-year-old man with well controlled human immunodeficiency virus presented to the emergency department with one week of severe rectal pain. He subsequently developed fevers and hematochezia with loose stools, prompting him to seek care. Past sexual history includes anal receptive intercourse and a previous diagnosis of anal human papilloma virus. On presentation, he was febrile to 103.2°F, but otherwise hemodynamically stable. Rectal exam was limited by severe pain, but was notable for mucopurulent discharge, perianal ulcers, and erythema (Figure A). Laboratory testing was significant for leukocytosis with white blood cell count of 12.6 /mm3 and an elevated C-reactive protein of 111 mg/L. A computed tomographic scan of his abdomen with intravenous contrast was performed and showed marked inflammatory changes of the rectum and surrounding soft tissue without abscess or other upstream colonic inflammation and multiple enlarged perirectal and retroperitoneal lymph nodes (Figure B). Extensive testing for multiple infectious diseases, including syphilis, herpes simplex virus, gonorrhea, and chlamydia, was negative. What is the diagnosis? Look on page 528 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Given high index of suspicion, he was placed on our standard precautions for monkeypox rule-out, which includes isolated room, gowns, gloves, eye protection, and N-95 filter. A rectal polymerase chain reaction swab for nonvariola orthopox virus returned positive, confirming a diagnosis of monkeypox virus. This was reported to the State Department of Health for contact tracing. The patient was treated with tecovirimat antiviral therapy under emergency use authorization, as approved by the Center for Disease Control and State Department of Health. He noted symptomatic improvement within a few days and was discharged to complete an oral course of 600 mg tecovirimat twice daily for a total of 14 days. Monkeypox virus is a zoonotic orthopox DNA virus that was previously endemic to Africa.1Thornhill J.P. Barkati S. Walmsley S. et al.Monkeypox virus infection in humans across 16 countries—April-June 2022.N Engl J Med. 2022; 387: 679-691Crossref PubMed Scopus (508) Google Scholar In the spring of 2022, cases outside of endemic regions began to rise and a global outbreak began. The presenting symptoms of monkeypox can be nonspecific, including fevers, myalgias, mucosal involvement, and skin lesions, which are vesicular and evolve over days to weeks.1Thornhill J.P. Barkati S. Walmsley S. et al.Monkeypox virus infection in humans across 16 countries—April-June 2022.N Engl J Med. 2022; 387: 679-691Crossref PubMed Scopus (508) Google Scholar Monkeypox has now been declared a public health emergency, and this case highlights many important considerations for diagnosis and treatment. First, the current monkeypox outbreak is disproportionately affecting men who have sex with men.2Guarner J. del Rio C. Malani P.N. Monkeypox in 2022—what clinicians need to know.JAMA. 2022; 328: 139-140Crossref PubMed Scopus (70) Google Scholar Transmission is thought to occur through to skin-to-skin contact. The lesions typically appear first at the site of inoculation, and thus anal/genital lesions may be more common. In a recent international case series published in the New England Journal of Medicine, 73% of the 528 patients with polymerase chain reaction–diagnosed monkeypox had anogenital ulcerations.1Thornhill J.P. Barkati S. Walmsley S. et al.Monkeypox virus infection in humans across 16 countries—April-June 2022.N Engl J Med. 2022; 387: 679-691Crossref PubMed Scopus (508) Google Scholar Also noted in that case series, the most common cause of hospitalization was anorectal pain.1Thornhill J.P. Barkati S. Walmsley S. et al.Monkeypox virus infection in humans across 16 countries—April-June 2022.N Engl J Med. 2022; 387: 679-691Crossref PubMed Scopus (508) Google Scholar The was true for our patient, who required intravenous pain medication on presentation. Symptomatic treatment with opioids, ibuprofen, topical anesthetics (lidocaine jelly per rectum), and stool softeners provided mild improvement while the patient was admitted. However, starting tecovirimat provided the greatest symptomatic improvement, and the patient was able to be discharged with only ibuprofen and stool softeners for pain control after 2 days of treatment. The World Health Organization believes the true number of monkeypox to be underestimated owing to lack of recognition of this infection that was previously only seen in a few countries.3World Health Organization Multi-country monkeypox outbreak: situation update. June 27, 2022.https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON396Google Scholar Thus, a high degree of suspicion must be maintained for the disease, even in patients with isolated anal ulceration or proctitis

“Malignant” Liver Lesions in an Incidental But High-Risk Patient

Question: A 48-year-old woman who suffered an accidental slip underwent abdominal computed tomography, which revealed multiple hepatic lesions in the whole liver. The patient was asymptomatic and physical examinations were unremarkable. She had normal growth and her body mass index was 23.9. No viral or autoimmune hepatitis was detected. The patient had a history of early-stage cervical carcinoma treated by radical hysterectomy 7 years ago without postoperative adjuvant therapy. History of smoking or taking oral contraceptives was denied. Laboratory tests showed the following results: alanine aminotransferase level of 14 U/L, aspartate aminotransferase level of 30 U/L, alkaline phosphatase level of 49 U/L, and bilirubin level of 13.1 μmol/L. Tumor markers of alpha-fetoprotein and CA19-9 were within normal range. Her blood count, electrolyte, glucose level, renal function, and coagulation tests were normal as well. Subsequent contrast-enhanced magnetic resonance (MR) imaging showed liver steatosis with multiple liver lesions in the whole liver. The largest lesion was found to be 28∗20 mm in segment V. The lesions were slightly hyperintense on T2-weighted sequences, with strong arterial enhancement, which persisted into the portal venous phase (Figure A). What is the diagnosis of the disease? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. The MR imaging showed multiple solid hepatic lesions characterized by predominant hypervascularization. Malignancy of multifocal hepatocellular carcinoma was first suspected, which is often hyper-vascular and encapsulated. However, cirrhosis and elevated tumor markers were not presented in our patient. Because the patient had a known primary malignancy of cervical carcinoma before, suspected diagnosis of hyper-vascular liver metastases was also included. In addition, focal nodular hyperplasia and liver adenomatosis sharing similar imaging features in noncirrhotic liver of women were considered for the differential diagnosis as well. The case was discussed with a multidisciplinary team. It was agreed that distinguishing the previously mentioned diseases might be challenging with imaging criteria alone and liver biopsy was required. The histopathologic examination showed cord-like arrangement of benign hepatocytes, which first excluded hepatocellular carcinoma and metastatic hepatic cancer. Additionally, moderate steatosis and lobar inflammation were observed (Figure B). The presence of fat and lack of portal venules distinguished adenomatosis from focal nodular hyperplasia, which led to the final diagnosis of liver adenomatosis. Additionally, adenomatosis is also characterized by thin-walled sinusoids supplied by arteries within hepatocytes, resulting in hypervascularity on arterial-phase imaging. Liver adenomatosis (LA) is defined as presence of 10 or more adenomas in the liver, which was first described by Flejou et al in 1985.1Flejou J.F. Barge J. Menu Y. et al.Liver adenomatosis. An entity distinct from liver adenoma?.Gastroenterology. 1985; 89: 1132-1138Abstract Full Text PDF PubMed Scopus (247) Google Scholar The known risk factors for the development of LA include exogenous estrogen or androgens, obesity, and glycogen storage disorder (GSD). Patients with GSD commonly present with hypoglycemia, hepatomegaly, and growth retardation at 3–6 months of age. LA of these patients usually has presentation of less than 20 years and progress in size and number. For our patient, oral contraceptives or steroids were denied. Although genetic testing was not performed, no typical clinical symptoms of GSD were observed at an early age, which lowered the risk of underlying GSD. The diagnosis of LA is mainly based on contrast-enhanced magnetic MR, which is the same for hepatic adenoma. Liver biopsy is recommended for cases in which imaging is inconclusive and histologic confirmation is able to distinguish between the 4 subtypes of adenomas.2Barbier L. Nault J.C. Dujardin F. et al.Natural history of liver adenomatosis: a long-term observational study.J Hepatol. 2019; 71: 1184-1192Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Based on imaging findings, LA can be further classified as massive or multifocal. The former has a higher risk of hemorrhage, whereas, for asymptomatic patients with multifocal type, the risk of malignant transformation is substantially higher.3Lammert C. Toal E. Mathur K. et al.Large hepatic adenomas and hepatic adenomatosis: a multicenter study of risk factors, interventions, and complications.Am J Gastroenterol. 2022; 117: 1089-1096Crossref PubMed Scopus (2) Google Scholar The patient in our case with multiple lesions raised the question of its management because liver resection is not possible. Considering the possibility that different subtypes of nodules may exist with high-risk malignant transformation, a 3-month imaging surveillance program with MR and tumor marker assessment were instituted in our case. After 2 years of follow-up, the patient lives a normal life without disease progress based on radiographical findings and blood tests.

Circumferential Gastric Wall Thickening With Lymphadenopathy

Question: A 78-year-old Japanese man with a history of hypertension and abdominal aortic aneurysm visited our hospital for epigastric discomfort lasting more than a week. Blood examination revealed mildly elevated white blood cell counts (9900/μL) and normal red blood cell and platelet counts. Biochemical analyses indicated no specific abnormalities except mildly elevated C-reactive protein levels (1.89 mg/dL, normal range <0.14 mg/dL). Serum tumor marker levels, including carcinoembryonic antigen and carbohydrate antigen 19-9, were within the normal ranges. Although Helicobacter pylori infection was detected via serum antibody test, he had not received eradication therapy previously. Contrast-enhanced computed tomography (CT) showed circumferential gastric wall thickening with hyperenhancement on the mucosal surface, accompanied by infrapyloric lymphadenopathies (Figure A). Minimal ascites was found around the liver and in the pelvis. On fluorodeoxyglucose (FDG) positron emission tomography–CT, the thickened gastric wall and swollen lymph nodes showed intense accumulation of FDG with a maximum standardized uptake value of 5.23 and 4.33, respectively (Figure B). Moreover, minor mucosal erosions and ulcerations on the gastric body and the antrum were observed during esophagogastroduodenoscopy (EGD) (Figure C). The distensibility of the gastric wall by CO2 insufflation was not impaired on EGD. Endoscopic mucosal biopsies were performed on the thickened gastric wall with ulcerations. What is the most likely diagnosis here, and how should these lesions be treated? Look on page 339 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Gastric linitis plastica (GLP), a distinct subtype of gastric cancer characterized by thickening and rigidity of the gastric wall,1Vivier-Chicoteau J. Lambert J. Coriat R. et al.Development and internal validation of a diagnostic score for gastric linitis plastica.Gastric Cancer. 2020; 23: 639-647Crossref PubMed Scopus (10) Google Scholar was primarily suspected from the imaging findings. Perigastric lymphadenopathies and ascites suggested lymph node metastases and peritoneal dissemination, reflecting the aggressive behavior of GLP.1Vivier-Chicoteau J. Lambert J. Coriat R. et al.Development and internal validation of a diagnostic score for gastric linitis plastica.Gastric Cancer. 2020; 23: 639-647Crossref PubMed Scopus (10) Google Scholar However, the biopsy obtained from the margins of the ulceration did not reveal any malignant cells suggestive of GLP. Hematoxylin and eosin (HE) staining showed infiltration of numerous histiocytes and noncaseating granuloma formation (Figure D). Because the superficial biopsy often results in inconclusive diagnosis of GLP, laparoscopic resection of the swollen infrapyloric lymph nodes was performed to obtain a more substantial amount of tissue. HE staining of the surgically resected lymph nodes showed the formation of multiple small-size epithelioid granulomas (Figure E). To determine the etiology of granuloma formation, various kinds of immunohistochemical studies were performed. Accumulation of H pylori was observed inside the granuloma of both gastric mucosa (Figure F) and lymph nodes (Figure G) with the use of H pylori–specific antibody (B0471; Dako, Denmark) whereas Epstein-Barr virus or tuberculosis was not detected by in situ hybridization or Ziehl-Neelsen staining. In addition, the possibility of gastric sarcoidosis was low because the serum angiotensin-converting enzyme level was not elevated and gastric granuloma was negative for immunostaining of monoclonal antibody against Propionibacterium acnes (D371-3; MBL, Japan).2Yamaguchi T. Costabel U. McDowell A. et al.Immunohistochemical detection of potential microbial antigens in granulomas in the diagnosis of sarcoidosis.J Clin Med. 2021; 10: 983Crossref PubMed Scopus (17) Google Scholar,3Inomata M. Ikushima S. Awano N. et al.Upper gastrointestinal sarcoidosis: report of three cases.Intern Med. 2012; 51: 1689-1694Crossref PubMed Scopus (16) Google Scholar Therefore, the diagnosis of granulomatous gastritis associated with H pylori infection was made. Successful H pylori eradication therapy with vonoprazan, amoxicillin, and clarithromycin improved his symptoms. Furthermore, gastric wall thickening on CT as well as gastric mucosal ulcerations on EGD disappeared entirely 6 months after the H pylori eradication (Figures H and I), which further verified the diagnosis. This case highlights that granulomatous gastritis associated with H pylori infection needs to be considered in the differential diagnosis when encountering H pylori–positive cases exhibiting circumferential gastric wall thickening with lymphadenopathy.

29-Year-Old Man With Acute Gastric Distention

29-Year-Old Man With Acute Gastric Distention