Episodes Of Vomiting Research Articles

Comparison of the Effect of Adding L-Carnitine to Propranolol in the Prevention of Cyclic Vomiting Syndrome Attacks in Children

Background: Cyclic Vomiting Syndrome (CVS) is an idiopathic, complex, multifactorial disorder that is often characterized by recurrent episodes of vomiting and is usually separated by asymptomatic episodes. Prophylaxis should be considered in children with frequent or severe periods. Prevention and treatment of CVS in children is very difficult and no specific and effective treatment has been proven in clinical trials. Propranolol is approved for the prophylaxis of CVS in children of all ages, but its effectiveness has been variable. In this study, we investigated the efficacy and safety of adding L-Carnitine to propranolol therapy in the prevention of pediatric CVS. Methods: 76 children who were diagnosed with CVS were included in this study. They were divided into two equal groups. The first group received high dose of Propranolol and the case group received L-Carnitine with low dose of propranolol for 6 months. Results: CVS attacks’ frequency in both groups of treatment with propranolol alone and in combination with L-Carnitine and propranolol, before and after the treatment was significantly reduced. But there is no significant difference between the two groups 70.6%) vs. 90.9%) (p-value=0.062). There was no significant reduction in the duration days between vomiting attack index in both groups (31.6 % vs.43.2%) (p-value= 0.345). Conclusion: Our research revealed that combination of low dose propranolol with L-Carnitine has comparable efficacy with high dose Propranolol in prophylaxis of CVS.

Outcome of Early Oral Feeding after Primary Repair of Traumatic Intestinal Injury: Prospective Observation in a Tertiary Hospital in Bangladesh

Introduction: A period of starvation is common practice after intestinal anastomosis. Starved patient became malnourished and underwent catabolic state, impairing the host immune response and thus increasing the risk of postoperative infections thereby long hospital stay. Objective: To observe the outcome of early oral feeding in patients having primary repair of traumatic intestinal injury and to assess its beneficial effect. Methods: This prospective observational study was conducted on 80 patients who underwent urgent intestinal resection with or without covering stoma in the Department of Casualty Surgery at Dhaka Medical College Hospital. Results: Early oral feeding is safe in the recently performed anastomosis even in emergency situations as there were no cases of clinical anastomotic dehiscence and no increase in morbidity. Among 80 patients 58(72.5%) patients had no complaints; rest 22(27.5%) patients had complication. Wound infection seen in 14(17.5%) patients among them 8(10%) patients had burst abdomen and 1(1.25%) patient had intraabdominal abscess. 14(17.5%) patients had chest infection. 10(12.5%) patients complained nausea and among them 8(10%) patients suffered from few episodes of vomiting. 1(1.25%) patient had diarrhoea. Abdominal distension was seen in 9(11.25%) patients. Hospital stay was significantly shorter in with a mean length of stay (9 ± 1) days. No hospital readmission rate was recorded. Conclusion: Early postoperative feeding is timely, safe and tolerable after emergency intestinal resection anastomosis without raised morbidity and mortality and has a considerable reduction in hospital stay with its physical, psychological and fiscal benefits. JAFMC Bangladesh. Vol 18, No 1 (June) 2022: 75-79

P-083 AMYANDS HERNIA WITH RENAL CELL CARCINOMA - A RARE CASE PRESENTATION

Abstract 47 year old gentleman presented to the emergency department with 2 days history of lower abdominal pain and right inguinal swelling which has increased in size during the same duration, he also had one episode of vomiting, bloating and constipation since 2 days. Investigations revealed an inflamed appendix within the right inguinal hernia along with a left renal lesion. The patient underwent emergency open primary repair of inguinal hernia with appendicectomy. Followed up with urology as an outpatient regarding renal lesion and with MDT discussion the patient was subjected for a partial nephrectomy.

GUILLAIN-BARRÉ SYNDROME AND COVID-19 VACCINATION: A DISCONCERTING ASSOCIATION

Guillain-Barré syndrome (GBS) is an acute, inflammatory peripheral nerve disorder characterized by rapidly progressive, ascending, symmetrical paresthesia, and motor weakness. Some patients may develop respiratory failure requiring ventilation. The annual incidence of GBS is ~1.7 persons per 100,000 population. We describe the case of a 61-year-old male complaining of headache, one episode of vomiting, giddiness, slight slurring of speech, and inability to close his left eyelid. The patient received intravenous immunoglobulin therapy, with improvement in his symptoms at the time of discharge. In addition, we have also summarized 41 cases of GBS reported on post-COVID-19 vaccination. The intention of this case report is to highlight on the incidence of GBS in individuals who have received COVID-19 vaccine. Moreover, physicians should be aware of GBS in every patient presenting with neurological complaints on OPD.

EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS WITHOUT ANY PERIPHERAL EOSINOPHILIA

EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS WITHOUT ANY PERIPHERAL EOSINOPHILIA

LEFT SIDE PREDOMINANT E-CIGARETTE OR VAPING USE-ASSOCIATED LUNG INJURY (EVALI): A CHALLENGING DIAGNOSIS OF EXCLUSION

LEFT SIDE PREDOMINANT E-CIGARETTE OR VAPING USE-ASSOCIATED LUNG INJURY (EVALI): A CHALLENGING DIAGNOSIS OF EXCLUSION

Can Heroin Poisoning Lead to Stomach Necrosis? A Case Report

Background: According to the last report of the United Nations Office on Drugs and Crime (UNOCD), opiate use (including heroin) is 1.2% of the world population. In Iran, about 2 million people are drug addicts. Heroin reduces gastric motility and prolongs gastric emptying time and causes gastric dilation which can be a reason for gastric ischemia. Gastric ischemia is an uncommon condition due to the rich gastric blood perfusion and collateral arteries. As some studies show, gastric dilation can be the cause of gastric necrosis. Methods: A 22-year-old woman presented to our hospital with severe abdominal pain and several episodes of vomiting. The patient declared that she had a history of addiction to methamphetamine and heroin. Abdominal examination revealed a soft and non-distended abdomen with generalized tenderness, mostly in the hypogastric region without rebound tenderness. Abdominal radiograph revealed that the stomach was highly distended. Abdominal CT without contrast confirmed severe gastric dilatation. In endoscopy, multiple necrotic lesions were seen throughout the stomach and mostly in the proximal part. Our finding in the laparotomy was gastric necrosis in the proximal part, which resulted in a total gastrectomy. Esophagojejunostomy was performed with roux en y reconstruction after total gastrectomy. Conclusion: Opioids can increase the risk of gastrointestinal (GI) dysfunction and can increase the risk of infection in the GI tract. In our case, heroin abuse caused gastric dilation and massive gastric necrosis.

S2434 A Rare Case of Epiphrenic Diverticulum as a Complication of Esophageal Motility Disorders

Introduction: Esophageal diverticula are a rare finding with an estimated incidence of 1:500 000 per year and a prevalence of 0.015–2%. It is usually associated with esophageal motility disorders, particularly Achalasia. The suspected mechanism is secondary to increased intraluminal pressure from the primary esophageal motility disorder, which leads to herniation of the mucosa and submucosa through the muscular layer. It is usually asymptomatic but can present with dysphagia, regurgitation, nausea, vomiting, aspiration, heartburn, weight loss, and retrosternal pain. Here we offer a case of a large esophageal diverticulum in a 52-year-old male who has been having symptoms for years. Given the symptomatic nature of his diverticulum, he underwent surgical repair. Case Description/Methods: A 52-year-old patient with no significant past medical history presented with complaints of dysphagia that was worsening over several years, associated with halitosis and food regurgitation. The patient was having a routine screening colonoscopy when he had an episode of coffee-ground emesis. He subsequently underwent an esophagogastroduodenoscopy which revealed a large epiphrenic esophageal diverticulum. He then had an esophagogram and Computer Tomography (CT) of chest and abdomen, which confirmed the presence of the diverticulum and significant narrowing of the GE junction. Esophageal manometry was not pursued, given the difficulty of placing the probe and the risk of perforation. He subsequently underwent left thoracotomy with resection of the large esophageal diverticulum, long myotomy (11 cm), and Besley fundoplication. Esophagram following surgery was negative for any leak (Figure). He was started on a clear liquid diet that was later advanced to full liquid, with the patient tolerating it well. He was subsequently discharged home. Discussion: Esophageal diverticula are rare findings with an estimated incidence of 1:500 000 per year and a prevalence of 0.015–2%. Most esophageal diverticula are acquired and present in older adults. Surgical repair is associated with mortality of 0 to 9% and morbidity of 20%. This case serves as a reminder to keep a broad differential diagnosis when approaching a patient with symptoms of a motility disorder. Early detection can provide timely management and prevent further complications.Figure 1.: Esophagram after surgical repair of epiphrenic esophageal diverticulum.

Rare Cause of Arrhythmia and Seizures in a Late-Preterm Newborn

Rare Cause of Arrhythmia and Seizures in a Late-Preterm Newborn

S1674 An Unusual Cause of Septic Shock Secondary to Lemmel Syndrome

Introduction: Lemmel syndrome (LS) is a rare cause of obstructive jaundice occurring in the absence of pancreaticobiliary tumors or choledocolithiasis and commonly caused by periampullary diverticulum (PAD) with an incidence of 1-27%. They are typically asymptomatic and underreported leading to complications in ∼5% of cases. Herein, we report a case of septic shock due to acute cholangitis secondary to Lemmel Syndrome. Case Description/Methods: A 58-year-old male with a medical history significant for hypertension who presented to the ER with right upper quadrant abdominal pain, jaundice, and multiple episodes of nonbloody-nonbilious emesis. On admission, the patient was febrile, tachycardic and hypotensive. Initial laboratory tests are shown in the Table. CT of the abdomen showed cholelithiasis and diffuse gallbladder thickening with no intra or extrahepatic biliary duct dilation. He developed septic shock requiring vasopressors. Blood cultures were positive for Escherichia coli, and antibiotics were administered. Emergent ERCP was performed due to the presence of acute cholangitis. He was found to have a large diverticulum located around the major ampulla. Double wire technique was performed to access the ventral pancreatic duct (VPD) and common bile duct (CBD). Fluoroscopic images revealed biliary tapering in the distal third but no visualized stones (Figure). Plastic stents were placed into the VPD and CBD and biliary sphincterotomy was performed. He also underwent laparoscopic cholecystectomy. The patient was discharged with resolution of symptoms. Discussion: The pathophysiology of LS is due to direct mechanical irritation of the diverticulum causing papillary fibrosis. Secondly, the diverticulum may cause sphincter of Oddi dysfunction. Thirdly, the distal CBD may be directly compressed by the periampullary diverticulum. The imaging modalities of choice to confirm the diagnosis include enhanced contrast CT and MRCP. ERCP allows for direct visualization of the duodenal diverticulum. Treatment of these entities is required if the patient becomes symptomatic. The mainstay of treatment is endoscopic sphincterotomy with stent placement or papillary balloon dilation. Due to the high recurrence rate, if endoscopic treatment fails then surgical approach via diverticulectomy is performed. It is important physicians remain vigilant regarding this condition since misdiagnosis leads to delay in therapy. The incidence of septic shock in LS is unknown and to our knowledge, there has only been one other reported case in literature.Figure 1.: A: Cholangiogram of biliary tree with no stones B: Cholangiogram with diverticulum, stent in place and no obvious stones C: Periampullary diverticulum after placement of CBD and pancreatic stent D: CT abdomen showing CBD stent in place with gallbladder sludge. Table 1. - Initial Laboratory Values Blood Chemistry Reference Range Sodium 137 mmol/L 136 - 145 mmol/L Potassium 3.8 mmol/L 3.5 - 5.3 mmol/L Blood urea nitrogen (BUN) 10.0 mg/dL 6 - 24 mg/dL Creatinine 1.0 mg/dL 0.6 - 1.2 mg/dL Lactic acid 5.3 mmol/L 0 – 2.0 mmol/L C-reactive protein 21.8 mg/dL 0.0-0.8 mg/dL TSH 1.1180 µIU/mL 0.400 - 4.500 µIU/mL Total bilirubin 3.3 mg/dL 0.2–1.2 mg/dL Direct bilirubin 1.94 mg/dL 0.0-0.3 mg/dL AST 487 U/L 10-36 U/L ALT 365 U/L 9-46 U/L Alkaline phosphatase 155 U/L 40-115 U/L Complete blood count White blood cell (WBC) 4.3x10 3/ uL 4.4 - 11 × 103/µL Hemoglobin 12.2 g/dL 13.5 - 17.5 g/dL Platelet 107 x103 /uL 150 - 450 × 103/µL

S3248 A Case of Drug-Induced Liver Injury Secondary to Clobenzorex Use

Introduction: Drug-induced liver injury (DILI) is a cause of both acute and chronic liver disease and is often a challenging condition for clinicians. It is a diagnosis of exclusion that requires a detailed history and workup to ensure other potential causes have been ruled out before affirming the diagnosis. There are numerous offending agents with varied presentations, often idiosyncratic in nature, with the additional challenge being a lack of specific testing or biomarkers to aid diagnosis. Case Description/Methods: We present a case of a 25-year-old male who immigrated from Mexico 4 months ago, with no reported past medical history, who presented to the emergency department for a two-day history of postprandial non-radiating right upper quadrant and epigastric pain. Associated symptoms include subjective fevers, chills, decreased appetite, nausea, one episode of blood-tinged emesis, night sweats and dyspnea. The patient worked as a driver in Mexico and was taking two different formulations of 30mg Clobenzorex, an amphetamine pro-drug, daily for two years to help him stay awake for work. These medications were available over the counter. He had not taken it since he moved to the US. He denies the use of illicit drugs, contact with any inmates or Tuberculosis patients. At the time of his presentation, he works in a wooden floor-making company. Labs revealed a markedly elevated total bilirubin of 4.4 mg/dL, INR 1.1, AST 1325 IU/L, ALT 3151 IU/L, LDH 745 IU/L and a mildly elevated ALP 220 IU/L. Acute hepatitis and autoimmune panels were not reactive. Serum acetaminophen level was also within normal limits. Ultrasound of the abdomen and MRCP noted gallbladder wall thickening but no biliary dilatation or pathology. The patient subsequently underwent a core-needle liver biopsy that displayed lobular infiltrates of inflammatory cells of predominantly lymphocytes (Figure 1). Given the absence of positive viral serology, a diagnosis of drug-induced hepatitis was concluded. Discussion: This case report documents a unique instance of drug-induced liver injury secondary to Clobenzorex use. This case highlights the importance of a detailed social history and should encourage clinicians not to neglect to ask about over-the-counter medications to help elucidate potential causes of liver injury. This is an important consideration, especially in the subset of patients from countries outside the United States who have access to a variety of OTC medications that are potentially hepatotoxic.Figure 1.: Core needle liver biopsy showing lobular infiltrates of inflammatory cells consisting of predominantly lymphocytes.

S3618 Gastric Outlet Obstruction as a Presenting Symptom of Duodenal Adenocarcinoma

Introduction: Gastric outlet obstruction (GOO) can be due to benign or malignant causes. Benign etiologies of GOO have been down-trending, resulting in 50-80% of cases of GOO attributable to malignancy. Of the malignant causes leading to GOO, pancreatic adenocarcinoma with extension to the duodenum or stomach is the most common cause, followed by distal gastric cancer. However, primary duodenal adenocarcinoma as the cause of GOO is relatively rare, and we present a case of moderate to poorly differentiated duodenal adenocarcinoma leading to GOO. Case Description/Methods: An 82-year-old man with no reported past medical history presented to the hospital with epigastric abdominal pain associated with worsening distention, nausea, multiple episodes of non-bloody projectile vomiting, and associated weight loss of 12 pounds in the past 2 months. The abdominal exam was unremarkable. Labs were nonsignificant. A computer tomography (CT) scan of the abdomen and pelvis revealed a massively dilated stomach with suspected circumferential narrowing in the distal stomach suggestive of gastric outlet obstruction (Figure A). NGT was placed for decompression, with significant relief of symptoms. The patient underwent EGD, and no gross mass or obstructive etiology was noted in the entire stomach, including pylorus and antrum. There was inflammatory appearing mucosa characterized by extensive edema and contact oozing resulting in mass effect with severe luminal narrowing in the duodenal sweep/D2 regions (Figure B). Biopsies were obtained and showed moderate to poorly differentiated adenocarcinoma (Figure C, D). Subsequently patient underwent palliative duodenal stent placement with symptomatic relief. Discussion: Clinical history is important in suspecting the diagnosis of GOO. Cross-sectional imaging aids in diagnosis but sometimes does not help differentiate benign vs. malignant etiologies. EGD is helpful when imaging is inconclusive and for definitive pathological diagnosis. Most patients achieve symptomatic relief with conservative measures like NPO and NGT decompression. The definitive treatment for GOO varies based on etiology. Most patients with malignant causes need surgery for a cure if suitable candidates. Until recently, surgical gastrojejunostomy was the primary approach for palliative purposes. However, duodenal stent placement has become the primary palliative option as it is a cost-effective, minimally invasive option with adequate symptom relief, shortened hospital stay, and faster resumption of oral intake.Figure 1.: A: CT abdomen/pelvis showed massively dilated stomach with suspected circumferential narrowing in the distal stomach suggestive of gastric outlet obstruction. Circumferential thickening and narrowing of the descending duodenum. B: EGD revealing inflammatory appearing mucosa with extensive edema and contact oozing resulting in mass effect with severe luminal narrowing in the duodenal sweep/D2 regions. C: Immunohistochemistry/histology of biopsies obtained during EGD revealing duodenal adenocarcinoma with tumor glands. D: Tumor emboli in the lymphatics of the duodenal villi.

S1729 Drug-Induced Pancreatitis: Meth, Cannabis, or Meth-Laced Cannabis?,

Introduction: Drug-induced pancreatitis (DIP) is a rare entity with a 0.1 to 2% incidence of acute pancreatitis cases. Methamphetamine is a serotonergic drug used as a stimulant. It has infrequently been observed to cause pancreatic and hepatic damage due to its keen vasoconstrictive properties. Cannabis in its recreational form has also been linked with drug-induced pancreatitis. We report a 36-year-old female who presented with findings of acute pancreatitis revealing a drug-induced etiology. Case Description/Methods: The patient is a 36-year-old previously healthy female who presented with diffuse, sudden in onset abdominal pain, radiating to the back, aggravated with food without alleviating factors of 3 days duration. She reported nausea on the first day of her pain along with a single episode of nonbilious vomiting that had self-subsided. Social history was remarkable for smoking marijuana since her teenage years unremarkable for alcohol and tobacco use. She reported resorting to street, methamphetamine laced marijuana, the past month. The patient was vitally stable with a physical exam remarkable for epigastric and left lower quadrant tenderness with negative peritoneal signs. Laboratory tests showed elevated lipase, amylase, and CRP with normal liver function tests, hematocrit, BUN, bilirubin, triglycerides, and phosphocalcium balances. Ultrasound was done corroborating the absence of obstruction. Computed tomography (CT) abdomen was subsequently performed showing irregular contour of the pancreatic margins, blurring of peripancreatic fat planes, soft-tissue stranding, and trace-free fluid at the pancreatic body and tail without bile duct dilatation. Serological survey for mumps virus, cytomegalovirus (CMV), epstein barr virus (EBV), and human immunodeficiency virus (HIV) was negative. Anti-nuclear antibodies (ANA), neutrophil anti-cytoplasmic antibody (ANCA), and serum Ig G4 were also negative. She was diagnosed with mild acute pancreatitis with the culprit agent being methamphetamine-laced cannabis. The patient was followed up 3 months after agent cessation with marked symptomatic improvement and unremarkable lab work. Discussion: This case highlights that methamphetamine might also be the precipitating cause of pancreatitis in street marijuana-associated pancreatitis cases. Drug-induced pancreatitis is often challenging because there are no unique clinical characteristics to distinguish drugs from other etiologies, let alone the possibility of identifying one potential drug versus another.

S2210 A Rare Retroperitoneal Mass Simulating a Complicated Diverticulitis

Introduction: Extra-gastrointestinal stromal tumors (EGISTs) are a group of rare neoplasm that arises from cells outside the gastrointestinal (GI) tract but with similar pathologic characteristics as of gastrointestinal stromal tumors (GISTs). They account for only 5% of all GISTs involving the retroperitoneum, mesentery or omentum. EGISTs typically presents as large intra-abdominal masses with unspecific symptoms and are known to have a more aggressive behavior than its GI counterpart. Case Description/Methods: A 50-year-old male inmate with no medical history presents to the ED after having unquantified episodes of non-bloody, non-watery diarrhea and vomiting of gastric content for 5 days prior to admission. The patient also reports subjective fever and constant left quadrant abdominal pain. Upon physical exam, he was found with signs of dehydration, a distended abdomen with hyperactive bowel sounds, and a non-mobile large mass on the left lower quadrant with tenderness to light palpation. Laboratories were remarkable for neutrophilic leukocytosis, thrombocytosis, and elevated inflammatory markers. Abdomino-pelvic CT revealed a large left heterogeneously enhancing retroperitoneal mass with central necrosis measuring 18.6 cm AP x 18.4 cm transverse x 25.3 cm CC causing mass effect over the left kidney with loss of intervening fat planes, flattening of the left adrenal gland and displacement of the stomach, small and large bowel with almost complete collapse of the distal transverse and descending colon. Core-needle biopsy revealed high-risk GIST with positive immunohistochemistry for C-KIT, CD34, CD56, actin, and desmin with a very high mitotic index (45 mitosis/25 HPF). Surgery was deferred due to large size of mass and closure to adjacent structures. Neoadjuvant therapy with Imatinib was started but patient was lost to follow up upon discharge. Discussion: This case describes a rare presentation of EGIST emerging from the retroperitoneum with a positive immunohistochemistry for desmin and manifesting as a complicated diverticulitis. Although there is limited data about its origin, EGISTs and GISTs are recognized to be molecularly identical. Furthermore, because EGISTs are found outside the GI system, symptoms only appear when the tumor has progressed to an advanced stage giving it a worse prognosis. As a result, having EGIST as a differential diagnosis for abdominal mass is crucial. More research is needed to better understand the behavior, prognosis, and treatment options of these tumors.

S3336 An Unusual Cause of Encephalopathy

Introduction: Hepatic encephalopathy, while common among cirrhosis patients, can occur without cirrhosis. In adults, 90% cases of hyperammonemia are due to cirrhosis. Ammonia is central to its pathophysiology produced by bacterial degradation in the gut from protein, urea, and glutamine. Ammonia acts as a neurotoxin which is metabolized by hepatocytes to urea for excretion via kidney and colon. Type B hepatic encephalopathy is due to portosystemic shunting without parenchymal liver disease. Case Description/Methods: A 69-year-old female with history of hepatoma with resection and chemoembolization in 1997, mucosa-associated lymphoid tissue, perforated diverticulitis status post colostomy and reversal in 2015 was in her usual state of health a day prior to admission when she presented with lethargy after episodes of nausea and vomiting. She was arousable and not able to follow commands. Her CT (computed tomography) of the brain with no acute changes followed by CT of abdomen showing dilated small intestine extending into ventral hernia with concern for obstruction. Blood tests revealed ammonia 141 umol/L, total bilirubin 4.1 mg/dL, direct bilirubin 1.5 mg/dL, international normalized ratio 1.2 and platelet 130 k/ul. Alkaline phosphatase, alanine and aspartate transaminases were within normal limits. Obstruction resolved with conservative management and she was started on rectal and oral lactulose with rifaximin via nasogastric tube. Her mentation improved significantly although the cause of her hepatic encephalopathy remained unclear. Then she underwent magnetic resonance imaging of the abdomen with contrast showing portal to hepatic vein shunt with stable postoperative changes. Shunt closure option was discussed and patient opted outpatient follow up. Discussion: Prompt diagnosis and treatment of hepatic encephalopathy is important to prevent cerebral edema. In patients with encephalopathy and elevated ammonia in absence of liver parenchymal disease, work-up for shunt and urea cycle enzyme deficiency should be done. In the absence of cirrhosis most portosystemic shunts are congenital or traumatic. This case brings a rare cause due to remote liver surgery and chemoembolization. The treatment of portosystemic shunts is evolving, balloon-occlusion retrograde transvenous obliteration is one such technique. In the absence of varices, bland embolization with ectopic coils and vascular plugs can be utilized. Endovascular treatment carries an improvement of hepatic encephalopathy by 50 to 80% at 18 to 24 months.

S3390 Celiac Disease and Systemic Eosinophilia: A Case Report

Introduction: Celiac disease is an immune mediated reaction to the gluten protein. this disease primarily affects the small intestine.it occurs in population with genetic predisposition, usually resolves with gluten free diet regimen. it was reported the association between eosinophilic gastrointestinal diseases and celiac disease but in the following case will discuss patient with significant peripheral eosinophilia and celiac disease without Eosinophilic gastrointestinal disorder. Case Description/Methods: 45 years old male, with history of hypertension, who presented with progressively worsening intermittent colicky lower abdominal pain for the past 2 months. Associated with recurrent episodes of nausea and vomiting, and non-bloody watery diarrhea.Patient Labs were significant for Hemoglobin 12 gm/dL, WBC’s 26,000 with 62% Eosinophils (16,500 /uL), Platelet of 332 Thou/uL. Peripheral blood smear was negative for parasites, stool was negative for parasites or bacterial infection. Patient went upper GI endoscopy that showed grade A reflux esophagitis, congestive gastropathy, Duodenitis, and non-bleeding gastric ulcer, Biopsies were obtained during the EGD. Pathology showed Duodenal mucosa with mild villous atrophy and focal increased intraepithelial lymphocytes suggestive of celiac disease,chronic gastritis, esophageal biopsy was negative for increased eosinophils. Patient was started on gluten free diet that was resulted in gradual resolution of his symptoms and also normal eosinophilic count after 1 month. (Figure) Discussion: Patient with celiac disease can present with typical gastrointestinal symptoms such as diarrhea, weight loss, bloating, abdominal pain, and also non-gastrointestinal abnormalities such as abnormal liver function test, iron deficiency anemia, and it may be asymptomatic. In this case patient presented with typical symptoms but was associated with significant peripheral eosinophilia, without evidence eosinophilic gastrointestinal disorder.Figure 1.: EGD showing stomach and duodenum.

S1855 Unusual Picture of Pancreatic Abscess in a Patient With a Near-Total Distal Pancreatectomy

Introduction: Pancreatic abscess is an infection of the pancreatic pseudocyst which usually occurs 4 weeks after the onset of acute pancreatitis, meanwhile other causes include but are not limited to chronic pancreatitis, iatrogenic intra-abdominal procedures, and seeding from distant sites. We hereby report a case of an unusual occurrence of pancreatic abscess in a patient with a near-total distal pancreatectomy. Case Description/Methods: Patient is a 56-year old male with past medical history of diabetes, pancreatic adenocarcinoma, status post near-total distal pancreatectomy 6 months earlier, pancreatic pseudocyst found 3 months ago and splenectomy presented with persistent progressive worsening left upper abdominal non-radiating pain, associated with nausea, eight episodes of bilious vomiting, abdominal distension and chills. Patient denied fever. Vitals and labs were insignificant. CT scan of the abdomen showed significant increase in the size of the pancreatic cyst by the head of the pancreas with gastric outlet obstruction. Patient was started on Unasyn and the GI team proceeded to EGD/EUS and cystogastrostomy on the same day. A stent was placed [with drainage into the stomach], the cyst was aspirated, the collected purulent fluid (Figure) was sent for culture which came back positive for klebsiella pneumoniae. Patient reported relief after the procedure and was discharged on ciprofloxacin for 2 weeks. After 3 weeks, a follow-up EGD was done for necrosectomy with removal of the stent. Discussion: Pancreatic abscess is most commonly caused iatrogenically during management of necrotizing pancreatitis, however it can happen in absence of pancreatitis, secondary to biliary tract disease or duodenal disease. A high index of suspicion should be maintained in patients with acute pancreatitis, who don’t improve after initial management especially with high RANSON score, and chronic pancreatitis with persistent pain which can lead to systemic inflammatory response syndrome and death. CT is the gold standard in diagnosis with a higher sensitivity than ultrasonography, however a following fine needle aspiration, has a sensitivity of almost 100%, and is crucial to distinguish sterile inflammation from infection. Gram negative bacteria is most commonly found in aspirated fluids, however gram positive can be seen. Invasive surgical cystogastrostomy or cystoduodenostomy, depending on the location of the abscess, should not be delayed and have better outcomes than solo antibiotic therapy or endoscopic intervention.Figure 1.: Stent placement.

32 Droperidol on Prevention of Emesis from Cannabinoid Hyperemesis Syndrome (DOPE Study)

Cannabis Hyperemesis Syndrome (CHS) is characterized by persistent nausea, vomiting and abdominal pain with episodes of cyclic vomiting associated with chronic cannabis use. CHS symptoms are difficult to manage and are often refractory to standard first-line antiemetics and analgesics. Recent prospective studies have demonstrated the superiority of haloperidol, a dopamine antagonist, over ondansetron for the treatment of CHS. Interim analysis of our study has determined that droperidol, also a dopamine antagonist, has equal or better efficacy to haloperidol.

Breaking bad: barriers in the timely diagnosis of brain tumors

<p>It is a very common practice to label the episodes of headache, sleepless nights, nausea, vomiting and weight loss as “routine complaints”. Though highly prevalent, such signs and symptoms can be an indicator of a life-threatening brain tumor. The general population of the underdeveloped and the developing countries is habitual of taking over-the-counter drugs to manage these presentations while avoiding  specialists' consultations till later stages of the brain tumours. Here, we try to discuss and identify few major barriers in the timely diagnosis of brain tumors and how to overcome them at the grass-roots level in Pakistan.</p>

Nonmorcellation-associated Parasitic Leiomyomatosis Causing Intermittent Volvulus

We present a case of a 28-year-old nulliparous Caucasian female patient with recurrent colic pain in the left hemi-abdomen and intermittent episodes of vomiting. Furthermore, she was experiencing a recurrence of dysmenorrhea and heavy menstrual bleeding. Her history included 3 previous myomectomies without morcellation.