Hepatobiliary Scan Research Articles

Atypical Primary Sclerosing Cholangitis Findings on a 99mTc-Mebrofenin Scan

Abstract We present an 80-year-old woman with cholestatic liver disease. Ultrasound, CT, and MR cholangiopancreatography showed no substantial findings. The patient was referred for a hepatobiliary scan to examine the physiological pathway of bilirubin and to determine for any level of obstruction. The findings on the hepatobiliary scan suggested intrinsic pathology affecting the entire biliary tree, and histology was recommended. Histology confirmed primary sclerosing cholangitis (PSC). Although hepatobiliary scintigraphy in biliary stasis is well-known and well-published, hepatobiliary scintigraphy in PSC in adults is not well-documented. The hepatobiliary scintigraphy provided the primary and definitive imaging technique in directing the management and diagnosis of PSC in our patient.

The Outcomes and Success Rates of Kasai Operation for Biliary Atresia Cases Using Presurgical Hepatobiliary Scan: Observations at NINMAS

The Outcomes and Success Rates of Kasai Operation for Biliary Atresia Cases Using Presurgical Hepatobiliary Scan: Observations at NINMAS

Development and Validation of a Machine Learning-Based Prediction Model for Detection of Biliary Atresia.

Biliary atresia is a rare and devastating bile duct disease that occurs during the neonatal period. Timely identification and prompt surgical intervention is critical for improving the outcome. The aim of the study was to develop a new machine learning-based prediction model for the detection of biliary atresia. Neonates aged <100 days with cholestasis at least once were retrospectively screened in 2 tertiary referral hospitals between 2015 and 2020. Simple demographic data, routine laboratory indices, and imaging findings of ultrasonography and hepatobiliary scintigraphy were used as features in the multivariate analysis. The extreme gradient boosting (XGBoost) framework was used to develop prediction models according to the diagnostic steps. Among 1605 enrolled neonates with all-cause cholestasis, 145 (9%) were included as having biliary atresia. Direct bilirubin, gamma-glutamyl transpeptidase, abdominal sonography, and hepatobiliary scan were the most impactful features in prediction models. The Step II XGBoost model, consisting of nonimaging inputs, showed excellent discriminatory performance (area under the curve= 0.97). The Step III and IV XGBoost models showed near-perfect performances (area under the curve= 0.998 and 0.999, respectively). In external validation (n= 912 with 118 [12.9%] biliary atresia), XGBoost-based prediction models consistently showed acceptable performances. Utilizing shapley additive explanation values also provided visualized insight and explanation of the contribution of features in detecting biliary atresia. The models were integrated into a web-based diagnostic tool for case-level application. We introduced a new machine learning-based prediction model for detecting biliary atresia in the largest cohorts of neonatal cholestasis.

PSAT049 A Case of Hypercalcemia as the First Presentation of Addison's Disease

Abstract Introduction Hypercalcemia is stratified into mild, moderate, and severe. This stratification is determined by serum ionized calcium and total calcium. For example, mild hypercalcemia is defined as a serum ionized calcium of 5.6 - 8. 0 mg/dL [1.4 - 2 mmol/L] or a total calcium of 10 - 12 mg/dL [2.5 - 3 mmol/L]. Hypercalcemia is commonly caused by primary hyperparathyroidism and malignancy. Other causes include vitamin D excess or immobilization. An uncommon cause that is pertinent to the patient is primary adrenal insufficiency. A patient with hypercalcemia can either be asymptomatic or have a wide array of symptoms, such as musculoskeletal pain, nausea/vomiting or constipation, and altered mental status. Case Presentation The patient is a 36 year old female who came to the ED due to sharp upper quadrant abdominal pain that waxed and waned for about 8 weeks in duration. During her visit in the ED, the patient was hypotensive and tachycardic, which improved with IVF. The patient was also experiencing loss of appetite, nausea/vomiting, diarrhea. She also reported to have lost 38 lbs unintentionally dating back to 07/2021. The patient had undergone an EGD and colonoscopy, however the results were unremarkable. She also required further evaluation of her hypercalcemia of 12.7. She reported to take an unknown amount of vitamin D on a daily basis. She stopped taking her calcium supplementation a few weeks prior to her visit. The patient was afebrile, moderately tachycardic, tachypneic, and hypotensive. The physical exam was remarkable for tenderness to palpation in the epigastric region and skin hyperpigmentation. CT chest, abdomen, pelvis with contrast revealed intralobular septal thickening, diffuse mild colitis, some reactive mesenteric and retroperitoneal lymph nodes. Bone survey, CT head without contrast, gastric emptying study and hepatobiliary scan were unremarkable. Labs revealed: Ca 12.7, Na 132, K 4.4. PTH 6.3, ACTH 2,400, Cortisol base &amp;lt;1. 0, Serum Aldosterone &amp;lt;3. 0, Positive 21-Hydroxylase Autoantibody, DHEA 0. 099, DHEA sulfate 8. 0. Total 25-Hydroxyvitamin D 34. 0, 1,25-Dihydroxyvitamin D 5.6. After hydrocortisone and florinef administration, the patient's hypercalcemia normalized. As a result, the patient's hypercalcemia was secondary to primary adrenal insufficiency. Discussion Primary adrenal insufficiency is an uncommon cause of hypercalcemia. This can be attributed to a hypovolemic state that arises from a reduction in mineralocorticoids. As a result, there is a reduction in the GFR, which reduces glomerular filtration of calcium and increases reabsorption of calcium in the proximal tubule. Another proposed mechanism is the increase in 1-alpha-hydroxylase due to a reduction in glucocorticoids. Consequently, an increase in 1-alpha-hydroxylase will increase calcitriol production, which subsequently increases intestinal calcium absorption. These proposed mechanisms highlight the importance of adrenal function on calcium regulation and homeostasis. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Prenatally diagnosed congenital agenesis of the gallbladder: A case report

Congenital agenesis of the gallbladder is a rare malformation of the biliary system. The etiology of the development of gallbladder agenesis is not fully known; malformation during embryonic development is considered its main cause. Although gallbladder agenesis detected in adults during surgery has been reported many times, prenatally diagnosed gallbladder agenesis has rarely been reported. Herein, we report a case of gallbladder agenesis that was diagnosed in a male neonate in the intrauterine period at 26 +3 weeks on prenatal ultrasonography (USG). In most cases, the gallbladder is visualized on a follow-up USG performed prenatally or after birth, even if the gallbladder is not seen once during prenatal USG. However, our patient's gallbladder was not visualized in the USG after birth also. Therefore, we performed a hepatobiliary scan and magnetic resonance cholangiopancreatography (MRCP) to find the gallbladder; however, the gallbladder was not visualized. Half of the patients with gallbladder agenesis experience right upper quadrant pain, nausea, or dyspepsia. However, our child did not show any symptoms. This case report will help to manage patients who have no gallbladder. • Congenital agenesis of gallbladder (GB) is rare (9 per 100,000). • Gallbladder agenesis detected in adults during surgery has been reported many times. • Prenatal diagnosed gallbladder agenesis has rarely been reported. • In this case, gallbladder agenesis case was prenatally diagnosed with ultrasound.

Diagnostic Imaging of Biliary Atresia

담도폐쇄증은 신생아 담즙 정체의 드물지만 중요한 원인이다. 적절한 치료와 예후를 위해서는 정확한 조기 진단이 중요하다. 본 종설에서는 초음파 검사, MRI, 간담도 핵의학스캔, 담관조영술 등의 영상 검사에서 담도폐쇄증의 영상 소견을 검토하였다. 지금까지 알려진 주요 영상의학적 소견들은 담낭의 비정상적인 모양과 크기, 간문맥 주변의 비후를 나타내는 ‘triangular cord’ sign, 총담관이 보이지 않고, 간동맥 혈류가 증가하는 소견 등과 함께 동반된 기형의 유무들을 보이는 것이다. 담도폐쇄증의 진단을 위해 초음파 검사, MRI, 간담도 핵의학스캔, 담관조영술 등의 여러 영상 검사들을 시행하며, 1차 영상 검사로 초음파 검사가 중요하다. 본 종설에서는 각 영상 검사들에서 지금까지 알려진 담도폐쇄증의 소견들과 함께 조기 신생아기에서 담도폐쇄증 진단의 어려움, 그리고 간 섬유화를 예측하기 위한 영상의 역할도 검토하였다. 본 종설이 담도폐쇄증 진단에 도움이 되길 바란다.

Trends in the utilization of nuclear medicine technology in Jamaica: Audit of a private facility.

This study sought to evaluate the types and frequencies of nuclear medicine studies that were carried out at a privately-run nuclear medicine facility in Kingston, Jamaica. Previous studies of this nature have not been done among this population, therefore the researchers sought to gather data which may prove to be useful for the growth of nuclear medicine practice in Jamaica. The study was a nonexperimental, retrospective study which involved an assessment of the records of all nuclear medicine patients who received a radiopharmaceutical during January 01, 2017, to December 31, 2018. The data extracted included age, gender, radiopharmaceutical administered, indication for study, and impression from scan. The total number of nuclear medicine scans that were carried out at the facility for the 2-year period was 3756. Of this number, 1889 (50.3%) were male and 1866 (49.7%) were female, with the age ranging from 3 months to 100 years. The types and frequencies of the most frequently occurring studies conducted were bone (2116, 56.3%), renal (867, 23.1%), thyroid (307, 8.2%), and lung (254, 6.8%). Patients aged 60 years and over accounted for the majority of the bone scans (1353/2116). The age group 26–59 years accounted for most of the scans of the lung (123/254), thyroid (209/307), parathyroid (34/65), and whole body (26/34). Patients under 12 years of age accounted for the majority of the renal (596/867), gastrointestinal (22/26), and hepatobiliary (16/28) scans. The audit of this private facility reflects the documented demand on the International Atomic Energy Agency database for Latin America and the Caribbean, and demonstrates the need for continuity of this specialized service in our population.

Liver fibrosis in patients with tetralogy of Fallot, an unrecognised complication?

Improved survival has led to a growing population of adults with congenital heart disease (CHD), followed by numerous reports of late complications. Liver disease is a known complication in some patients, with most studies focusing on Fontan associated liver disease. Whether liver disease also exists in other patients with CHD is not fully investigated. Elevated central venous pressure is considered pivotal in the development of liver disease in Fontan associated liver disease, and other patients with alterations in central venous pressure may also be at risk for developing liver fibrosis. We wanted to see if liver fibrosis is present in patients with tetralogy of Fallot. Many patients with tetralogy of Fallot have severe pulmonary regurgitation, which can lead to elevated central venous pressure. Patients with tetralogy of Fallot may be at risk of developing liver fibrosis. Ten patients (24-56 years) with tetralogy of Fallot and pulmonary regurgitation were investigated for liver fibrosis. All patients were examined with magnetic resonance elastography of liver, hepatobiliary iminodiacetic acid scan, indocyanine green elimination by pulse spectrophotometry, elastography via FibroScan, abdominal ultrasound including liver elastography, and blood samples including liver markers. Three out of ten patients had findings indicating possible liver fibrosis. Two of these had a liver biopsy performed, which revealed fibrosis stage 1 and 2, respectively. The same three patients had an estimated elevated central venous pressure in previous echocardiograms. Mild liver fibrosis was present in selected patients with tetralogy of Fallot and may be related to elevated central venous pressure.

Cholescintigraphy for Differentiation of True Duodenal Obstruction from Pseudo Obstruction.

Small-bowel obstruction is a fairly common cause of abdominal pain. Differentiating between true duodenal obstruction and pseudo obstruction is important given differing treatment strategies. Here, we present augmentation of a hepatobiliary scan with a small amount of oral liquids and delayed imaging to differentiate between these two entities.

2692 Dunbar Syndrome: A Rare Cause of Abdominal Pain

INTRODUCTION: Dunbar Syndrome, also known as median arcuate ligament syndrome (MALS), is a rare condition with a reported incidence of 2 per 100,000. It is characterized by an extrinsic compression of the celiac trunk, and should be considered when evaluating patients with abdominal pain of unknown etiology. CASE DESCRIPTION/METHODS: A 78 year old female presented with a complaint of epigastric discomfort that was post-prandial in nature, with associated weakness and early satiety. Her symptoms had been persistent for one year. Workup prior to her presentation included a normal nuclear medicine (NM) gastric emptying scan and normal NM hepatobiliary scan with CCK. A detailed history revealed that her pain was particularly worse after eating and was associated with early satiety. Laboratory results on admission were unremarkable. Contrast-enhanced CT scan of the abdomen and pelvis showed external compression and indentation of the superior aspect of the proximal celiac axis with post-stenotic dilation. Further diagnostic evaluation utilized end-inspiratory phase CT angiography of the abdomen, which showed an approximately 1 cm length segment of proximal celiac arterial narrowing, measuring 70% maximally at its origin. She was diagnosed with MALS after review of the CTA reconstructive images which showed moderate external compression of the celiac artery. DISCUSSION: MALS predominantly affects women between the ages of 30 and 50 and is marked by the hallmark feature of postprandial abdominal pain. Other signs and symptoms may include nausea, vomiting, and consequent weight loss from an inability to tolerate oral intake. Symptoms are thought to have both a vascular (mesenteric ischemia) as well as neurogenic component (somatic pain thought to originate from the splanchnic plexus). CT angiography and conventional angiography are considered to be gold standard imaging modalities for Dunbar syndrome. They demonstrate focal stenosis that has a characteristic hooked appearance due to the indentation of the celiac trunk on its superior surface. Imaging for an accurate diagnosis should ideally be performed during the end-inspiratory phase, as indentation of the celiac trunk may be seen normally during expiration. Additional imaging features may include post-stenotic dilation, prominent collateral vessels, and thickening of the median arcuate ligament. Treatment includes endovascular transluminal angioplasty and stent placement, as well as laparoscopic division of the arcuate ligament and resection of the celiac plexus.

2463 Infliximab Drug-Induced Autoimmune Hepatitis in Patient With Crohn's Ileocolitis

INTRODUCTION: Infliximab is an anti-tumor necrosis factor alpha inhibitor commonly used in the treatment of Crohn's disease. It is known to produce mild elevations in liver enzymes, however, severe damage and marked elevations in transaminases related to drug-induced autoimmune hepatitis (AIH) are rare. We present a case of a patient with Crohn's disease who recently began infliximab and presented with severe infliximab-induced autoimmune hepatitis. CASE DESCRIPTION/METHODS: A 37-year-old man with Crohn's ileocolitis, diagnosed at age 28 and recently inducted with infliximab, presented with fatigue, weakness, and epigastric pain. He had previously been on 6-mercaptopurine, adalimumab, and ustekinumab, but had most recently been on azathioprine (AZT) and began infliximab two months prior to presentation. Approximately one month prior to presentation, he developed elevated transaminases with aspartate transaminase (AST) and alanine transaminase (ALT) in the 300s, so AZT was discontinued as this was thought to be the cause. Despite discontinuation of AZT, his liver function tests (LFTs) rose dramatically, prompting hospitalization. Labs on admission revealed a hepatocellular pattern with total bilirubin 7.1, AST 2153, ALT 2931, alkaline phosphatase 156, and international normalized ratio 1.25. Notably, antinuclear antibody was positive 1:1280, smooth muscle antibody was weakly positive, and cytomegalovirus (CMV) IgM was elevated. Hepatobiliary scan and magnetic resonance cholangiopancreatography were consistent with hepatocellular disease. Core liver biopsy revealed active hepatitis with moderate activity (interface moderate), cholestasis, and an infiltrate of eosinophils and plasma cells. CMV staining was negative. Overall, the testing was consistent with drug-induced AIH. Infliximab was stopped and steroids were begun, resulting in normalization of LFTs. DISCUSSION: Infliximab has been implicated in mild cases of hepatotoxicity, and therefore, it is recommended to check LFTs before and after beginning the medication. There are very few reports of severe AIH that have been linked specifically to infliximab, as cases of hepatotoxicity are often secondary to reactivation of viral hepatitis or CMV infections, or related to other biologic therapies. This is a rare case of infliximab-induced AIH, and it is an important consideration in patients with elevated LFTs after starting this drug. Treatment involves cessation of infliximab and treatment with steroids, which usually leads to resolution of the hepatitis.

Is Liver Function Homogenous? Correlation between CT Liver Volumes and Liver Function as Determined by Functional Hepatobiliary (HIDA) Scan

Background &#x0D; A hepatobiliary (HIDA) scan is a study historically done to evaluate for cholecystitis and more recently shown to be an effective way to measure liver function. Volumetric analysis on computed tomography (CT) is the most common way to evaluate future liver remnant prior to planned partial hepatectomy or radiation therapy. The aim of this study is to determine to what degree do lobar CT volume ratios correlate with distribution of functionality. &#x0D; Experimental Design &#x0D; A retrospective review and analysis of the images for 63 patients with liver cancer, imaged between 2016 and 2018, was performed. All functional HIDA scans were processed using MIM software. Total liver function, with lobar ratios, were obtained. Whole liver and lobar volume analysis on CT was also performed. &#x0D; Results &#x0D; The mean age was 63.6 [Symbol] 11.0 years with a male to female ratio of 1.3:1. The mean total liver volume on CT was 1611.3 [Symbol] 590.5 mL (Right lobe: 961.5 [Symbol] 405.3 mL, Left lobe: 649.8 [Symbol] 331.7 mL). The mean ratio of right to left lobar volumes was 59.5 [Symbol] 13.5 % to 40.6 [Symbol] 13.5%. The mean ratio of right to left lobar liver function was 60.7 [Symbol] 20.7% to 39.5 [Symbol] 21.1%. &#x0D; Conclusion and Potential Impact &#x0D; The overall average ratio between right and left lobe liver function appears to closely relate to the volumetric ratio between the lobes. These promising results suggest that liver function is fairly homogenous, which could provide great value in planning future liver operations and radiation therapy.

Acne Treatment Gone Erratic: A Rare Case of Minocycline-induced Eosinophilic Cholecystitis, Myopericarditis, and CNS Vasculitis

Eosinophilic cholecystitis (EC) is a rare entity that has a clinical presentation indistinguishable from acute cholecystitis and is diagnosed based on classical symptoms of cholecystitis with the presence of > 90% eosinophilic infiltration within the gallbladder wall. EC has never been reported before in combination with eosinophilic myopericarditis and an isolated central nervous system (CNS) vasculitis. Minocycline is commonly used to treat dermatologic conditions. One of the rare drug-reaction is eosinophilia with systemic symptoms. We present an extremely rare case of minocycline-induced hypereosinophilia, which resulted in simultaneous onset of acute cholecystitis, myopericarditis, and non-granulomatous eosinophilic CNS vasculitis. A 36-year female who was started on minocycline for back acne a month ago presented with an acute onset of right-upper-quadrant abdominal pain and tenderness associated with nausea. Ultrasound demonstrated thickened gallbladder wall with pericholecystic fluid in the absence of gallstones. Hepatobiliary scan (HIDA) documented conclusions consistent with biliary dyskinesia. She underwent cholecystectomy for acalculous cholecystitis. A week later, she presented with chest pain and weakness. A marked increase in peripheral eosinophilia was observed. Electrocardiogram revealed low-voltage in frontal leads without ST or T wave changes. Cardiac enzymes were elevated. Imaging modalities showed findings consistent with eosinophilic myopericarditis. During hospitalization, the patient also developed focal weakness. Magnetic resonance imaging revealed at least 40 diffuse scattered brain infarcts. She was started on steroids after ruling out infectious causes and had a rapid resolution of symptoms. To our knowledge, this is the first case of minocycline-induced hypereosinophilia presenting as a combination of eosinophilic cholecystitis, myopericarditis, and CNS vasculitis. Our patient had a remarkable and speedy recovery with steroid treatment. Our case illustrates that acalculous cholecystitis in the presence of peripheral eosinophilia should raise suspicion of EC and ensuing end-organ damage from eosinophilic infiltration. Peripheral eosinophilia indicates that EC is likely to be a manifestation of a systemic hypereosinophilic disorder. A high eosinophil count can provide an essential diagnostic clue to initiate early aggressive management.2469_A Figure 1. Diffusion-weighted magnetic resonance imaging showing multiple brain infarcts predominantly concentrated at the margin of the vascular territories representing watershed infarcts.2469_B Figure 2. Gallbladder submucosa with predominantly eosinophilic inflammatory infiltration2469_C Figure 3. Gallbladder submucosa with predominantly eosinophilic inflammatory infiltration.

Chronic Abdominal Pain in a 47-Year-Old Woman

Question: A 47-year-old woman presented for a second opinion for a two month history of unexplained epigastric pain and a 5 kg weight loss. She described the pain as intermittent and exacerbated by meals. She denied other accompanying gastrointestinal symptoms including nausea, vomiting, or changes in her bowel habits. Her past medical history was significant for chronic sinusitis and a prior Cesarean section. Physical examination revealed moderate tenderness to palpation over the lower sternal and epigastric region without associated rebound tenderness or guarding. The remainder of the physical examination including vital signs was unremarkable. An evaluation prior to presentation including computed tomography (CT) of the abdomen and pelvis, esophagogastroduodenoscopy, and hepatobiliary scan had been unrevealing. Laboratory investigation was significant for elevated C-reactive protein and erythrocyte sedimentation rate (280 mg/L and 65 mm/1h, respectively). CT angiography demonstrated patent mesenteric vasculature and subtle beading of the right and left renal arteries (Figure A, arrows). In the setting of ongoing abdominal pain, a conventional mesenteric and renal angiography was performed and showed multiple small- to medium-sized branch aneurysms, areas of luminal irregularity, and occlusive disease (Figures B and C, arrows). Additional laboratory studies revealed normal antinuclear antibodies, cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA), proteinase 3 antibodies (PR-3), and cryoglobulin levels. Which of the following diagnoses likely accounts for the patient’s abdominal pain?A.Microscopic polyangiitisB.Granulomatosis with polyangiitisC.Polyarteritis nodosaD.Eosinophilic granulomatosis with polyangiitis Look on page 628 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image(s) to Practical Teaching Cases. The correct answer is C. The radiographic findings of aneurysms involving small- to medium-sized arteries on angiography (Figures B and C) in combination with normal laboratory testing for ANCA, PR-3, and cryoglobulin levels in the setting of chronic abdominal pain and weight loss are most consistent with a diagnosis of PAN. In this case, following negative testing for hepatitis B (HBV) and C virus (HCV), she was initiated on combination therapy with a prednisone taper and intravenous cyclophosphamide and achieved disease remission with resolution of her symptoms after six months of therapy. Although vasculitides are infrequently encountered in clinical practice, gastrointestinal (GI) involvement by these conditions is common and often manifest with non-specific symptoms including abdominal pain, nausea, vomiting, diarrhea, and bleeding. This case highlights how radiographic features and laboratory data may be used to distinguish between vasculitic entities. Microscopic polyangiitis (answer A) is an ANCA-associated vasculitis (AAV) characterized by involvement of small arteries and veins which conflicts with the findings in this case. Histology-confirmed features of necrotizing granulomatous vasculitis facilitate a diagnosis of granulomatosis polyangiitis (answer B) which is also frequently associated with c-ANCA and PR3 antibodies. Eosinophilic granulomatosis with polyangiitis (answer D), or Churg-Strauss syndrome, while an important consideration in patients with unexplained abdominal pain, is unlikely in the absence of concomitant asthma and peripheral eosinophilia and would not account for the described radiographic features. PAN represents a non-AAV capable of predominately affecting the muscular medium-sized arteries of any organ system except the lungs.1De Virgilio A. Greco A. Magliulo G. et al.Polyarteritis nodosa: A contemporary overview.Autoimmun Rev. 2016; 15: 564-570Crossref PubMed Scopus (121) Google Scholar GI manifestations of this condition are variable but abdominal pain, often secondary to ischemia resulting from mesenteric arteritis2Ebert E.C. Hagspiel K.D. Nagar M. et al.Gastrointestinal involvement in polyarteritis nodosa.Clin Gastroenterol Hepatol. 2008; 6: 960-966Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar is the most common.3Levine S.M. Hellmann D.B. Stone J.H. Gastrointestinal involvement in polyarteritis nodosa (1986-2000): presentation and outcomes in 24 patients.Am J Med. 2002; 112: 338-349Abstract Full Text Full Text PDF Scopus (122) Google Scholar While PAN is a clinical diagnosis and does not require histologic confirmation, its association with several infections including HBV and HCV infection is well-recognized and should prompt evaluation for these conditions if identified de novo. Treatment is tailored toward disease severity and the presence of concomitant disease processes. Induction of remission in moderate to severe disease is usually achieved with combination glucocorticoids and cyclophosphamide,1De Virgilio A. Greco A. Magliulo G. et al.Polyarteritis nodosa: A contemporary overview.Autoimmun Rev. 2016; 15: 564-570Crossref PubMed Scopus (121) Google Scholar although antiviral therapy is essential in HBV and HCV infection while limiting immunosuppressive medications. CME Exam 2: Chronic Abdominal Pain in a 47-Year-Old WomanGastroenterologyVol. 155Issue 3Preview Full-Text PDF

Non-operative management of blunt hepatic injury: Early return to function, chemical prophylaxis, and elucidation of Grade III injuries

Background: Selective non-operative management of blunt hepatic trauma has shown decreased mortality and iatrogenic injury. Evidence-based recommendations are difficult to obtain regarding management of Grade III hepatic injuries and safe timing to implement return to function measures (enteral intake, chemical deep vein thrombosis [DVT] prophylaxis, and ambulation). Materials and Methods: This is a prospective, observational study of 130 trauma patients with blunt hepatic injuries over 2 years. A guideline was utilized to emphasize early hepatobiliary iminodiacetic acid scan and return to function measures at 24 h after injury. Patients were treated non-operatively with endoscopic retrograde cholangiopancreatography, percutaneous drainage, or embolization per evidence-based guidelines. Results: Fifty-seven patients suffered Grade III–V blunt liver injury. The biliary leak rate was higher for Grade IV and V liver injuries than Grade III (48%, 43%, and 12%, respectively) compared to lower grade injuries (0%). There was no significant difference in complications from initiation of chemical DVT prophylaxis, ambulation, or early enteral intake as a function of grade of hepatic injury. The average time to progression of treatment was 24 h and independent of the grade of liver injury. High-grade liver injuries were associated with lower age, increased injury severity score, and increased Intensive Care Unit length of stay. Conclusions: Trauma providers should consider Grade III liver injuries as low-grade injuries and treat accordingly. However, Grade IV and V injuries fail non-operative management more often than other grade injuries. Early enteral nutrition, chemical DVT prophylaxis, and ambulation are safe regardless of the grade of hepatic injury. The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice-based learning and improvement, Systems-based practice.

Intrahepatic Cholestasis Complicating Superior Mesenteric Artery Syndrome

Superior mesenteric artery (SMA) syndrome is a rare but potentially life-threatening entity of proximal intestinal obstruction, and characterized by extrinsic compression loss of fatty tissue of the aortomesenteric aperture as a result of a variety of debilitating conditions. Various gastrointestinal presentations of SMA syndrome have been documented. We herein describe a rare complication of SMA syndrome, in form of intrahepatic cholestasis. SMA syndrome seemingly appears under-diagnosed and the condition is more common in debilitating patients. A high awareness for timely recognition of SMA syndrome is important for proper management. Keywords: Hepatobiliary scan; Intrahepatic cholestasis; Superior mesenteric artery syndrome; Upper gastrointestinal obstruction

Hepatobiliary Scans Should Be Used to Confirm Acute Cholecystitis in Critically Ill Patients with a Non-Biliary Admitting Diagnosis Prior to Placement of a Percutaneous Cholecystostomy

Hepatobiliary Scans Should Be Used to Confirm Acute Cholecystitis in Critically Ill Patients with a Non-Biliary Admitting Diagnosis Prior to Placement of a Percutaneous Cholecystostomy

Drug-Induced Necrotizing Pancreatitis with a Focus on Canagliflozin

Introduction: Acute necrotizing pancreatitis is an inflammatory condition of the pancreas characterized by inflammation associated with pancreatic parenchymal necrosis most commonly attributed to gallstones, alcohol abuse and metabolic disorders such as hyperlipidemia and hypercalcemia. Although several drugs have been implicated in acute pancreatitis they are often overlooked. Here we present a case of necrotizing pancreatitis likely associated to canagliflozin; a new drug in the class of subtype 2 sodium-glucose transport protein inhibitors used for the treatment of type 2 diabetes mellitus (DM T2). Case: A 71 year old female with a history of DM T2 on sitagliptin-metformin 50-1000mg twice daily and canagliflozin 100mg daily (started 84days prior to presentation) presented with complaint of sharp right upper quadrant abdominal pain, radiating to her spine and right flank with severity of 9/10. She denied recent fever/chills, nausea/vomiting or night sweats. She did report a poor appetite with 20lbs weight loss over the preceding several weeks along with daily soft stools, but no melena or hematochezia. MRI abdomen revealed a 13.0cm x 5.0cm x 5.8cm air containing mass like lesion partially encasing the pancreas. The lesion was noted to be displacing the duodenum and encasing the superior mesenteric vein. These findings were most concerning for necrotizing pancreatitis although hemorrhage or neoplasm could not be excluded by the imaging. A hepatobiliary scan was also performed showing no evidence for common bile duct or cystic duct obstruction. The results of an ultrasound guided endoscopic FNA of the pancreatic lesion showed an acute inflammatory process without nuclear atypia. The patient was treated for necrotizing pancreatitis with ertapenem and subsequent repeat CT imaging of the abdomen showed interval decrease in the size of fluid collection in the pancreatic bed. Discussion: As the prevalence of DM T2 in the United States increases, the medications used to combat the disease will increase. Our case highlights canagliflozin in the treatment of DM T2 and its potential side effects. The case identifies the importance of drug-induced pancreatitis, as it is commonly neglected in patients with multiple medical comorbidities who are on numerous medications. Current literature review revealed 3 other cases of reported canagliflozin induced pancreatitis. Prompt identification can decrease morbidity and mortality in these individuals.

Gallbladder Carcinoma Presenting with Manubrium Metastasis: A Rare Phenomenon

Gallbladder carcinoma is the 5th most common malignancy of the gastrointestinal tract. Symptoms in the early stages are similar to other benign diseases and thus it is rarely diagnosed early. Distant metastasis to bone is uncommon with the most common sites of metastasis being regional lymph nodes, liver parenchyma, peritoneum, and lungs. A 78-year-old female with past medical history of hypertension, gastroesophageal reflux disease, and complete heart block with a dual chamber pacemaker presented with chest pain that developed after PO intake. The pain typically lasted for 30 minutes and was associated with increased belching, bloating, and mild constipation. Patient was a former smoker and had moderate alcohol use. Physical exam showed no jaundice, abdominal tenderness, or palpable masses. Labs showed AST 19 U/L, ALT 16 U/L, total bilirubin 0.7 mg/dL and elevated ALP at 123 U/L. Patient's recent cardiac stress test showed no ischemia. Abdominal ultrasound showed common bile duct dilatation at 1.5 cm and a hypoechoic mass-like area in the neck of the gallbladder suspicious for a gallbladder mass. Hepatobiliary (HIDA) scan revealed an abnormal function response to cholecystokinin (CCK) with an ejection fraction of 8.7%. General surgery was consulted and a diagnostic laparoscopic cholecystectomy was performed. A thickened gallbladder wall was found and pathology was sent, which resulted positive for poorly differentiated adenocarcinoma of the gallbladder. Computed tomography (CT) chest ordered for staging showed a 3 cm mass with bony destruction involving the left manubrium. Interventional radiology performed ultrasound-guided biopsy of the left manubrium, which revealed metastatic moderately differentiated adenocarcinoma with mucinous features. Positron emission tomography (PET) scan showed increased FDG uptake within the cervical and thoracic spine and sternum and hypermetabolic lymph nodes. Magnetic resonance cholangiopancreatography (MRCP) showed mild intra and extrahepatic biliary ductal dilation but no filling defects, strictures, or masses were identified in the biliary ductal tree. The patient ultimately refused further treatment, including chemotherapy, and was discharged with home hospice. Although rare, gallbladder carcinoma can present with chest pain secondary to bone metastasis. Further work-up should be considered in patients presenting with chest pain of unknown etiology and associated gastrointestinal symptoms.Figure 1Figure 2

The Epstein Barr Virus: An Unusual Source of Gastritis

The Epstein-Barr virus (EBV) has been implicated in both causing and mimicking lymphoma. Its association with gastritis has rarely been documented in the literature. We present a case of EBV-associated gastritis with features suspicious for malignancy. A 29-year-old female with menorrhagia presented with abdominal pain, nausea, vomiting, sore throat, fatigue, fevers and chills for 7 days prior to admission. Her family history was significant for gastric polyps in her mother and gastric cancer in her maternal grandmother. On physical exam, she was afebrile with a resting tachycardia. She had diffuse abdominal tenderness to palpation without rebound or guarding. She had a hemoglobin 6.3 g/dL, platelet count 118 x 10ˆ3/mcL, and WBC of 9.24 x 10ˆ3/mcL with 62% lymphocytes and occasional atypical lymphocytes. Her iron panel was positive for deficiency. Her comprehensive metabolic profile was normal. Her stool was positive for occult blood. An abdominal ultrasound showed a thickened gallbladder wall, with hepatobiliary scan showing an ejection fraction of 0% with unusual blood pooling activity in the left upper quadrant. After adequate transfusion and proton pump inhibitor therapy, she underwent an EGD that revealed polypoid masses within the stomach and no foci of bleeding. Tissue biopsy showed gastric oxyntic mucosa with increased numbers of chronic inflammatory cells in the lamina propria which included lymphocytes and plasma cells. Helicobacter pylori immunostaining was negative and in situ hybridization for Epstein-Barr virus RNA (EBER) was positive. Antral polyp histology revealed edema of the lamina propria, reactive changes and moderate chronic active inflammation. The gastric antral mucosa showed moderate chronic gastritis. An abdominal CT showed splenomegaly and inguinal lymphadenopathy. An inguinal lymph node was biopsied and revealed polymorphous lymphocytes without necrosis, granuloma or tumor. Heterophile antibody testing was positive. With clinical improvement, the patient discharged home with PPI therapy and returned for follow up 2 months with full resolution of symptoms and negative H. pylori and EBER studies on repeat upper endoscopy.Figure 1Figure 2This case highlights the rarely described EBV-gastritis and the ability of EBV to mimic malignancy via radiographic, endoscopic, and histologic assessment. Differentiation of acute EBV infection from malignancy is imperative.