Large Fluid Collection Research Articles

THE KNOCKOUT PUNCH: A RARE CASE OF AGGRESSIVE METASTATIC SARCOMA

SESSION TITLE: Fellows Disorders of the Mediastinum Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Soft tissue sarcomas (STS) are a heterogeneous mix of mesenchymal tumors that account for 1-2% of adult cancers worldwide. Though instances of prior trauma have been described in the literature as the precipitant for sarcoma formation, the pathophysiology is overall poorly understood. CASE PRESENTATION: A 24 year old male presented to the ED with increasing neck pain and progressive swelling following a punch to the neck during a boxing class. A CT of the neck revealed a large right-sided inferior neck hematoma. He was evaluated by vascular surgery, who recommended conservative management, and was subsequently discharged home. Three months following the initial injury, he re-presented to the ED with progressive dyspnea. A CT Chest was performed, revealing a large fluid collection thought to be extension of the hematoma into his right chest wall with associated mass effect on the mediastinum. He was admitted, and underwent a VATS washout with biopsies with cardiothoracic surgery. Pathology from the biopsy demonstrated undifferentiated sarcoma with epithelioid features. After consulting radiation and medical oncology, he began urgent radiation and chemotherapy. Despite this, the tumor was highly aggressive and continued to spread into his lungs and abdomen. Repeat imaging revealed a large loculated hemorrhagic effusion with mediastinal and upper abdominal content shifts. He underwent another VATS washout removing 2.2 liters of congealed blood from his chest. After a prolonged hospital course, he was eventually discharged to a rehab facility. His clinical course was further complicated by two more hospital admissions for dyspnea, revealing progressive disease with distant metastasis to the bowel. Despite aggressive measures including repeated blood transfusions and vasopressors in the ICU, he clinically deteriorated. He was transitioned to comfort measures, and eventually passed away. DISCUSSION: Several studies have explored the supposed correlation between trauma and STS formation. These hypotheses include initiator-promoter models that describe sarcoma formation after an initial genetic shutdown of tumor protein and local injury in mouse models. Autopsy of our patient revealed extensive local and metastatic disease to the neck, pleura, lungs, mediastinum, pericardium, diaphragm, liver, spleen, serosa of the small and large bowel, and the bladder. Could our patient have had an inherited oncogenic insult that predisposed him to sarcoma formation following injury? CONCLUSIONS: This case potentially substantiates a link between traumatic injury and STS formation. Additionally, it highlights that high grade sarcomas may mimic traumatic intramuscular hematomas early in their disease course. Reference #1: Jo VY, Fletcher CD. Pathology. WHO classification of soft tissue tumours: an update based on the 2013 (4th) edition. 2014 Feb; 46(2):95-104. Reference #2: Van Mater D, et al. Acute tissue injury activates satellite cells and promotes sarcoma formation via the HGF/c-MET signaling pathway. Cancer Res. 2015 Feb 1; 75(3):605-14. Reference #3: Gomez P, Morcuende J. High-grade sarcomas mimicking traumatic intramuscular hematomas: a report of three cases. Iowa Orthop J. 2004;24:106–110. DISCLOSURES: No relevant relationships by Rasika Chepuri, source=Web Response No relevant relationships by Anuj Shukla, source=Web Response

Management of a large delayed esophageal perforation in a fresh liver transplant patient with endoscopic placement of a nasopleural drainage tube—a case report

Esophageal perforation in liver transplant recipients is a rare phenomenon. We herein report a case of an esophageal perforation due to Sengstaken–Blakemore tube in a liver-transplant recipient diagnosed 6 weeks post-transplant. A 2.5-cm mid-esophageal perforation communicating with large complex fluid collection in the pleural space was found. During endoscopy, 16Fr Salem Sump nasopleural tube (NP) was placed traversing through esophageal perforation into inferior aspect of the collection. Over the following 4 weeks, NP decompressed the cavity, allowed its closure and the tube was slowly retracted. By the end of 4 weeks, NP was removed with follow-up esophagogram showing no extravasation of contrast and a healed perforation. Hence, the esophageal perforation was successfully treated via this unique nonoperative approach without the need for major surgery. In instances of chronic leak with a stable patient, this nonoperative strategy should be considered even in immunocompromised patients.

Patient with progressive chest pain and dyspnea after aortic valve replacement.

A 45‐year‐old man presented to the emergency department (ED) with progressive chest pain and dyspnea 3 months after aortic valve replacement. He had been evaluated by his primary care physician and cardiologist and no diagnosis had been made. On arrival, the emergency physicians performed point‐of‐care ultrasonography, which showed a large hypoechoic collection compressing the right ventricle. This prompted further workup, including a computed tomography of the chest, which revealed a large fluid collection in the anterior mediastinum. Subsequently, cardiothoracic surgery was consulted and the patient was taken to the operating room for a sternal washout with evacuation of the collection.

Case of an Epidural Hematoma Following a Lumbar Epidural Steroid Injection in a Patient Taking Aspirin and Duloxetine

Background: Epidural hematoma (EDH) formation is one of the most feared complications associated with epidural steroid injections (ESI) as persons may experience permanent neurological deficits including paraplegia. The risk of developing an EDH following an ESI is expectedly increased in the context of concomitant anticoagulant and/or antiplatelet agent usage. While there exists significant evidence for the risks associated with anticoagulant and anti-platelet agents in epidural procedures, the anti-platelet effects of serotonin reuptake inhibitors medications (SRIs) in particular have received less attention. Case Report: A 70-year-old female with numerous cardiovascular comorbidities (on aspirin 81 mg daily for primary prevention of coronary artery disease) and fibromyalgia (on duloxetine 60 mg daily) underwent a fluoroscopically guided L3-L4 level interlaminar ESI for lumbar radiculopathy. Starting 6 hours post-procedure, the patient started to manifest severe back pain, bowel and bladder incontinence, and paraplegia. Magnetic resonance imaging (MRI) of the thoracic and lumbar revealed a large epidural fluid collection compressing the spinal cord and cauda equina. Unfortunately, a delay in care prevented the patient from receiving neurosurgical decompression. Conclusion: SRI associated coagulopathy may predispose to EDH formation by diminishing platelet aggregation. Therefore, weaning these medications, as dictated by the latest guidelines, should be highly considered, if possible and reasonable, to ensure favorable safety profiles for ESI procedures, especially in persons with multiple risk factors. Regardless of appropriate strategies to mitigate ESI associated bleeding risks, proceduralists should always maintain a healthy index of suspicion for EDH formation in the post-procedural phase as early diagnosis and intervention may prevent devastating neurological outcomes. Key words: Epidural hematoma, paraplegia, aspirin, duloxetine

Patients With Modular-Neck Total Hip Arthroplasty: A Brief Five-Year Follow-Up Study

BackgroundWe have previously reported the early clinical results of a modular-neck stem identifying an early 2-year revision rate of 13% due to neck-stem corrosion. This report updates our findings to a midterm mean follow-up of 5 years. MethodsThis is a consecutive retrospective review of 186 modular-neck hips in 175 patients with a mean follow-up period was 60.1 ± 22.9 months (range 24-100). We reviewed clinical findings, routine radiographs, detailed imaging (metal artifact reduction software-magnetic resonance imaging, ultrasound), and serum ion levels of cobalt and chromium. We performed a survival analysis with the endpoint defined as revision total hip arthroplasty due to neck-stem corrosion. ResultsWe revised 41 hips (22.0%) for neck-stem corrosion. Clinical symptoms (groin pain ± local swelling) were consistently present in those that came for revision. Mean serum cobalt ion levels increased as time passed in all patients. Detailed image findings showed that larger fluid collections and local soft tissue masses were seen predominately in symptomatic patients. However, 14% of patients who underwent revision did not have positive magnetic resonance imaging or ultrasound findings. The survival rate was 87% (95% confidence interval 81-92) at 3 years postoperatively and 72% (95% confidence interval 64-80) at 7 years postoperatively. ConclusionThe revision rate for this modular-neck stem due to neck-stem corrosion at mid-term follow-up almost doubled in comparison to previous short-term results. It seems reasonable to consider clinical follow-up alone as symptoms, rather than blood testing for ion levels, seem to be the defining characteristic of failure.

IR-guided endoscopic pancreaticojejuostomy for post-whipple pancreaticocutaneous fistula

Presenter: Elliot Scott MD | Virginia Mason Medical Center Background: A 67yF presented with biliary obstruction and computed tomography (CT) suggested a distal bile duct tumor. She underwent an ERCP with brushings for stenting and to but unfortunately developed severe acute pancreatitis (SAP). Although technically resectable after complete staging without evidence of distant disease, she was not felt to be a surgical candidate and was referred for neoadjuvant chemotherapy while. Unfortunately, after one cycle of gemcitabine and cisplatin, her SAP progressed to walled-off necrosis (WOPN) requiring percutaneous and endoscopic drainage. Therefore, after a period of recovery, she was taken to the operating room for an attempt at curative resection. A pylorus-preserving pancreaticoduodenectomy (PD) was performed, however, the pancreas was scarred without a visible duct and adherent to a thrombosed splenic vein with sinistral portal hypertension form WOPN. Decision was made to suture the pancreatic remnant without an anastomosis. The patient did well until POD#4 when a CT performed for abdominal pain revealed a large fluid collection. This was drained percutaneously and was consistent with a pancreatic leak. The patient convalesced from her operation but was left with a pancreaticocutaneous fistula. Methods: Since transgastric internalization was not feasible post-PD, a combined interventional radiology (IR) and gastroenterology (GI) rendezvous approach was utilized. An endoscopic ultrasound (EUS) scope was passed into the afferent limb while a balloon catheter was passed through the drain tract. The balloon was visualized by EUS and punctured in order to grab an IR wire and pass it into the afferent jejunal limb. Two pigtail stents were then deployed in order to create a pancreaticojejunostomy (See Figure). Results: The patient did well post procedure and deemed ready for adjuvant therapy for her T2N1 distal cholangiocarcinoma. Conclusion: This challenging case highlights the multidisciplinary strategy required not only for optimal oncologic treatment of biliary tumors but also to manage the complications of therapy.

2937 Endoscopic Ultrasound-Guided Drainage and Treatment of Symptomatic Walled-Off Pancreatic Necrosis: A Single Center Case Series

INTRODUCTION: Walled-off pancreatic necrosis (WOPN) develops within 4-6 weeks after acute necrotizing pancreatitis. Endoscopic transgastric pancreatic necrosectomy has emerged as a promising therapy for WOPN. We aim to evaluate the clinical success and outcomes of patients treated with endoscopic therapy for symptomatic WOPN. METHODS: Retrospective chart review of all patients who underwent endoscopic pancreatic necrosectomy from January 2015 until November 2018 was performed. Patients' demographics were obtained including etiology of pancreatitis, size of WON, number of endoscopic necrosectomies, time to resolution of necrosis, and outcome. RESULTS: 15 patients underwent endoscopic necrosectomy for symptomatic WOPN. 60% were male, average age was 56 years. Etiologies of pancreatitis included: Biliary (46%), alcohol induced (20%), hypertriglyceridemia (13%), and idiopathic (20%). Nine (60%) cases presented with infected necrosis diagnosed by cross-sectional imaging and clinical criteria. The Median size of peripancreatic fluid collections was 14 cm (Range: 8-20 cm). Endoscopic necrosectomy was performed through the transgastric route in all patients. All patients underwent initial necrosectomy at time of cystgastrostomy. 13 (87%) patients had luminal apposing stents (LAS) (Axios, Boston Scientific). Axios 15 mm × 10 mm were most common. The mean number of endoscopic therapy sessions was 3.4 (Range 1-8). Two (13%) patients had migrated LAS within 4 weeks. One patient underwent repeat cystgastrostomy to remove an internal migrated stent. There were no reported complications of bleeding, procedure-related infection, or perforation associated with cystgastrostomy or necrosectomy. None of the patients suffered death. Clinical success was achieved in 80% of our patient population defined by resolution of fluid collection and necrosis and clinical improvement. 3 (20%) patients required additional surgical intervention. One required surgical intervention for a pancreatic fluid collection not accessible by the endoscope. One underwent surgery prior to presenting to our center. The third had a large sized necrosis with multiple admission for sepsis and failure to thrive. CONCLUSION: Sequential endoscopic transgastric necrostectomy is a promising therapy for WOPN and should be the first modality to treat patients with infected or symptomatic walled-off necrosis. Large fluid collections, recurrent admissions, failure to thrive, and collections not accessible by the endoscope were indicators for surgical intervention.

1411 A Rare Cause of Acute Pancreatitis in a Transgender Female

INTRODUCTION: While hypertriglyceridemia and certain medications are known causes of acute pancreatitis, estrogen resulting in secondary hypertriglyceridemic acute pancreatitis (HTG-AP) is rare. To our knowledge, this is only the third case of a transgender female presenting with acute pancreatitis secondary to estrogen-induced hypertriglyceridemia. CASE DESCRIPTION/METHODS: A 31-year-old transgender female presented to the hospital with epigastric pain, fever, chills and decreased appetite. Laboratory work-up was significant for lipase >7,500 u/L, triglycerides >7,000 mg/dL and calcium of <4 mg/dL. The patient denied alcohol use, diabetes, hypothyroidism or family history of pancreatitis. Initial management included aggressive intravenous fluid resuscitation. CT scan of the abdomen was performed and was notable for a large peripancreatic fluid collection most consistent with walled off necrosis (Figures 1 and 2). Three retroperitoneal drains were placed into the fluid collections with clinical improvement. Upon further questioning, it was discovered that several months prior to admission, the patient had started taking oral estrogen therapy obtained via an online store to transition from male to female, which was ultimately felt to be the most likely cause of her very severe hypertriglyceridemia. Two weeks after discharge, patient had IR drain exchange and repeat CT scan showed almost complete resolution of the fluid collections and her drains were removed. DISCUSSION: Medications are often described as the etiology for why people develop pancreatitis. However, to clearly prove a medication as the inciting factor, reinitiation of that medication needs to occur in order to establish a temporal relationship. Estrogen is a rare cause of drug-induced pancreatitis with approximately 40 cases reported worldwide. It is one of the few medications that has a described mechanism, hypertriglyceridemia, for the development of pancreatitis. Of the 40 cases described only 2 published case reports involve transgender females (7) (Table 1). The number of transgender patients presenting to the healthcare system for care is growing (9.2 per 100 000). Importantly, transgender females require supraphysiologic doses of estrogen therapy to maintain secondary sexual characteristics. Accounting for these factors, it is important for healthcare providers to understand their risk for and ways to prevent acute pancreatitis from occurring in their transgender patient population (8).

1435 Pancreaticoenteric Fistula: A Very Unique Complication of Acute Pancreatitis

INTRODUCTION: Pancreaticoenteric fistulas are a rare complication of acute pancreatitis. Spontaneous fistulation has been described in the literature in cases where acute pancreatitis is complicated with infection or necrosis. As a direct consequence to the fistula formation, direct vascular injury may occur, resulting in blood loss and rapid clinical deterioration. CASE DESCRIPTION/METHODS: A 77-year-old male with past medical history of essential hypertension, type 2 diabetes mellitus and coronary artery disease status post coronary artery bypass grafting in 2017 was brought to Emergency Room due to sudden onset right leg pain. He was admitted due to subacute limb ischemia and started on antiplatelet and anticoagulation medical therapy. Hospital course complicated with abdominal pain and four episodes of large volume port wine stools per rectum and significant drop in hemoglobin levels. After initial resuscitation measures, which include intravenous hydration and supportive blood products transfusions, patient was consulted to Gastroenterology service for evaluation and recommendations. Esophagoduodenoscopy revealed large clean base ulcerated lesion with an associated fistulous process in the first portion of the duodenum. No active bleeding nor blood remnants were noted. Abdominopelvic CT scan was immediately done and showed extensive devitalization of the pancreas along with large peripancreatic fluid collection with abundant internal gas suggestive of a contained perforation of duodenum. Interventional radiology and General surgery was consult. DISCUSSION: Spontaneous pancreaticoenteric fistula in the setting of pseudocysts formation secondary to necrotizing pancreatitis is a very rare and unique complication. Typical management is conservative, with medical therapy resulting in closure of the vast majority of fistulas. The infrequency with which pancreaticoenteric fistulas are encountered makes them a formidable diagnostic and treatment challenge. Even though it has been described in the literature, there still much to investigate regarding upper gastrointestinal fistulas and its associated vascular complications after acute pancreatitis.

1684 Paging Dr. MacGyver: A Novel Approach to Redeploying a Dislodged AXIOS Stent During a Pancreatic Necrosectomy

INTRODUCTION: Although multiple modalities exist for managing walled off and infected pancreatic necrosis, EUS-guided transmural drainage is often favored due to its minimally invasive and highly effective nature. The AXIOS stent has demonstrated clear superiority over double pigtail and fully covered self-expanding metal stents in this setting. Although the radial force from its wide luminal diameter and its dumbbell shape helps secure the stent in place, stent migration and dislodgement can still occur. Here, we present a case of stent dislodgement during a pancreatic necrosectomy, which was salvaged by stent extraction and endoscopic re-deployment using a stone extraction balloon catheter sheath. CASE DESCRIPTION/METHODS: A 68-year-old woman with a medical history notable for prior acute pancreatitis presented to the ED with abdominal pain, nausea, and vomiting. CT Abdomen revealed a large pancreatic fluid collection with surrounding necrosis. She was admitted to the SICU for management of necrotizing pancreatitis, and underwent cystgastrostomy with an AXIOS stent on day 14 of admission. During her necrosectomy one week later, the previously placed AXIOS stent was accidentally displaced into the stomach. The displaced stent was grasped with a rat tooth forceps and removed from the patient. One end of the extracted AXIOS stent was stretched so that it became thin enough to be inserted into an empty stone extraction balloon catheter sheath. The other end was then back-loaded into the larger channel of a double-channel gastroscope. The scope was then re-introduced and advanced into the pancreatic cyst cavity. A rat tooth forceps was inserted into the instrument channel and used to advance the back-loaded stent forward, re-deploying the stent under endoscopic guidance only, such that it again traversed the cystic cavity and stomach. The stent was then adjusted into its desired position using rat tooth forceps. DISCUSSION: As Interventional Endoscopy’s technologies continue to evolve, it will become increasingly important for the skilled endoscopist to understand the mechanics of the tools being used, and trouble shoot these technologies as unforeseen complications arise. The novel method for AXIOS stent re-deployment described here not only demonstrates this understanding, but also serves as an example of a cost saving recourse for dislodged AXIOS stent re-deployment. Indeed, in an era of cost-conscious care, one must trouble shoot in a manner that is both clinically effective and financially efficient. Watch the video: http://bit.ly/2O2RYbW.

1922 The Use of a New Hemostatic Powder in Refractory Pseudocyst Wall Bleeding

INTRODUCTION: Despite multiple endoscopic hemostatic devices available, GI bleeding can still be difficult to treat. A new hemostatic device was recently approved by the FDA as an non-surgical treatment option of upper and lower GI bleeding. The hemostatic powder forms a mechanical and adhesive barrier by absorbing water and promotes thrombus formation by concentrating and activating platelets and coagulation factors with high primary hemostasis rates. It has been reported as a successful hemostatic technique for common causes of GI bleed, but not for pseudocyst bleeding. CASE DESCRIPTION/METHODS: 84-year-old male admitted to our institution ten days after a surgical cystgastrostomy with one day history of abdominal pain associated with nausea and vomiting. Hemoglobin decreased from 11 to 8 mg/dl after the surgery and occult blood in stool was positive. Initial CT angiogram revealed no active bleeding but a large complex fluid collection 13.1 × 11.6 × 12.9 cm from the pancreatic tail and involving the stomach. Gastroenterology was consulted to assess the cystgastrostomy patency and evaluate for GI bleeding as the cause of anemia. Endoscopy was performed and revealed that the pseudocyst gastrostomy in the proximal gastric body had stenosed to 0.5 cm from 6 cm and the pseudocyst cavity was filled with large clots but no evidence of active bleeding. Due to the stenosis, double pig tail plastic stents were placed. Patient developed melena and hemoglobin decreased again from 9 to 7 mg/dl. Repeated endoscopy revealed active bleeding within the pseudocyst wall near the anastomosis. The tissue was very friable. Epinephrine injection, coaptive coagulation with bipolar cap and hemostatic clip placement were all unsuccessful to stop the bleeding. Finally, hemostasis was achieved using a new hemostatic powder through endoscopic delivery catheter. The powder was sprayed successfully to the anastomosis and proximal cavity of the pseudocyst without complication or further bleeding. Follow up a month later did not showed any evidence of active bleeding. Repeat CT abdomen revealed decreased in size of the pancreatic pseudocyst with plastic stents still in place. DISCUSSION: To our knowledge, this is the first report of the use of hemostatic powder delivered via endoscopy outside the GI tract to achieve hemostasis from pancreatic pseudocyst wall bleeding. This device can be considered as a rescue modality for those cases where the standard treatment has failed. Further studies are needed to assess its safety in this setting.

2143 A Unique Complication of Gastrostomy Tubes

INTRODUCTION: In 1979 the Gauderer-Ponsky technique was developed to allow endoscopic placement of gastrostomy tubes (G-tubes). The procedure allowed fistulation between the stomach and abdominal wall. G-tubes are often placed for enteral feeding in patients who have either an inability or insufficiency of intake by mouth. Complications of G-tubes are often seen but an overwhelmingly majority of them are minor. At times G-tubes lead to soft tissue & skin infections, colocutaneous fistulas, & visceral perforations. These more serious complications can occur up to 11-15%. Smaller complications such as dislodgement or G-tube dysfunction are far more common. CASE DESCRIPTION/METHODS: A 49 year-old male with a past medical history of traumatic brain injury with placement of a percutaneous endoscopic gastrostomy tube (G-tube) who presented to the ED after pulling out his G-tube. Unable to place the G-tube back at bedside, interventional radiology reinserted under fluoroscopy. After discharge he presented back to the ED with coffee ground emesis & aspiration. He was noted to have klebsiella pneumonia. Despite being appropriately treated for his pneumonia he continued to have worsening septic shock abdominal distention. CT imaging was positive for large collection of fluid, gas, & contrast filling his peritoneum. Emergent exploratory laparotomy found 6L of peritoneal fluid & a perforated fistulous tract draining into his peritoneal cavity. Meanwhile his abdominal viscera was coated with a white film. Labs & cultures confirmed peritonitis caused by klebsiella, enterococcus, & candida. He received antibiotics and antifungal therapy, required multiple washouts, & surgical correction of the perforation with a wedge gastrectomy. DISCUSSION: This patient developed a rare & serious complication after G-tube placement. Dislodging the G-tube in a traumatic fashion caused drainage into his peritoneum. Even though the G-tube was replaced under radiographic guidance he developed a terrible case of peritonitis. The rates of complications are statistically the same in radiographically or endoscopically placed G-tubes. This patient required surgical placement of another G-tube along with and a wedge gastrectomy. This complication of fungal peritonitis & aspiration pneumonia show us that G-tubes are not always benign. Endoscopic, surgical, and radiographic techniques may all have a different approach to ensure good outcomes but a patient’s ability to receive good G-tube care is essential in preventing long term complications.

3029 Complications from Hypertriglyceridemia-Induced Acute Pancreatitis

INTRODUCTION: Pancreatitis accounts for 275,000 hospital admissions annually. While alcohol consumption and gallstones are responsible for the majority of cases, hypertriglyceridemia accounts for only 7%. Most are treated successfully with intravenous hydration, pain control and triglyceride-lowering agents but complications do occur 15% of the time. We present a case of one such complication. CASE DESCRIPTION/METHODS: A 40-year-old previously healthy female presented with a 12-hour history of nausea and severe LUQ abdominal pain. She was admitted with acute pancreatitis secondary to hypertriglyceridemia. Labs revealed a lipase of 3653 U/L and triglycerides of 6160 mg/dL. Abdominal CT scan confirmed acute pancreatitis. She was treated supportively with aggressive IV hydration. Repeat imaging 5 days later showed a large fluid collection inferior to the gastric antrum, an extensive amount of free fluid layering the abdomen and a small to moderate left pleural effusion. Eventually her symptoms due to the evolving pseudocyst improved and she was discharged on day 22 with Fenofibrate and Omega-3-Acid Ethyl Esters. Six days later she was admitted for sepsis secondary to infected pancreatic pseudocyst. CT showed an extensive multi-locular fluid collection and worsening left pleural effusion. Ultrasound-guided drainage was performed and cultures reported E. coli. Antibiotics were tailored but patient remained hypotensive and tachycardic. At that point the patient underwent a diagnostic laparoscopy, which was converted to Roux En Y pancreatic cystjejunostomy for continuous drainage. Repeat imaging on post-op day one demonstrated an interval decrease in size of fluid collection. Eventually the patient was discharged home in stable condition. DISCUSSION: While pancreatitis due to hypertriglyceridemia remains common, life threatening complications are rare. Aggressive supportive care is the mainstay of therapy with early surgical intervention as needed.

Understanding the Head and Neck Ultrasound: From Simple to Complicated Cases: Submandibular Abscess

A 43-year-old man was referred to center of maxillofacial surgery and dentistry with a very painful and severe swelling in the left submandibular area, redness of the neck, fever for 1 week, and slight worsening of swallowing. According to history of patient`s complaints, 10 days ago in the area of the present swelling, several movable lesions in the depth of soft tissue were noted. Longitudinal gray scale ultrasound (US) (Panel B, US using linear probe; Panel C, US using convex probe) showed subcutaneous oedema (white asterisk), large collection of well-defiened hypoechoic fluid (indicated by ‘+’ and ‘×’ calipers) under the platysma muscle (arrowheads). Movement of the fluid during dynamic compression was noted. The usual artifact for fluid-contained objects, posterior acoustic enhancement, is indicated by black asterisks. No ultrasound signs of gas loculations in the soft tissue and fluid were found. This allows assuming the absence of gas-forming organisms. Also, the enlarged lymph nodes were noted at the left neck. The diagnosis of submandibular abscess due to non-odontogenic inflammation and suppurate fusion of the lymph nodes was established. The abscess was lanced, and drained using submandibular approach. 18 ml of purulent material was obtained. At the next morning after surgery, the patient felt significant improvement; 1 week follow-up the patient was clinically well.

Two cases of uterine and vaginal malformations

Objective: To evaluate the efficacy of hysteroscopy and laparoscopy for oblique uterine septum and oblique vaginal septum. Case Report: There were one patient with oblique uterine septum and another patient with oblique vaginal septum. Case 1 was a 14-year-old female, who revealed a left unicornuate uterus and right non-communicating rudimentary horn with a cavity. Using a resectoscope with a needle electrode, the authors made a transverse incision on the bulging area of the septum at the level of the tubal ostium. Case 2 was a 14-year-old female with a double vagina, large fluid collection in the occluded right hemivagina, and absent of the right kidney. The authors performed a hysteroscopy, resection of the vaginal septum, and vaginoplasty. Conclusion: Intraoperative ultrasound monitoring can improve surgery safety, with the advantages of lesser amounts of trauma, a good therapeutic effect, fewer complications, less bleeding, quick recovery, and simultaneous protection of the hymen.

Physeal separation in pediatric osteomyelitis

In children, acute osteomyelitis, an infection of the bone, is most commonly hematogeneous in origin. Osteomyelitis is most often diagnosed with magnetic resonance imaging (MRI) and findings may include marrow signal changes on T1 and T2, with abnormal enhancement after gadolinium. Imaging helps detect any associated intraosseous or subperiosteal abscesses, which may require orthopedic drainage. In this pictorial essay, we demonstrate the association of acute pediatric osteomyelitis with physeal separation, resulting in what may be confused for simple trauma, although there was no known history of trauma in any of the cases we researched. All of the cases had a large subperiosteal fluid collection with marked separation of the epiphysis from the metaphysis. It is important to recognize this potential association in osteomyelitis, as it is readily visible by radiographs and may lead to diagnostic uncertainty.

MON-343 Nocardia Farcinia Adrenal Abscess Mimicking Adrenal Adenoma

Background: Infection by Nocardia in immunocompetent individuals is uncommon. Isolated adrenal involvement by Nocardia is rare. We report a case of unilateral Nocardia adrenal abscess that presented as lesion mimicking adrenal adenoma which resulted in dissemination in an immunocompetent host. Case Presentation: A 67 years old male with past medical history of coronary artery disease presented to his physician’s office with 5/10 pain in the left flank area for two weeks that radiated into the left upper quadrant. He had weight loss more than 10 pounds in one month, anorexia and night sweats. On examination, he was hemodynamically stable and there was no abdominal tenderness. Routine blood work and a computed tomography [CT] scan of abdomen was obtained that showed a heterogeneously enhancing 8.1 cm x 4 cm x 5 cm partially necrotic left adrenal mass [Figure 1]. Lab work revealed that serum aldosterone, serum renin, plasma metanephrine and urine free cortisol were in normal range. In a few days, patient presented with acute episode of hypotension to the Emergency department. A CT scan of abdomen was that revealed he had large retroperitoneal fluid collection. He received intravenous fluid resuscitation and was started on empiric treatment with Vancomycin and Piperacillin-tazobactam for concern of sepsis. He underwent surgical exploration, incision and drainage of left retroperitoneal abscess collection with removal of two liters of purulent fluid [Figure 2]. Initial gram stain had shown filamentous, acid fast bacteria. He was started on treatment empirically with Amikacin, Trimethoprim–sulfamethoxazole [TMP–SMX] and Imipenem- Cilastatin. The patient was found to have disseminated nocardiosis with positive blood cultures and abdominal abscess growing Nocardia farcinica. Antibiotics were tapered to Imipenem- Cilastatin, Amikacin and Moxifloxacin to complete six weeks of antibiotic therapy. CT scans of chest and head were obtained which did not reveal any signs of abscess. Patient recovered well with repeat imaging studies showing resolution of the abscess. Conclusion: Nocardia involvement of adrenal gland is a rare phenomenon, it can present as solitary adrenal lesion or with dissemination. This can mimic adrenal adenoma on CT scan. On review of existing medical research, less than ten cases of isolated Nocardia adrenal abscess leading to dissemination has been described so far. Isolated involvement of the adrenal gland poses diagnostic challenge because of non-localizing symptoms and late presentation with dissemination. Figure 1 Partially necrotic left adrenal massFigure 2 Retroperitoneal abscess

Complicated acute appendicitis presenting as a necrotizing fasciitis of the abdominal wall: a case report

Acute appendicitis is one of the most common surgical diseases, but necrotizing fasciitis of the abdominal wall because of perforation is extremely rare. A 50-year-old male presented to the emergency department with severe right-sided abdominal pain for a week. He was hypothermic, hypotensive, and tachycardic. His abdomen was distended, with a large, tender, erythematous region over the right abdominal wall. Laboratory evaluation revealed leukocytosis, acute kidney injury. Computed tomography revealed large collections of fluid and gas in the right abdominal wall as well as inflammation surrounding the right colon. The patient was resuscitated with intra-venous fluid, started on broad-spectrum antibiotics, and emergently brought to the operating room. The patient underwent an exploratory laparotomy, and was found to have appendicitis, which perforated into his abdominal wall resulting in a necrotizing soft tissue infection. It is important to recognize this complication early and proceed immediately to the operating room.

A Case of Perforated Cholecystitis Presenting as Persistent Pleural Effusion

Gallbladder perforation is an uncommon complication of cholecystitis that can result in perihepatic abscess. We present a case of persistent right-sided pleural effusion secondary to perihepatic abscess from perforated gallbladder. A 46-year-old male with paraplegia secondary to T4 spinal cord injury was admitted after presenting with fever, cough, and shortness of breath. He had previously been treated at an outside hospital with an oral antibiotic course for a presumed pneumonia. CT chest showed a large rightsided pleural effusion. A pleural pigtail catheter was placed with persistent large-volume output. Initial imaging of the chest incidentally revealed a large peri-hepatic fluid collection. This was further investigated with an abdominal CT which revealed a large perihepatic rim-enhancing fluid collection with multiple gallstones in the gallbladder neck and small collections in the gallbladder fundus suspicious for a site of perforation. He was sent for interventional-radiology guided drain placement with plan for outpatient cholecystectomy. Output from the pleural pigtail decreased and the drain was removed with resolution of sepsis and shortness of breath. Gallbladder perforation is a relatively infrequent complication of acute cholecystitis. Often, intial symptoms of cholecystitis are masked due to uncontrolled diabetes or, as in this case, spinal cord injury. As far as the authors of this case are aware, perforated gallbladder resulting in pleural effusion has not yet been described in the literature.2921 Figure 1. Perihepatic abscess

Spontaneous Rupture of a Pancreatic Pseudocyst: A Fatal Complication

Pancreatic pseudocyst is one of the complications of acute pancreatitis, most commonly due to alcohol use and typically resolves with conservative management. Presentation can range from abdominal pain to biliary and gastro-duodenal obstruction, pancreatic ascites and pleural effusion to serious complications such as intracystic hemorrhage or spontaneous rupture. Pseudocyst rupture is a potentially fatal complication and requires emergent surgical intervention. Fortunately, this is an extremely rare occurrence with very few reports in the literature We present a case of a 59-year-old male with a medical history of alcohol abuse, gastroesophageal reflux disease and gastrointestinal bleed who presented with acute left lower quadrant abdominal pain associated with back pain and nausea. On admission, he was hypotensive and tachycardic with tensely distended and diffusely tender abdomen along with involuntary guarding concerning for peritonitis. Laboratory values revealed leukocytosis (13,300),lactic acidosis (2.2), elevated serum amylase (291 U/L) and lipase (475 U/L).CT scan of the abdomen and pelvis revealed ascites and a large abdominal fluid collection with a thick enhancing wall posterior to the stomach measuring 11.4x7.6x10.5 cm and communicating with the pancreas consistent with rupture of a pancreatic pseudocyst Emergent exploratory laparotomy was performed which revealed 5 liters of turbid ascitic fluid. A large decompressed pseudocyst was noted with a small lateral perforation draining contents into the peritoneal cavity. The defect was closed to prevent further leakage. Gastrotomy was performed through the anterior stomach wall and a surgical cystogastrostomy was constructed to allow internal drainage of the pseudocyst into the gastric lumen. The skin was left open and the wound was managed with a negative pressure wound dressing [VAC™]. Post-operatively, patient received antibiotics and octreotide. Repeat CT scan on post-operative day (POD) 5 revealing interval decrease of the pseudocyst to 10.1x6.5 cm as well as decrease in ascitic fluid. The patient improved clinically an6d was discharged home on POD 11 While spontaneous rupture of a pancreatic pseudocyst is a rare event, it is a surgical emergency. Patients should be treated urgently with surgical intervention to minimize the complications associated with spillage of pseudocyst content into the peritoneal cavity. This strategy can be a life-saving intervention, as was the case in our patient