Left Upper-quadrant Abdominal Pain Research Articles

Persistent hiccups as a rare presenting symptom of empyema: a case report

BackgroundEmpyema is uncommon owing to antibiotic use but still affects patient health if not treated. Hiccups as the initial symptom of empyema are rare; however, empyema should be considered if a patient has persistent hiccups with unexplained fever.Case presentationWe present a case of persistent hiccups, left upper quadrant abdominal pain, and fever on day 1, and total left lung white-out and empyema on day 3. The hiccups resolved gradually after antibiotic treatment and surgical decortication.ConclusionsClinicians should consider the possibility of empyema and conduct a chest computed tomography study if unexplained fever and persistent hiccups coexist.

Gastrosplenic fistula due to diffuse large B-cell lymphoma: case report

BackgroundGastrosplenic fistula (GSF) is a rare complication of various benign and malignant etiologies. Splenic lymphoma is the most common cause of GSF. Most cases are due to diffuse large B-cell lymphoma (DLBCL).Case presentationA 39-year-old male patient presented at the emergency department with left upper quadrant abdominal pain. CT scan showed necrotic splenic mass with fistulous tract between the spleen and the gastric cavity. The patient underwent splenectomy and partial gastrectomy. The histopathological diagnosis was DLBCL.ConclusionsGastrosplenic fistula is a rare complication of diffuse large B-cell lymphoma. Radiologists should be aware of it and consider it in the diagnosis.

A case report of a large Splenic epidermoid cyst treated with partial splenectomy

Introduction and importance: Splenic epidermoid cysts are rare primary congenital cysts composed of an epithelial lining that represent a small proportion of nonparasitic splenic cysts. Despite their infrequency, there is a lack of uniform diagnostic and treatment guidelines for these cysts, emphasizing the need for further research and standardized reporting. Case presentation: A 45-year-old female presented with left upper quadrant abdominal pain, characterized by a pressing sensation. Physical examination revealed a palpable mass in the upper left quadrant. Laboratory test results were normal. Abdominal ultrasonography and CT tomography confirmed a large splenic unilocular cyst consistent with an epidermoid cyst. Surgical intervention involved aspiration of the cystic fluid, partial splenectomy, and pathological examination. The patient’s postoperative recovery was uneventful. Clinical discussion: The origin of splenic epidermoid cysts remains unclear, with theories suggesting entrapment of mesothelial cells during embryonic development. The clinical presentation varies with cyst size, often causing abdominal pain and a palpable mass. Diagnostic modalities include ultrasonography and CT scans. Surgical intervention is recommended for symptomatic or suspicious cysts to prevent complications. The chosen approach depends on cyst characteristics and patient factors. This case highlights the challenges and considerations in managing splenic epidermoid the cysts and emphasizes the need for individualized treatment approaches. Conclusion: This case contributes to the understanding of splenic epidermoid cysts and demonstrates a successful subtotal splenectomy as a treatment approach. Further research and standardized guidelines are essential to improve the management of these rare lesions and to provide better insights into their etiology and optimal treatment strategies.

Pancreaticopleural Fistula: Navigating the Enigma of an Elusive Diagnosis

BACKGROUND: Pancreaticopleural Fistula is a Rare Complication of Acute and Chronic Pancreatitis. This Usually Presents With Chest Symptoms Due to Pleural Effusion, Pleural Pseudocyst, or Mediastinal Pseudocyst. Diagnosis Requires a High Index of Clinical Suspicion in Patients Who Develop Alcohol-induced Pancreatitis and Present With Pleural Effusion Which is Recurrent or Persistent. Analysis of Pleural Fluid for Raised Amylase Will Confirm the Diagnosis and Investigations Like Ct. The Rarity of Pancreaticopleural Fistulas, Especially Without the Context of Chronic Pancreatitis, Makes This Case Noteworthy. The Presence of Pleural Effusion in the Absence of Lung Disease Prompted Thorough Investigation, Leading to the Identification of an Unusual Etiology. THE CASE: A 35-year-old Alcoholic Male Presented to Emergency Room With 4-day History of Breathlessness Which Was Sudden Onset, Gradually Progressing to Grade-3 Dyspnea on NYHA Scale, Associated With Dry Cough. Hospitalization and Chest Radiograph1 Revealed Gross Right Side Pleural Effusion. Emergency thoracentesis and Intercostal Drainage Tube Placement were done and Patient Was Referred to Pulmonology Department. On further Evaluation, Patient Also Complained of Mild Persistent Left Upper Quadrant Abdominal Pain for More Than 6 Months Which Was Relieved on Medication Hence, Ignoring the Complaint. Thoracentesis Procedure Yielded 1.5l Amylase-rich Fluid in the Pleural Space. The Patient Was Then Referred to Surgical Department for Further Evaluation. Usg Abdomen Was Inconclusive. Lab Reports Revealed Mildly Elevated Pancreatic Enzymes. contrast- Enhanced Computed Tomography (Ct) Scan of the Abdomen and Chest Revealed a Dilated Main Pancreatic Duct and Multiple Direct Communication Between the Pancreatic Duct(see Figures 1) and the Right Pleural Space, Leading to the Formation of Massive Pleural Effusion and Complete Collapse of Right Lung. Rest of the Pancreas Appeared Normal With No Evidence of Calcification. After a Thorough Clinical Evaluation, Laboratory Investigations, and Imaging Studies, the Patient Was Diagnosed With a Pancreaticopleural Fistula. The Patient Was Managed Through a Multidisciplinary Approach Involving Gastroenterology, radiology, and General Surgery Teams. Initial Management Included Aggressive Medical Treatment With Bowel Rest, Total Parenteral Nutrition, Antibiotics and Administration of Proton Pump Inhibitors. The Patient Showed Gradual Improvement Post-drainage, With a Significant Decrease in Pleural Effusion Volume and Resolution of Dyspnea. Follow-up With CT scan Was Advised. The patient Was Subsequently Monitored Continuously With Dietary Recommendations. CONCLUSION: the Chosen Case is Significant Due to Its Diagnostic Intricacies and the Necessity for Collaboration Among Various Medical Specialties. The Management of Pancreaticopleural Fistulas Requires a Tailored Approach. This Case Underscores the Importance of Early Diagnosis, Meticulous Evaluation, and Timely Intervention in Achieving Successful Outcomes for Patients. In conclusion,by Sharing This Case, I Aim to Contribute to the Understanding of This Rare Condition and Emphasize the Significance of Timely Diagnosis and Appropriate Management Strategies.

Successful management of portal hypertension with splenomegaly and cavernous transformation of the portal vein: a rare case report

Abstract Portal hypertension, often stemming from liver cirrhosis or vascular anomalies, can result in cavernous transformation of the portal vein, a rare condition associated with biliary obstruction, variceal hemorrhage, and splenomegaly. This case report details a unique occurrence of portal hypertension, splenomegaly, and cavernous transformation of the portal vein successfully managed through splenectomy and spleno-renal shunt. A 30-year-old female with a history of portal hypertension, portal gastropathy, and splenomegaly presented with left upper quadrant abdominal pain. She had previously undergone esophageal variceal ligation and required intermittent blood transfusions. Additional complications included easy bruising, heavy menstrual bleeding, and a prior episode of hematemesis. Clinical assessment confirmed splenomegaly, while a CT scan confirmed the diagnosis. A tailored surgical approach was chosen, leading to splenectomy and spleno-renal shunt.

Case report on splenic abscess with pleural effusion caused by enteric fever

Splenic abscess is an infrequent complication of enteric fever caused by Salmonella typhi. The incidence rate ranges from 0.14-2%. Clinical manifestations are often nonspecific and may be presented as fever with left upper quadrant abdominal pain and a palpable tender mass. Diagnosis is often difficult and splenic abscess management is based on surgical interventions and antibiotic therapy. In this case report we would like to highlight splenic abscess with left reactive pleural effusion as a rare complication of Salmonella typhi infection.

Splenic abscess due to non-operative management of splenic injury: a case report

BackgroundSplenic abscess is a rare disease, with incidence of 0.2–0.7% in previous studies. It often appears with left upper quadrant abdominal pain, fever, chills. Splenic abscess often happens because of hematogenous spreading of infections, endocarditis, angioembolization and some other rare reasons. Treatment relies on one of these two methods: percutaneous drainage or surgery.Case presentationA 68-year-old diabetic Asian female (Asian woman) presented with generalized abdominal pain, low blood pressure, tachycardia, fever, lethargy and elevated level of blood sugar. She had history of conservative therapy in intensive care unit due to blunt abdominal trauma and splenic injury. She had a huge splenic abscess in ultrasonography and computed tomography scan so she went under splenectomy. Our patient had a splenic abscess without performing any intervention like angioembolization.ConclusionImmune compromised patients who are selected for nonoperative management after splenic injury need close follow up and evaluating about abscess formation for at least 2 weeks. Early diagnosis and treatment with two methods including percutaneous drainage or splenectomy should be considered and it depends on patient’s risk factors, vital signs, general conditions and presence or absence of sepsis.

Splenic lymphangioma in adult patient treated with laparoscopic splenectomy: A rare case report

Splenic lymphangioma is a benign cystic tumor that develops as a result of lymphatic vessels' congenital abnormalities. It is a rare condition that mostly occurs in children and young adults. Due to the lack of typical symptoms and signs, splenic lymphangioma is difficult to diagnose and often incidentally revealed during radiological examinations. We report a case of a 55-year-old Asian female, who presented with left upper quadrant abdominal pain in the past 3 days. She had mild upper abdominal tenderness, with no other specific findings. Abdominal contrast material-enhanced computed tomography revealed three hypodense lesions arising from a normal-sized spleen. The histologic findings after laparoscopic splenectomy demonstrated a 3-cm-diameter yellowish-white tumor made up of multiple cystic structures. Primary benign splenic tumors are exceedingly rare, especially in adults over 20. While small lesions are mostly asymptomatic, bigger lesions can cause organ compression or even rupture. Therefore, even in adults with pain in the left upper quadrant abdomen or enlarged spleen, splenic lymphangioma should be taken into account in the differential diagnosis. The case serves as an example of a rare congenital splenic tumor. Treatment of this benign splenic abnormality with laparoscopic splenectomy is a good, safe approach.

Unusual and extremely rare sites of metastases in gallbladder carcinoma

Gallbladder carcinoma is an aggressive neoplasm that is often diagnosed only in the later stages of the disease progression. Common sites of distant metastases of primary carcinoma gallbladder include lymph nodes, peritoneum and lung. Only a few cases of metastases to adrenal glands and kidneys have been reported in literature. Cutaneous and muscular metastases from gallbladder cancer are also unusual, and an extensive literature search revealed only a few cases to date. We present two such cases of gallbladder carcinoma which presented with metastases to these rare sites at the time of diagnosis which were detected by 18 fluorodeoxyglucose positron emission tomography/ computed tomography (18F FDG PET/CT). The first case is of a 45-year-old lady who presented to the general surgery department with complaints of abdominal pain, loss of appetite and nausea for 2 months. Conventional imaging with ultrasound and contrast-enhanced computed tomography (CECT) of the abdomen showed asymmetric gallbladder wall thickening occupying the fundus and body with extensive regional lymphadenopathy. 18F FDG PET/CT revealed a metabolically active gallbladder mass with bilateral adrenal gland lesions with cutaneous, muscular and skeletal metastases. The second case is of a 35-year-old lady who complained of left upper quadrant abdominal pain and nausea for one month. Successive CECT and Magnetic Resonance Cholangiopancreatography (MRCP) studies made the radiological diagnosis of gallbladder neoplasm. Pre-operative 18F FDG PET/CT showed a metabolically active gallbladder mass with bilateral adrenal gland lesions, lymph node involvement and bilateral renal metastasis. The Third case was 75 years old male who had incidental carcinoma gall bladder on cholecystectomy and PETCT was done for staging, and it showed metabolically active liver SOL, Bilateral adrenal deposits with mediastinal abdominal, retroperitoneal and lymph nodes. The fourth case is a 55 year old female who was diagnosed as neck gall bladder wall thickening on ultrasonography on further evaluation PETCT was done which showed hypermetabolic gall bladder neck wall thickening along with bilateral adrenal lesion and abdominal, retroperitoneal and retro-crural and right supraclavicular lymph nodes. Adrenal and other metastasis detection on 18F FDG PET/CT led to a change in the management from curative surgery to palliative chemotherapy in all patients. Thus,18F FDG PET/CT is a valuable modality in such type of cases that aids decision making regarding staging, appropriate management and monitoring response to therapy.

A Teenager With Acute Abdominal Mass: A Case of Gastro-Gastric Intussusception

A previously healthy 17-year-old boy presented to the emergency department with worsening left upper quadrant abdominal pain, a history of nonbloody, nonbilious emesis for 2 days, more recent bloody emesis for 1 day, and an abdominal “mass.” He had eaten dinner as usual 3 days earlier and gone to sleep. He woke up that morning with abdominal pain and felt a “mass” in the left side of his upper abdomen, which he stated would decrease in size by applying pressure. He started vomiting the same day, which initially contained food contents and exacerbated his pain.

S1708 Combination of Pancreatic and Hepatic Pseudocyst in a Patient With Pancreatitis: A Case Report

Introduction: Pancreatic pseudocysts are common occurrences after episodes of acute pancreatitis. Up to 20% of pseudocysts are extra-pancreatic throughout the abdomen including intrahepatic. There are only a few cases of hepatic pseudocysts reported in the literature. We report this unique case with both pancreatic and intrahepatic pseudocysts occurring at the same time in a patient with pancreatitis. Case Description/Methods: A 56-year-old White woman with history of alcoholism and chronic pancreatitis, presented with epigastric and left upper quadrant abdominal pain radiating to the left shoulder. Examination revealed tenderness in the epigastric and left upper quadrant of the abdomen. Labs showed an elevated lipase of 217 IU/L (13-60), normal total bilirubin and transaminases, hemoglobin of 9.1 g/dL(11.5-15), and slight leukocytosis 12.6 K/uL (3.7-10.4). She was admitted 3 times in the last 4 months. Prior computerized tomography (CT) scan showed pseudocysts in the head and tail of the pancreas. CT scan this admission showed a decreased size of pseudocyst in the pancreatic head from 2.5 cm to 2.2 cm and pancreatic tail from 4.2 cm to 3.7 cm (Figure). It also showed 2 subcapsular fluid collections in the left lobe of the liver measuring 9X5X2cm and 9X7X3 cm. Percutaneous drainage of the hepatic cysts with the placement of a drainage catheter was performed by interventional radiology. 50 mL of bilious appearing fluid was drained with negative gram stain and cultures with an elevated fluid amylase level of 1,765 U/L. The patient’s pain improved and a subsequent CT a few weeks after discharge showed a decrease in the size of the hepatic cysts. Discussion: This is the first documented case of combined pancreatic and intrahepatic pseudocyst formation. Elevated amylase level in the hepatic fluid analysis confirmed the diagnosis of a hepatic pseudocyst. The interesting fact is that the size of the pancreatic pseudocyst decreased as the hepatic pseudocyst increased because of fluid tracking likely in the pre-renal space or along the hepato-gastric ligament. The diagnosis of hepatic pseudocyst needs to be considered in a patient with new hepatic fluid collection with a recent history of pancreatitis and pancreatic pseudocyst.Figure 1.: A – Axial CT showing previous pancreatic pseudocyst prior to admission B – Axial CT showing new hepatic pseudocyst adjacent to falciform ligament during admission C – Axial CT showing drain in hepatic pseudocyst.

Man with Left Upper Quadrant Pain

A 37-year-old man with liver cirrhosis and chronic pancreatitis presented to the emergency department with a 4-day history of dull left upper-quadrant abdominal pain accompanied by fever and chills. Three weeks previously, he had undergone endoscopic retrograde cholangiopancreatography and drainage for obstructive pancreatitis. On examination, his blood pressure was 127/87 mm Hg, pulse rate was 147 beats/min, and temperature was 39.1 °C. He experienced tenderness over the epigastrium and left upper quadrant.

A splenic hamartoma: Adding a new case to the literature: A case report.

IntroductionSplenic tumours are relatively rare and include malignancies such as lymphomas, angiosarcomas, plasmacytomas, primary malignant fibrous histiocytomas, and splenic metastases. Benign tumours of the spleen such as hemangiomas, cysts, and inflammatory pseudotumours are very rare (Kaza et al., 2010, PisaniCeretti et al., 2012) [1], [2]. There are fewer than 160 cases of splenic hamartoma or splenomas having been reported in the literature (Basso et al., 2012) [3]. Only 20% of the cases were detected in children (Abramowsky et al., 2004) [4]. Although multi-modality imaging findings were described preoperatively, the final diagnosis was splenic hamartoma based on histology and immunohistochemistry.Case reportHere, we report a case of a14 year old child left upper quadrant abdominal pain and worsening sickness. Multi-modality imaging detected a solid lesion of the spleen, who required splenectomy and was pathologically diagnosed as a splenic hamartoma. The postoperative course was uneventful.DiscussionSplenic hamartoma is very rare. Only 20% of hamartomas occur in children. They are commonly found incidentally on imaging with no symptoms.ConclusionSplenic hamartoma is a benign vascular proliferative lesion that requires a multi-modality imaging studies for diagnosis and confirmed by histopathology. It must be included in the differential diagnosis of splenic mass forming lesions.

Splenic Abscess, an Important Differential Diagnosis of Left Upper Quadrant Abdominal Pain

<p>脾膿瘍是很少見的疾病，但若延誤診斷則有高致死率，好發於免疫功能不全患者譬如有糖尿病或肝硬化等疾病。由於糖尿病及癌症盛行率的增加及免疫抑制劑的使用，使得脾膿瘍盛行率有逐漸增加的趨勢。</p> <p>本篇個案報告為一位56歲男性，過去有高血壓及酒精性肝硬化病史，此次因畏寒、倦怠及左上腹痛至門診就醫。理學檢查發現肝脾腫大，超音波顯示肝臟腫大且邊緣不規則，脾臟有一個低迴音性病灶，經腹部電腦斷層證實為多葉型脾膿瘍。病人住院後，接受超音波導引之膿瘍引流及使用抗生素治療，順利出院。希望藉此個案報告，讓基層醫師在鑑別診斷左上腹痛時，能想到可能是少見但有致命危險的脾膿瘍，尤其是遇到肝硬化、糖尿病或免疫不全病史的病人。</p> <p> </p><p>Splenic abscess is an uncommon but complicated disease whose risk of mortality increases with delayed diagnosis and treatment. Splenic abscess occurs mainly in patients with immunocompromised conditions like diabetes mellitus and liver cirrhosis. Due to increased prevalence of diabetes mellitus and cancer, and increased immunosuppressant agent use as well, the risk of splenic abscess has been rising recently.</p> <p>A 56-year-old male patient, who had hypertension and alcoholic liver cirrhosis visited our outpatient department with complaints of chillness, fatigue, and left upper quadrant abdominal pain. Physical examination revealed hepatomegaly and splenomegaly. Abdominal sonography showed hepatomegaly with an irregular surface and hypoechoic lesions in spleen. Abdominal computed tomography showed multiloculated splenic abscess. After admission, sonography-guided splenic abscess drainage was performed smoothly and antibiotic treatment was also given. The patient was discharged after successful treatment, In conclusion, when physicians encounter patients with left upper abdominal pain, splenic abscess, though uncommon, can be excluded only after careful and thorough examination; this is especially the case with patients with liver cirrhosis, diabetes mellitus, or immunocompromised condition.</p> <p> </p>

S2803 An Uncommon Presentation of a Common Illness: Epstein-Barr Virus Resulting in Splenic Infarction

Introduction: When a patient presents with fever, malaise, sore throat a viral etiology may come to mind. Findings of splenomegaly, elevated liver enzymes and lymphadenopathy may even point towards Infectious Mononucleosis, especially in a patient in their teens and early twenties. However, when a patient in their fifties presents with fever, transaminitis and imaging revealing splenic infarction, does Infectious Mononucleosis come to mind? Here is why it should. Case Description/Methods: Our patient is a fifty-seven year old female with a past medical history of monoclonal gammopathy of undetermined significance (MGUS) who presented to the emergency department for evaluation of abnormal liver enzymes noted by her hematologist/oncologist on routine outpatient blood work. Her aspartate transaminase (AST) was 1241 and alanine transaminase (ALT) was 1372 on presentation. She complained of fever, malaise and left upper quadrant abdominal pain. Imaging of her abdomen revealed a liver without focal abnormality and a small wedge shaped hypodensity in the spleen likely representing a small splenic infarct. The gastroenterology service was consulted for further evaluation of her transaminitis. A chronic liver disease workup was negative for viral hepatitides, autoimmune hepatitis and several rheumatological conditions. A urine toxicology screen, tylenol level and alcohol level were unremarkable. Other etiologies including drug induced liver injury and shock liver were also ruled out. Given her sore throat, Epstein-Barr Virus (EBV) test was ordered and results confirmed Infectious Mononucleosis as the etiology of her presenting symptoms. Our patient was managed conservatively and her liver function tests continued to downtrend with AST and ALT in the 200s on day of discharge. Patient was seen by hematology who recommended three months of anticoagulation for splenic infarction due to Infectious Mononucleosis, a rare complication with only a few reported cases. Discussion: Although Infectious Mononucleosis is often considered a benign, self-limiting viral illness, it is important to rule out splenic infarction which can result in serious and even life threatening complications. With early diagnosis and management of EBV complicated by splenic infarction our patient was followed outpatient with notable improvement in her presenting symptoms and normalization of her liver enzymes.Figure 1.: Computed Tomography (CT) imaging of our patient's abdomen and pelvis revealing a small hypodensity in the spleen likely representing splenic infarction.

S1521 Solid Pseudopapillary Neoplasm: Case Report of a Rare Pancreatic Tumor

Introduction: Solid pseudo-papillary neoplasm (SPN) is a rare low-grade malignant cystic exocrine neoplasm of the pancreas with a distinctive pathologic architecture. It is usually diagnosed incidentally, and complete resection is mainly curative with excellent long-term prognosis despite a small malignant potential. Case Description/Methods: A 28 yo female with history of lumbar disc herniation and subsequent micro-discectomy, presented to the emergency department with a 1-day history of severe left upper quadrant abdominal pain, nausea, and vomiting. She denied any other symptom or previous trauma. On physical examination, the abdomen was soft with mild tenderness in LUQ, and no rebound or palpable mass. Lab evaluation showed a mild leukocytosis (16.5K), but otherwise liver tests and pancreatic enzymes were within normal limits. CT scan showed an obstructing ureteral calculus and a large 7.1 cm incidental mass in the pancreatic tail with chronic splenic vein occlusion. MRCP later confirmed a 6.8 x 7.5 x 7.7 cm heterogeneous but well defined/encapsulated arising from the pancreatic tail/distal body. The lesion had heterogeneous enhancement, diffusion restriction, and areas of T1 hyperintensity. The patient successfully underwent a laparoscopic distal pancreatectomy and splenectomy and was discharged home after 3 days. Pathology confirmed the suspected diagnosis of SPN of the pancreas with samples negative for foci of malignancy. Immuno-histochemical stains revealed tumor cells to be positive for beta-catenin, cyclin D1, CD10 and synaptophysin, while negative for chromogranin. Discussion: SPN is considered a low-grade malignant pancreatic tumor according to the WHO Classification of Digestive System Tumors, with reported malignant transformation of around 15-16%. Despite this, SPN still has a generally excellent long-term prognosis. SPNs have a characteristic appearance on cross-sectional imaging, appearing as a mixed solid and cystic pancreatic lesion, however cytologic analysis is usually done for confirmation of the diagnosis. The use of pre-operative biopsy or EUS-FNA has been controversial and is felt to be of limited benefit. In our patient, the post-operative cytologic diagnosis after surgery proved valuable for establishing the diagnosis with no need for pre-operative EUS-FNA. Treatment usually is surgical resection, which is curative; appropriate clinical follow-up is warranted due to risk of local recurrence. There is no clear role for systemic chemotherapy, hormonal therapy, or radiotherapy.Figure 1.: A. MRI abdomen and pelvis with contrast T2 Coronal showing a heterogenous well defined and encapsulated partially exophytic mass arising from the pancreatic tail/distal body. B. Axial LAVA (3D T1 weighted sequence with Fat Suppression) pre-contrast. C. LAVA post-contrast Figure 2-D. Solid sheet of uniform tumor cells showing focal loosely cohesive pseudopapillary architecture (Hematoxylin & Eosin, x 100). E. Nuclear and cytoplasmic immunoreactivity for B-catenin (B-catenin immunohistochemical stain, x 200).

S2969 Abdominal Pain: A Silent and Unlikely Cause

Introduction: While diverticulosis is commonly found in the large intestine it is a rare disease found in the small intestine accounting for only 0.06-1.3% of cases. Although most cases are asymptomatic, roughly 30-40%, it is crucial that it is on the differential of acute abdominal pain as it can be life threatening and potentially require surgical management. Case Description/Methods: On initial visit to the emergency room a 61 year old Hispanic male was found to have a perforated jejunal diverticula on Computed Tomography (CT) scan after initially presenting with left upper quadrant abdominal pain. He had a past medical history of hypertension and Helicobacter pylori (H. Pylori) gastritis found on esophagogastroduodenoscopy (EGD) in 2019. His past surgical history was significant for an exploratory laparotomy 25 years ago secondary to a gunshot wound in his right upper quadrant. The pain initially began in his left upper quadrant and progressed to diffuse abdominal pain. He was hemodynamically stable, afebrile and saturating well on room air. A CT scan was performed in the emergency department which displayed a perforated duodenal ulcer at the distal 3rd/4th segment of the duodenum with small surrounding retroperitoneal air and mild fat stranding. He was admitted under the surgery department and taken to the operating room. Upon dissection of the duodenum, approximately 5cm from the ligament of Treitz, a microperforation was seen which was consistent with a mesenteric jejunal diverticulum. Discussion: Jejunal Diverticulosis is a rare phenomena that can lead to life threatening complications. As most cases are asymptomatic and often miss diagnosed it is imperative that physicians consider it as a differential when the diagnosis of abdominal pain or acute abdomen is presented.Figure 1.: What was thought to be a perforated duodenal ulcer and a thin wisp of contrast adjacent to three extraluminal foci of gas, denoted by the yellow arrow, which turned out to be a perforated jejunal diverticula visualized during surgery.

Abstracts and Case Studies for the College of American Pathologists 2021 (CAP21) Annual Meeting

The following abstracts and case studies were accepted for the CAP21 Virtual Abstract Program. Shown before each poster session are the subject areas for that session.(Poster No. 1)Haiyan Lu, MD, PhD1 (yanhailv@gmail.com); Breanna Perlmutter, MD2; Robert Naples, MD2; Toms Augustin, MD2; Daniela Allende, MD.1 Departments of 1Pathology and 2General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.Context: Gallbladder adenocarcinoma has a poor overall survival (<5% at 5 years). We aim to design a risk-stratification model with novel and traditional features.Design: We retrospectively identified 57 gallbladder adenocarcinoma resection specimens from January 2009 through December 2017 at Cleveland Clinic Foundation. Clinical data were gathered and histologic features were obtained. Involvement by adenocarcinoma was defined as localized when a single anatomic region; remaining cases were considered diffuse. Kaplan-Meier analysis was used to estimate overall survival (OS) by using XLSTAT. Patients were risk stratified by using 2 prediction models, and receiver operating characteristic curve and area under the curve (AUC) were used to compare the models. P < .05 was considered statistically significant.Results: Of the 57 cases, 25 patients (43.9%) had localized disease at resection, whereas the rest had diffuse involvement of the gallbladder. The median follow-up was 29.7 months (range, 3.5–122 months). Twenty-six patients (45.6%) were dead from disease, with a median survival of 22.9 months (range, 3.8–61.5 months). Significant predictors of worse OS included diffuse involvement (P < .001), advanced stage (P = .02), and moderate to poor differentiation (P = .02). Lymphovascular invasion (LVI) showed a trend toward significance (P = .08). The risk-stratification model 1 (localized/diffuse extend of tumor, T stage, and tumor grade) provided better prediction for outcome (AUC = 0.721, P = .001) than model 2 (model 1 plus LVI) (AUC = 0.685, P = .009) (Table).Conclusions: Diffuse involvement, advanced stage, and moderate to poor differentiation are independent prognostic factors of worse outcome in gallbladder adenocarcinoma. Our risk-stratification model (disease extent, T stage, and tumor grade) provides substantial prediction on outcome.(Poster No. 2)Haiyan Lu, MD, PhD (yanhailv@gmail.com); Daniela Allende, MD; Xuefeng Zhang, MD, PhD. Department of Pathology, Cleveland Clinic Foundation, Cleveland, Ohio.Context: Diabetes mellitus (DM) is a risk factor for pancreatic cancer, but its impact on postoperative outcomes remains controversial. It is unknown if prediagnostic diabetic status affects patient survival in tumors with any specific pathologic features.Design: We retrospectively identified 507 patients with pancreatic ductal adenocarcinoma (PDAC) between January 2008 and December 2018 at Cleveland Clinic Foundation. Clinical data and pathologic features were compared between patients with and without DM prior to the diagnosis. Statistical analysis was performed using IBM SPSS Statistics 19. Overall survival was compared in DM and non-DM groups using Kaplan-Meier analysis in XLSTAT. P < .05 was statistically significant.Results: In the cohort, 187 patients were diagnosed with DM prediagnostically and 320 patients stayed nondiabetic status prior to the diagnosis. Patients with DM tended to demonstrate worse overall survival (P = .06). In male patients, DM tended to negatively affect patients' overall survival (P = .06). Among the pathologic features, DM status was significantly related to a worse survival in patients with poorly differentiated carcinoma (P = .03), lymphovascular invasion (P = .02), or lymph node metastasis (P = .045). In patients with pT1 tumors defined by AJCC 7th or AJCC 8th edition, DM was significantly associated with a worse survival (AJCC 7th, P < .001; AJCC 8th, P = .04). In patients with AJCC 8th T2 tumor, there was a tendency that DM negatively affected patients' survival rate (P = .06) (Table).Conclusions: Prediagnostic DM status is associated with worse survival in PDAC patients with poorly differentiated carcinoma, lymphovascular invasion, or lymph node metastasis. DM tends to negatively affect survival rate in male patients and in patients with pT1 and pT2 tumors (AJCC 8th).(Poster No. 3)Subramanya Sakaleshpura Mallikarjunappa, MD (drsubramanyasm@gmail.com); Lin Cheng, MD, PhD; Shriram Jakate, MD. Department of Pathology, Rush University Medical Center, Chicago, Illinois.Context: Traditional serrated adenomas (TSAs) are the rarest of all the serrated polyps with distinctive endoscopic (“pine cone–like”) and histologic features. However, TSAs are underdiagnosed and the assessment of dysplasia in TSA is disputed. We retrospectively evaluated 62 TSAs to assess their clinicopathologic characteristics and associations.Design: A review of our database from 2014 through 2020 found 62 patients (32 men, 30 women, ages 34–84 years) diagnosed with TSA. Their clinical presentation, endoscopic/morphologic findings, sizes, multiplicity, distribution, associated other polyps, surveillance frequency, degree of dysplasia, and potential progression to invasive carcinoma were reviewed.Results: Most cases (59 of 62) were incidentally detected on screening colonoscopies. Polyps were 3–40 mm (mean, 12 mm). TSAs >10 mm were cold or hot snared and showed characteristic endoscopic pine cone appearance. Fifteen patients (24%) had solitary TSA and the rest showed other conventional adenomas and/or SSAs (76%). The majority (85%) of TSAs were in the distal colon: sigmoid (21), rectosigmoid (4), and rectum (28). All TSAs showed typical histologic features including ectopic crypt formation, slitlike serrations, elongated penicillate nuclei, and eosinophilic cytoplasm. Only 1 of 62 cases (1.6%) showed high-grade dysplasia.Conclusions: TSAs are incidentally detected on screening colonoscopy and are often associated with other conventional polyps than solitary TSA. Most TSAs are located in the sigmoid colon and rectum. High-grade dysplasia appears to be quite rare, even in large TSAs. Multicenter long-term studies are needed to evaluate the true risk of colorectal carcinoma in these unique polyps.(Poster No. 4)Miao Cui, MD, MS1 (Miao.Cui@mountsinai.org); Isaak Heon, DO2; Binny Khandakar, MD3; Daniel Chung, MD4; Jihong Sun, MD.2 1Department of Pathology, St Luke's-Roosevelt Hospital Center, Icahn School of Medicine at Mount Sinai, New York, New York; 2Department of Pathology, Mount Sinai West, New York, New York; 3Department of Pathology, Mount Sinai St. Luke's Roosevelt Hospital, New York, New York; 4Department of Pathology, Mount Sinai West, Icahn School of Medicine, New York, New York.Context: Pyloric gland adenoma (PGA) is a rare neoplasm of the gastric mucosa, involved in the gallbladder (GB), main pancreatic duct, and duodenum. Intracholecystic lesions of >1 cm are identified as intracholecystic papillary-tubular neoplasms (ICPNs), and lesions <1 cm are referred to pyloric gland hyperplasia/metaplasia. Our study aims to compare groups of PGA/metaplasia (<1 cm) in the GB and the luminal counterpart.Design: A retrospective study included cases of PGA or metaplasia at Mount Sinai West, New York, from January 1, 2000, to June 30, 2020. PGA from GB, >1 cm, or ICPN were excluded. Clinicopathologic parameters were analyzed, including age, gender, location of lesion, dysplasia, and the number of lesions (1/>1).Results: Forty-one cases (Table) were included. Among them, 14 cases were from both GB and duodenum, and 13 were from the stomach only. The mean age of presentation was 73 years. The mean age of GB, stomach, and duodenum groups was 59, 85, and 70 years, respectively. Chronic cholecystitis was present in 85% of cases. All cases involving the GB were >0.3 cm, with 6 cases >0.5 cm and another 4 cases 0.3–0.5 cm.Conclusions: According to our study, the terminology of “PGA” in the GB could aptly describe the lesions that are purely composed of pyloric glands in the GB, which may represent a true benign tumor rather than an inflammatory metaplastic process. “Adenoma” could be applied for mixed lesions, with overlapping morphology composed of an admixture of pancreaticobiliary and pyloric type, based on size or molecular signature.(Poster No. 5)Catherine E. Turner, MS (cet288@health.missouri.edu); Deepthi Rao, MD; Feng Yin, MD. Department of Pathology and Anatomic Sciences, University of Missouri–Columbia.Amyloidosis defines a group of disorders characterized by extracellular misfolded protein deposition, such as AL, AA, ATTR, and Aβ2M proteins. Clinical manifestations depend on the biochemical composition and site of deposition. Common sites include kidney, heart, and liver, but gastrointestinal amyloidosis is rare. The overall incidence of primary amyloidosis is 9 new cases per million persons, and involvement of gastrointestinal tract is exceptionally rare, with only an incidence of less than 1 per million. A 62-year-old man with past medical history of diverticulitis and colon resection presented to his physician with blood per rectum, unintentional weight loss, nausea, and vomiting for 1 month. He underwent esophagogastroduodenoscopy and colonoscopy. Biopsies of stomach and colon showed waxy, pale eosinophilic extracellular aggregates on microscopy (Figure 1.5, A), suggestive of amyloidosis, confirmed by Congo red staining (Figure 1.5, B) with apple-green birefringence in polarized light (Figure 1.5, C). These amyloid fibrils had a nonbranching, antiparallel twisted, β-pleated sheet configuration. Additional organ involvement was not found with imaging. This patient had no previous medical history of chronic inflammation, hematologic malignancy, renal disease, or family history, and the absence of risk factors suggested primary amyloidosis. The patient's κ:λ ratio and serum electrophoresis were unremarkable, proving primary amyloidosis. To our knowledge, this was the first ever reported case of gastric amyloidosis at University Hospital (Columbia, Missouri). Recognizing amyloidosis in a differential diagnosis is important, as early recognition of this disorder could prevent further complications for the patient, shorten time to diagnosis, and explore management options in an efficient manner.(Poster No. 6)Alexander Reese, DO1 (ahreese@usf.edu); Nushani Jaryatne, MD1; Kun Jiang, MD, PhD.2 1Department of Pathology, University of South Florida, Tampa; 2Department of Pathology, Moffitt Cancer Center, Tampa, Florida.Context: Gastrointestinal graft-versus-host disease (GVHD) poses a significant clinical and pathologic challenge following allogeneic hematopoietic transplantation. GVHD diagnosis requires clinical, laboratory, and histopathologic confirmation. Endoscopy has been fundamental in ensuring accurate diagnoses in numerous entities; however, an established correlation between endoscopic findings and GVHD remains undetermined.Design: The endoscopic findings of 185 histopathologically confirmed GVHD and 11 viral enterocolitis cases were reviewed retrospectively.Results: Among the 185 GVHD cases, 146 were grade 1, 26 were grade 2, 8 were grade 3, and 5 were grade 4. In the grade 1 cases, endoscopy was “normal” in 111 (76%) and abnormal in 35 (24%). Among the grade 2 cases, 21 were endoscopically “normal” (81%) whereas 5 appeared focally abnormal (19%). In the grade 3 cases, 6 (75%) were still considered “normal” and 2 abnormal (25%). Lastly, in the grade 4 cases a “normal” endoscopy was documented for 3 (60%), whereas an abnormal endoscopy was confirmed in only 2 (40%). Overall, endoscopic examination was “normal” in 141 of 185 GVHD cases (76%) and abnormal in only 44 (24%). Notably, in all 11 viral enterocolitis cases (7 cytomegalovirus and 4 adenovirus cases in which GVHD was clinically suspected), endoscopy was “normal.”Conclusions: To summarize, neither a satisfactory endoscopic sensitivity nor specificity was observed in the 185 GVHD cases; therefore, no correlation can be established between endoscopic findings and histopathologic GVHD. Furthermore, endoscopic abnormities are not only restricted to GVHD, but are also seen with infection, drug, and chemical-related injuries. Astute histopathologic inspection and ancillary tests remain the gold standard for discerning GVHD from its various mimickers.(Poster No. 7)Eric Ollila, MD1 (eollila@uabmc.edu); Abrar Alghamdi, MD1; Sameer Al Diffalha, MD1; Samuel Borak, MD.2 1Department of Pathology, University of Alabama at Birmingham; 2Department of Pathology, University of Alabama at Birmingham, Montgomery.Langerhans cell histiocytosis (LCH) is a group of idiopathic disorders characterized by an abnormal proliferation of dendritic mononuclear cells that mostly involves the skin and bones. Involvement of the gastrointestinal tract by LCH is exceedingly rare, and few cases have been reported. Here, we present 2 cases of LCH with gastrointestinal involvement and BRAF testing. The first case involves a 51-year-old man who presented with intermittent abdominal pain. Five polyps were found on colonoscopy. Histopathologic examination revealed an infiltrate in the lamina propria consisting of small to intermediatesized cells with variably irregular and focally reniform nuclei, with occasional nuclear grooves and mild amount of cytoplasm (Figure 1.7, A and B). Occasional mitotic figures and scattered eosinophils were present. These cells were immunohistochemically reactive with CD1a (Figure 1.7, C), S-100 (Figure 1.7, D), and CD43. BRAF testing was positive for the V600E mutation. The second case involves a 76-year-old woman who presented with a history of anemia and multiple episodes of C difficile colitis that resulted in gastrointestinal distress and weight loss. Two polyps were found on colonoscopy. Histopathologic examination revealed active inflammation involving surface epithelium and underlying crypts surrounded by prominent histocytes. These cells were reactive with S-100 and CD1a. BRAF testing results were negative. Although involvement of the gastrointestinal tract by LCH is rare, it should be considered in the differential diagnosis when a histiocytic proliferation is present. To our knowledge, these are the first cases of lower gastrointestinal tract involvement in polyps by LCH with reported BRAF testing, which may prove helpful in diagnosis and treatment.(Poster No. 8)Jiani N. Chai, MD, PhD1 (jichai@montefiore.org); Linlin Yang, MD, PhD2; Shaomin Hu, MD, PhD3; Yanhua Wang, MD, PhD1; Qiang Liu, MD1; Xuejun Tian, MD, PhD.1 1Department of Pathology, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York; 2Department of Pathology, The MetroHealth System, Cleveland, Ohio; 3Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio.Context: EZH2 is a histone methyltransferase associated with a poorer prognosis in several cancers. The regulation of EZH2 in colorectal cancer is unknown. Here we investigated EZH2 expression in colorectal cancer and its association with MYC, p-MAPK, and p-STAT3, potential regulators of EZH2.Design: One hundred fourteen colorectal cancer cases were collected. Immunohistochemical staining for EZH2, MYC, p-MAPK, p-STAT3, and Ki-67 was performed. EZH2 overexpression was defined if ≥60% neoplastic cells exhibited moderate to strong staining. MYC was positive if ≥40% neoplastic cells displayed moderate to strong staining. Statistical analysis was performed using Fisher exact test and Pearson correlation coefficient by Graphpad Prism (San Diego, California).Results: Eighty-six of 108 cases (79.6%) overexpressed EZH2. EZH2-overexpressed cases were more abundant in the moderate, moderate to poor/poor groups as compared with the well-differentiated tumor (P < .05) (Figure 1.8, A). Furthermore, EZH2 expression correlated positively with Ki-67 (P < .05) (Figure 1.8, B). We then investigated EZH2 expression in association with MYC, p-MAPK, and p-STAT3. Sixty-three of 103 cases (61.2%) expressed MYC, whereas very few expressed p-MAPK (2 of 104) or p-STAT3 (1 of 106). Among EZH2-overexpressed cases, 59 of 82 (72%) coexpressed MYC. EZH2 expression correlated positively with MYC (P < .001) (Figure 1.8, C). MYC also showed a positive correlation with Ki-67 (P < .01) (Figure 1.8, D).Conclusions: EZH2 overexpression is associated with more aggressive behavior in colorectal cancer, as indicated by the correlation with Ki-67 and tumor grade. Furthermore, MYC-related signaling, not p-MAPK or p-STAT3, might be involved in EZH2 regulation and correlated with tumor progression. Therefore, EZH2 and MYC could serve as potential prognostic and therapeutic targets for colorectal cancer.(Poster No. 9)Maria F. Gonzalez, MD1 (maferg13@yahoo.com); Allison L. Kerper, MD.2 Departments of 1Pathology and 2Medicine, College of Medicine, University of Illinois at Chicago.Context: Although the national incidence of colorectal cancer (CRC) has decreased in recent years, it remains the fourth most common cancer in the United States. The objective of this study is to identify if there is a statistically significant difference in the pathologic and molecular findings of CRC by race and ethnicity at our institution.Design: Patients with CRC resected from 2016 to 2019 were divided into 4 groups: white/non-Hispanic or Latino (N-HL), black/N-HL, Asian/N-HL, and other/HL. Risk factors, tumor location, grade, stage, size, invasion, and mutations were compared.Results: A total of 138 patients were included. A higher percentage of the tumors were located in the rectum in Asians/N-HL and others/HLs. In blacks/N-HL and whites/N-HL, CRCs were located in the right and left colon, respectively. CRC was resected earlier in whites/N-HL (60.0) and blacks/N-HL (61.7). Rectal carcinomas were more symptomatic and presented earlier (50s–60s) than colonic carcinomas (60s–70s), especially in whites/N-HL. In contrast, blacks/N-HL and Asians/NH-L showed a later peak in age for rectal cancer (70–79) than colon cancer (50–59). Most cases were diagnosed at early stages in blacks/N-HL and other/HL. Twenty-two patients (15.9%) had young-onset CRC. Most of the CRCs were microsatellite stable. Microsatellite-instable-high CRC (14.5%) presented as advanced well/moderately differentiated rectal carcinomas in blacks/NHL (Table).Conclusions: Our study demonstrates that the pathologic parameters for the examination of CRC described by the College of American Pathologists do not display statistically significant differences among races/ethnicities. The high percentage of CRC in the rectum in white/NHL, Asian/N-HL, and other/HL has important implications for CRC screening via rectosigmoidoscopy.(Poster No. 10)Xiaobang Hu, MD, PhD1 (xiaobang.hu@phhs.org); Elena Lucas, MD1; Amarpreet Bhalla, MD2; Maria Westerhoff, MD3; ILKe Nalbantoglu, MD4; Nicole Panarelli, MD2; Jerome Cheng, MD3; Suntrea Hammer, MD1; Purva Gopal, MD, MS.1 1Department of Pathology, UT Southwestern Medical Center, Dallas, Texas; 2Department of Pathology, Albert Einstein/Montefiore Medical Center, Bronx, New York; 3Department of Pathology, University of Michigan, Ann Arbor; 4Department of Pathology, Yale School of Medicine, New Haven, Connecticut.Context: A preliminary study by our group suggested for patients with biopsy diagnosis of active or inactive chronic gastritis (CG) with a pattern that is highly suggestive of Helicobacter pylori (HP) infection but negative HP immunohistochemistry (IHC), a comment raising the possibility of HP infection can change the clinical management.Design: We conducted a retrospective comparison study of patients from an academic center in the South (group 1) to 3 centers in the Midwest/Northeast (group 2), all with a diagnosis of CG with negative HP IHC.Results: A total of 19.2% of group 1 patients and 56.8% of group 2 patients were on a nonsteroidal anti-inflammatory drug (NSAID) prior to biopsy (P < .01), whereas 36.4% of group 1 patients and 63.9% of group 2 patients were on a proton pump inhibitor (PPI) prior to biopsy (P < .01). Group 1 patients more frequently had HP history (47.4% versus 21.6%, P < .01). After the diagnosis, 48.7% of group 1 and 11.1% of group 2 received treatment (P < .001). Of those treated, 14.1% and 6.7% received HP treatment, respectively (triple or quadruple therapy; P > .05). In cases with a comment in the pathology report raising the possibility of HP, patients from the South received HP treatment more often as compared with cases without a comment (25.6% versus 2.6%, P < .01). This trend is similar for the Midwest/Northeast institutions (14.3% versus 0%, P = .06) (Table).Conclusions: Our data suggest a regional difference in patient management after diagnosis of CG with negative HP IHC in that patients from the South were more frequently treated. A comment in the pathology report describing HP-pattern gastritis despite negative HP IHC increased HP treatment, especially in the South.(Poster No. 11)Khairya Fatouh, MD (khairya.fatouh@ascension.org); Sulmaz Zahedi, MHSs; Basim Al-Khafaji, MD. Department of Pathology, Ascension St. John and Medical Center, Detroit, Michigan.Colonic mixed neuroendocrine-nonneuroendocrine neoplasms are a rare entity. The term has evolved with the World Health Organization adopting the current nomenclature in 2017. We present a case of a 59-year-old woman who presented with acute abdomen and a perforated viscus. Explorative laparotomy revealed 2 right colon masses with tumor seeding of multiple peritoneal sites. Histologic evaluation of the tumor identified 2 components, one forming 40%, consisting of sheets of poorly differentiated small hyperchromatic cells with conspicuous nuclei, admixed with a conventional colonic adenocarcinoma; both involved the full thickness of bowel wall and invaded into peri-colonic fibroadipose tissue. Strong positive staining of immunohistochemical markers synaptophysin, chromogranin, CD56, cytokeratin AE1/AE3, cytokeratin 20, and with focal positivity for CDX2 and negativity for TTF-1, was identified in the neuroendocrine component, whereas the conventional adenocarcinoma was positive only for Ber-EP4, CDX2, cytokeratin AE1/AE3, and cytokeratin 20. Additionally, Ki-67 showed 100% positive staining within the entire tumor. Subsequently, the patient developed seizures associated with brain metastasis and expired 2 months later. Mixed neuroendocrine-nonneuroendocrine neoplasms with a poorly differentiated neuroendocrine component are associated with an extremely poor prognosis with an average of 4.5-month survival in patients with stage 4. Mixed neuroendocrine-nonneuroendocrine neoplasm is a rare entity that requires diligent histologic evaluation to identify the neuroendocrine component histologically and immunohistochemically. Although the current criteria suggest a minimal 30% portion of each component, further clinical and histopathologic studies are required to validate these measures and establish appropriate therapy regiments.(Poster No. 12)Irene Y. Chen, MD (irene_chen@urmc.rochester.edu); Xiaoqing Liu, MD, PhD; Sierra Kovar, MS, CT(ASCP); Xiaoyan Liao, MD, PhD. Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York.Context: Appendiceal goblet cell adenocarcinoma (GCA) is a unique tumor composed of gobletlike cells. The 2019 World Health Organization criteria recommend a 3-tiered grading system based on proportion of low-grade and high-grade patterns. We aim to validate this grading schema with correlation to tumor stage, immunohistochemistry, and patient survival.Design: All cases of GCA staged pT3 and above were retrieved (2005–2020). P values <.05 were considered significant.Results: Our cohort consisted of 13 males and 12 females with median age of 62.5 years. Pathologically, 13 were pT3 and 12 were pT4, with 9 cases (36%) demonstrating lymph node and/or distant metastasis. Clinically, 15 (60%) were stage II, 4 (16%) stage III, and 6 (24%) stage IV. Using the 3-tier grading system, 10 (40%) were G1, 7 (28%) G2, and 8 (32%) G3. Immunohistochemically, all cases were mismatch repair proficient. Loss of nuclear SMAD4 expression and abnormal p53 expression occurred at equally low frequencies (n = 3, 12% each). Seven cases (28%) showed nuclear β-catenin positivity. The Ki-67 index (range, 1%–80%) were tiered into low (<5%, n = 8), intermediate (5%–20%, n = 10), and high (>20%, n = 7). Statistically, the histologic grade correlated with clinical stage (P < .001), but not with sex, age, Ki-67 index, or nuclear SMAD4/p53/β-catenin abnormalities. The histologic grade, T stage, lymph, node and distant metastasis were associated with reduced survival (P < .05).Conclusions: The current grading system for GCA correlated well with clinical stage and disease outcomes. A small percentage of GCA demonstrated nuclear SMAD4, p53, or β-catenin abnormalities, which did not correlate significantly with histologic grade, tumor stage, or patient survival.(Poster No. 13)Abdullah Osme, MD (abdullah.osme@uhhospitals.org); Wei Xin, MD, PhD. Department of Pathology, University Hospitals Cleveland Medical Center/Case Western University, Cleveland, Ohio.Primary pancreatic signet ring cell carcinoma (PPSRCC) is a rare histologic variant of pancreatic ductal adenocarcinoma. We report a case of PPSRCC in a 52-year-old woman with a confirmed personal history of hereditary nonpolyposis colorectal cancer with MSH2 germline mutation. The patient had abdominal pain, and computed tomography showed a pancreatic body mass. Ultrasound-guided fine-needle aspiration (FNA) biopsy of the pancreas was nonconclusive. Eventually, the patient underwent distal pancreatosplenectomy. Gross examination revealed a tan-white, poorly demarcated and unencapsulated mass located at the body, measuring 1.9 × 1.4 × 1.0 cm, and obstructing the pancreatic duct. Hematoxylin-eosin sections showed a polypoid mass occupying the pancreatic duct consisting of a predominant signet ring cell carcinoma. There was also some well-differentiated ductal adenocarcinoma component (20%). Because of the tumor obstruction of the pancreatic duct, distal pancreas showed extensive chronic pancreatitis. Immunostains showed the loss of MSH2 and MSH6 in the signet ring cell carcinoma with proper positive background staining. The patient did not have signet ring cell carcinoma in other parts of the gastrointestinal (GI) tract. Therefore, this is a primary signet ring cell carcinoma in a Lynch syndrome patient. The most common signet ring carcinoma site is the stomach and occasionally can be found in other parts of the GI tract, but pancreas is a rare place for the primary signet ring cell carcinoma. Lynch syndrome tends to be associated with poorly differentiated carcinoma, including signet ring cell carcinoma in colon, but has not been reported in pancreas. It imposes a diagnostic challenge for FNA cytology and frozen section if not aware of this rare variant.(Poster No. 14)Yan Wang, MD (ywang3@metrohealth.org); Ali Shahabi, MD; Agnes Loeffler, MD, PhD. Department of Pathology, Metrohealth Medical Center, Cleveland, Ohio.Context: During the past 3 decades, multiple diagnostic terms have been applied to the entity we now call low-grade or high-grade appendiceal mucinous neoplasm (LAMN/HAMN). We undertook this study to understand the rate of adoption of World Health Organization guidelines regarding the reporting of this entity in a community practice setting.Design: We conducted a retrospective study of all the neoplastic appendiceal cases in a county hospital in Cleveland from 1999 to 2019. The cases were reviewed by 3 pathologists, including 1 gastrointestinal pathologist. In the cases of appendiceal mucinous neoplasm, we compared the terminology used at the time of diagnosis with contemporary nomenclature and grading.Results: A total of 32 patients with appendiceal mucinous neoplasia were identified (LAMN [n = 30] and HAMN [n = 2]), 13 of these since 2010. Twenty-six of the cases (81.2%) would now receive another name, and of these, there were diagnostic discrepancies in 5 cases (19.2%) (Table). Anachronistic terminology continued to be used at least until 2019 (7 of 13 cases; 53.8%). None of these changes would have had an impact on the further management or clinical follow-up of the patients.Conclusions: Despite frequent updates and consensus guidelines for pathologic assessment of appendiceal mucinous lesions, in the past 2 decades there has been considerable confusion around how these entities should be named and graded. Our findings suggest that pathologists should consider a second opinion in these unusual cases, especially since a history of terminologic abundance has created inconsistency in the diagnostic approach to the entity.(Poster No. 15)Bitania Wondimu, MD (bmw35@uw.edu); Benjamin Bradley, MD, PhD; Joshua Lieberman, MD, PhD; Seth Cohen, MD, MSc; Lynda Bui, MLS; Deepti Reddi, MD. Department of Pathology, University of Washington Medical Center, Seattle.Isolation of Cokeromyces recurvatus, a dimorphic fungus in Zygomycete family, is equivocal because it is uncertain whether the organism is a pathogen or a tissue contaminant/colonizer. We report a case of C recurvatus present in a circumferential duodenal lesion. The patient is a 64-year-old man with medical history notable only for heavy consumption of edible marijuana, admitted with a 3-week history of left upper quadrant abdominal pain. Computerized tomography scan identified duodenitis with significant gastric outlet obstruction, confirmed by a partially obstructing nonbleeding duodenal ulcer on upper endoscopy (Figure 1.15, A). The histology showed variably sized spherical structures with bubbly internal contents and no nuclei, reproductive tracts, or alimentary tracts. Small, clustered spherules representing putative endospores were observed within the larger structures and in the exud

Nutcracker Syndrome Masquerading as Renal Colic in an Adolescent Athlete: A Case Report.

IntroductionAbdominal pain and flank pain cause a significant proportion of emergency department (ED) visits. The diagnosis often remains unclear and is frequently associated with repeat visits to the ED for the same complaint. A rare cause of left upper abdominal and flank pain is compression of the left renal vein between the aorta and the superior mesenteric artery known as nutcracker syndrome. Diagnostic findings on ultrasound include increased left renal vein diameter proximal and peak blood flow velocity increase distal to the superior mesenteric artery. We describe such a patient presenting to an ED repeatedly with severe pain mimicking renal colic before the final diagnosis and intervention occurred.Case ReportA 16-year-old female, long-distance runner presented four times complaining of intractable left upper quadrant abdominal pain radiating to the left flank after exercise. On each visit urinalysis revealed proteinuria and hematuria, and on two visits abdominal computed tomography revealed no kidney stone or dilatation of the collecting system. Ultimately, she was referred to vascular surgery where Doppler ultrasonography was used to diagnose left renal vein compression. Transposition of the left renal vein improved Doppler diameter and flow measurements and eliminated symptoms.ConclusionEmergency physicians must maintain a large list of possible diagnoses during the evaluation of abdominal and flank pain with a repetitive and uncertain etiology. Nutcracker syndrome may mimic other causes of abdominal and flank pain such as renal colic and requires appropriate referral.

Ewing's Sarcoma of the Pancreas

A 23-year-old previously healthy woman presented with a 2-day history of progressively worsening left upper quadrant abdominal pain with associated abdominal distention, nausea, and bloating. Computed tomography of the abdomen revealed a 14 × 12.5 × 11 cm multilobulated mass inferior to the stomach causing marked extrinsic compression of the stomach and encasing the splenic artery and celiac axis (Figure A). Magnetic resonance imaging of the abdomen confirmed the previously described abdominal mass emanating from the pancreatic body and tail demonstrating diffuse restricted diffusion with heterogeneous enhancement.