Moderate Ascites Research Articles

P49 Belimumab as a potential therapy for lupus enteritis – a case report

Abstract Introduction Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease with varied clinical manifestations. Gastrointestinal (GI) complaints are common in 40–60% of SLE patients. Most are mild; however severe life-threatening manifestations may occur. Lupus enteritis (LE) is a rare but severe GI manifestation of SLE, characterised by vasculitis or inflammation of the bowel. Belimumab is a recombinant human monoclonal antibody against the soluble B-lymphocyte stimulator protein (BLyS) and was the first licensed treatment for SLE and lupus nephritis. Herein, we report a case of lupus enteritis that responded well to belimumab therapy. Case description We present a 42-year-old Sri Lankan woman who was diagnosed with SLE in 2015 based on arthritis, Raynaud’s, haemoproteinuria, positive antinuclear antibodies (ANA), anti-double stranded DNA (dsDNA), and anti-Ro antibodies with low complements C3, C4. Renal biopsy confirmed class III a+c lupus nephritis. She was managed with prednisolone, mycophenolate mofetil, hydroxychloroquine and ramipril. She responded well to treatment. She was admitted in August 2018 with recurrent abdominal pains, distension, diarrhoea, nausea, vomiting, 20kg unintentional weight loss, arthritis, lymphadenopathy, and peripheral oedema. Over the last 12 months, she had 5 admissions with similar GI symptoms, which were managed as viral gastroenteritis. Investigations showed nephrotic range proteinuria - urine PCR 330 (0-15 mg/mmol), low albumin = 27 (40-52 g/L), positive anti-dsDNA antibodies = 211 (0-10 IU/ml), CRP 7 (0-4 mg/L), ESR 44 (0-12 mm/hr) with low complements C3 0.36 (0.90-1.80 g/L) and C4 0.07 (0.10-0.40 g/L). Contrast enhanced computed tomography (CECT) scan of the abdomen revealed diffuse oedema of the large bowel extending from the splenic flexure to the rectum, several areas of small bowel thickening, peritoneal enhancement, and moderate volume ascites. Infective causes for colitis were ruled out including abdominal tuberculosis. Sigmoidoscopy and biopsy ruled out inflammatory bowel disease, whereas surgical and gastroenterology reviews ruled out other causes for her presentation. She was diagnosed with lupus enteritis with flare of lupus nephritis and managed with pulsed intravenous methylprednisolone followed by tapering high dose oral prednisolone. Her symptoms gradually improved, and she was discharged. Unfortunately, over the next month, she had recurrent admissions with flares of lupus enteritis requiring further intravenous methylprednisolone. As a result, she was commenced on monthly IV belimumab. Since starting belimumab, she has not had any further flares of lupus enteritis and her anti-dsDNA antibody and complements C3, C4 levels have normalised. Discussion Lupus enteritis (LE) presents with non-specific GI symptoms such as abdominal pain (most common), nausea, vomiting, diarrhoea and ascites. In most cases, it develops months to years after SLE diagnosis but in some cases, may be the presenting feature. Its pathogenesis remains unknown; however, mesenteric vasculitis and/or thromboses are thought to play a role. Contrast enhanced computed tomography (CECT) abdomen is the gold-standard investigation and usually shows bowel wall oedema, dilated bowel loops (>3 cm), bowel wall thickening with peripheral enhancement (“target sign”/”double halo sign”), engorgement of mesenteric vessels with a palisade pattern (“comb-sign”), increased attenuation of mesenteric fat and/or ascites. Laboratory investigations usually reveal markers of active lupus. Significant proteinuria (>0.5 g/24 h) is usually found in around 50% of patients. LE is very steroid responsive, with most patients achieving disease remission with steroids alone. Additional immunosuppression (such as cyclophosphamide, MMF, azathioprine, HCQ or rituximab) may be used concomitantly, for other manifestations of SLE or in those with relapsing or refractory disease. Belimumab has previously been licensed for use in SLE and lupus nephritis; however, there is sparse literature about its use in lupus enteritis. Our patient responded very well to belimumab, with both clinical and immunological remission. Key learning points • Lupus enteritis is a rare but severe gastrointestinal (GI) manifestation of SLE that presents with non-specific GI symptoms such as abdominal pain (most common), nausea, vomiting, diarrhoea and ascites. Clinicians managing SLE patients should have a high index of suspicion regarding the diagnosis, else it may be easily missed leading to recurrent admissions and delayed treatment. • Contrast enhanced CT abdomen is the gold-standard investigation and shows characteristic changes - bowel wall oedema, dilated bowel loops (>3 cm), bowel wall thickening with peripheral enhancement (“target sign”/”double halo sign”), engorgement of mesenteric vessels with a palisade pattern (“comb-sign”), increased attenuation of mesenteric fat and/or ascites • Lupus enteritis is very steroid responsive, with most patients achieving disease remission with steroids alone. Some patients with other SLE manifestations, or relapsing/refractory disease may require additional immunosuppression. Belimumab may be another option to consider in such patients.

An unusual case of Anasarca-Rapunzel syndrome

Rapunzel syndrome is a rare form of gastric trichobezoar extending into the intestine, often associated with malnutrition and protein-losing enteropathy. A 12-year-old female presented with epigastric abdominal pain, facial puffiness, bilateral lower limb swelling, and anorexia. She was a known case of sickle-thalassemia double heterozygous state but had never received a blood transfusion. Family history revealed parental separation and harsh paternal behavior. The patient was undernourished but otherwise developed normally. On examination, she was lethargic, exhibited generalized anasarca, severe anemia, signs of congestive cardiac failure, and patchy hair loss on the scalp. Abdominal examination revealed moderate ascites, hepatosplenomegaly, and a firm, mobile, non-tender epigastric mass (10×8 cm), suggestive of gastric bezoar. Laboratory findings showed microcytic hypochromic anemia with macro-ovalocytes in the context of sickle-thalassemia heterozygosity. The child required multiple blood and serum albumin transfusions for severe anemia and hypoproteinemia with anasarca. Hepatic and renal causes of anasarca were excluded. Cardiovascular and respiratory systems were normal. Contrast enhanced computed tomography (CECT) abdomen confirmed the gastric bezoar. After stabilization, exploratory laparotomy and trichobezoar evacuation were performed. Psychiatric counseling and diversion therapy were provided. The child was discharged in stable condition, with follow-up showing significant improvement in nutritional status, mood, and general well-being. This case highlights the unusual presentation of Rapunzel syndrome with generalized anasarca in a pediatric patient with underlying sickle-thalassemia, emphasizing the importance of multidisciplinary management and follow-up.

Feasibility and safety of EUS-guided biliary drainage in inexperienced centers: a multicenter study in southwest Japan

Background and AimsEndoscopic ultrasound-guided biliary drainage (EUS-BD) has shown promising procedural outcomes in high-volume centers. While inferior procedural outcomes were reported in inexperienced centers during the early days of EUS-BD, the current outcomes are unknown. This study aimed to clarify the feasibility and safety of EUS-BD in centers that recently introduced EUS-BD. MethodsThis multicenter retrospective study was conducted at 22 centers that introduced EUS-BD between 2017 and 2022. A maximum of 20 initial EUS-BD cases at each center were evaluated. The clinical outcomes and experience of 84 endoscopists who performed these procedures were examined. The primary outcomes were the rate of technical success and adverse events (AEs). The secondary outcomes were risk factors associated with technical failure and procedure-related AEs. ResultsA total of 255 patients were enrolled. The technical success rate was 91.4% (233/255). Among technical failure cases (n=22), guidewire manipulation failure was the most common cause (n=12), followed by tract dilation failure (n=5). The AE rate was 10.2% (26/255). Multivariate analysis identified a puncture target diameter of <5 mm (odds ratio, 3.719; 95% confidence interval, 1.415-9.776; p=0.008) and moderate ascites extending to the liver surface (odds ratio, 3.25; 95% confidence interval, 1.195-8.653; p=0.021) as independent risk factors for technical failure and procedure-related AEs, respectively. Endoscopists’ procedural experience was not a risk factor for technical failure or procedure-related AEs. ConclusionsThe feasibility and safety of EUS-BD were maintained during the induction phase at inexperienced centers. These will be helpful in better understanding the current status of EUS-BD.

Marantic Endocarditis Associated with Metastatic Fibrolamellar Hepatocellular Carcinoma in a Young Adult: About a Case

We describe the case of a 21-year-old patient presenting with marantic endocarditis of the aortic valve occurring in the context of underlying metastatic fibrolamellar hepatocellular carcinoma. The patient was admitted due to a pulmonary embolism complicating deep vein thrombosis in the right lower limb. Upon admission, the patient was hemodynamically stable and afebrile, with a poor general condition. Physical examination revealed a painful swelling in the right lower limb extending up to the thigh, hepatomegaly suggestive of a tumor, and moderate ascites. Cardiac auscultation did not reveal any murmurs or abnormal sounds. Laboratory tests showed a non-specific inflammatory syndrome, and blood cultures were negative. The electrocardiogram indicated regular sinus tachycardia. Echocardiography revealed a mobile, hyperechoic mass located on the ventricular aspect of the aortic valve, without regurgitation or stenosis. The patient was started on heparin therapy. Unfortunately, the patient passed away at home two weeks later, and no autopsy was performed.

Congenital Hepatic Fibrosis in an Aborted Holstein-Friesian Fetus

Abstract Congenital hepatic fibrosis (CHF) is a rare condition characterized by abnormal accumulation of fibrous tissue in the liver, leading to liver dysfunction. While CHF has been documented in various animal species, it has rarely been reported in cattle. This report presents a case of CHF in an aborted Holstein-Friesian fetus. During the necropsy, the most notable macroscopic findings included an enlarged liver with an irregular “cobblestone appearance” on the surface and firm parenchyma, as well as moderate ascites. Histopathological examination revealed extensive hepatic fibrosis in the portal areas, accompanied by bridging fibrosis extending between portal tracts and bile duct proliferation within the fibrous tissue. Screening for infectious agents as the cause of abortion or liver lesions was unremarkable. The necropsy and histopathological findings confirmed CHF, constituting the first case described in Holstein-Friesian calves in Serbia. Further research is required to determine whether this condition has a genetic basis or is influenced by yet to be identified factors in Holstein-Friesian cattle.

Phase 1 study to evaluate safety and preliminary efficacy of padeliporfin vascular targeted photodynamic therapy (VTP) in patients with locally advanced (LA) unresectable pancreatic ductal adenocarcinoma (PDAC).

TPS4204 Background: Pancreatic cancer is the third most common cause of cancer death. Surgery offers the best survival rates however only a minority of patients are eligible. Approximately 15-20% of patients are deemed unresectable due to vascular involvement LA. Conversion of unresectable tumors, due to vascular involvement to resectable, is an unmet clinical need. Methods: A novel approach was developed to destroy the tumor encasing the artery combining padeliporfin, a photosensitive drug, locally activated by laser light illumination. The effectiveness of the strategy was confirmed in an orthotopic mouse model. A proof-of-concept study using 12 non-tumor pigs demonstrated an acceptable safety profile. A phase I dose escalation trial (NCT5918783) will be performed to evaluate the safety and maximal tolerated dose (MTD) of laser light dose of padeliporfin VTP. VTP will be delivered through an endovascular fiber integrated in a standard angioplasty balloon. The balloon will be advanced under fluoroscopy to the encased vascular segment of the superior mesenteric artery (SMA) and inflated. Following IV administration of padeliporfin, it will be activated by the laser light. Part A will be a classic 3+3 dose-escalation design to determine the MTD of laser light. The identified MTD will be applied in the Part B for preliminary efficacy evaluation. The primary objectives are to determine safety and MTD and/or recommended phase 2 laser light dose of VTP treatment. Secondary objectives are: rate of surgical conversion; evaluation of the pattern of disease progression (local regional and/or metastatic disease) after VTP based on CT. Standard of care surgery can be performed after 14 days post VTP. Key inclusion criteria: patients with histologically/cytologically confirmed stage III unresectable LA-PDAC in the head/uncinate process of the pancreas, with SMA solid tumor contact ˃180° with measurable disease per RECIST 1.1 and ECOG 0-1. Key exclusion criteria: metastatic disease, other malignancy, photosensitive skin diseases or porphyria, concurrent investigational therapy within past 30 days, medically uncontrolled moderate or severe ascites, previous radiation to pancreas, SMA variants. Recruitment begins in April 2024. Conversion of unresectable locally advanced pancreatic cancer to surgery is a critical unmet need. This phase I trial explores a novel approach to treat the tumor encasement enabling surgery. Clinical trial information: NCT5918783 .

Differential Effects of Ascites and Hepatic Encephalopathy on Waitlist Mortality in Liver Transplantation by MELD 3.0.

MELD 3.0 introduces changes to address waitlist disparities for liver transplant (LT) candidates. Ascites and hepatic encephalopathy (HE) are important milestones in the natural history of cirrhosis regardless of the Model for End-Stage Liver Disease (MELD) score. We aim to assess the impact of ascites and HE and its interaction with MELD 3.0 on waitlist mortality. This is a retrospective study of patients listed for LT in the Organ Procurement and Transplantation Network database from 2016 to 2021. The primary outcome was waitlist mortality (death/delisting for too sick to LT). Ascites/HE were classified as moderate ascites without moderate HE (mAscites), moderate HE without moderate ascites (mHE), both moderate ascites/HE (mBoth), and neither. MELD 3.0 scores were categorized as <20, 20-29, 30-39, and ≥40. Of 39 025 candidates, 29% had mAscites, 3% mHE, and 8% mBoth. One-year waitlist mortality was 30%, 38%, and 47%, respectively, compared with 17% (all P < 0.001) for those with neither. In multivariable Cox regression, the adjusted risk of waitlist mortality associated with mAscites (versus neither) was a hazard ratio (HR) of 1.76 (95% confidence interval [CI], 1.55-2.00) when the MELD 3.0 score was <20, significantly higher than when the MELD 3.0 score was 20-29 (HR 1.40; 95% CI, 1.27-1.54), 30-39 (HR 1.19; 95% CI, 1.04-1.35), and ≥40 (HR 1.14; 95% CI, 0.91-1.43, interaction P < 0.05 for all). A similar pattern was observed by MELD 3.0 for both moderate ascites/HE. The presence of moderate ascites alone, or combined with moderate HE, not only increases the risk of waitlist mortality but also has a differential effect by MELD 3.0, especially at lower MELD scores. Earlier strategies addressing this group and improving treatment plans or access to LT regardless of MELD remain needed.

Patients with Steroid Sensitive Nephrotic Syndrome: A Case Series

Nephrotic syndrome (NS) is one of the most common kidney diseases found in childhood. The prevalence of nephrotic syndrome worldwide is approximately 16 cases per 100,000 children with an incidence of two to seven per 100,000 children. Nephrotic syndrome may affect adults and children of both genders and any race. Nephrotic syndrome in children can be classified into three groups; secondary, congenital, infantile, and idiopathic. In first case, a 3-year-old male patient was presented with complaints of fever, cough for 6 days and swelling all over the body, decreased urine output, oral intake for 2 days, edema of face, body and tiredness for 3 days. Laboratory investigations showed elevated ESR, ferritin and lipid profile. Urine routine examination showed elevated urine albumin levels (+++). USG abdomen and pelvis conveyed right basal pleural effusion. In second case, a 4-year-old male patient was presented with complaints of facial puffiness, fever, breathing difficulty, abdominal distension and pain but no edema. He had history of right inguinal hernia and atrial septal defect. Cholesterol level was found to be elevated. Urine routine examination showed elevated urine albumin levels (+++). USG abdomen and pelvis showed mild ascites and right pleural effusion. Presenting third case, a 12-year-old female patient was presented with complaints of edema and decreased urine output. Patient had history of recurrent episodes of edema and decreased urine output for 11 months. Laboratory investigations showed elevated total cholesterol, declined LFT test and RFT test was found to be normal. Urine routine examination showed elevated urine albumin levels (+++), pus cells, RBC, granular cast and bacteria present. USG abdomen and pelvis indicate acute glomerulo nephritis and acute to moderate ascites. Here case series with 3 cases showed the sequence of nephrotic syndrome which is treated with corticosteroid with its side effects and cumulative dose of steroid in children. Keywords: Nephrotic syndrome, Hypocholesteremia, Hypoproteinuria, Hyponatremia, pediatric

Clinical and epidemiological characterization of eosinophilic ascites in Egypt: a single center experience

Background & aimsEosinophilic ascites is non-common and challenging disease. This study aimed to describe the clinical presentation and treatment of eosinophilic ascites.MethodsThis was a prospective single-center study that included cases with eosinophilic ascites who were admitted to Tropical Medicine and Gastroenterology Department, Assiut University Hospital, Assiut, Egypt, during the period between May 2020 to May 2023. The clinical presentation, investigations, treatment, and follow-up data of the included patients were collected and analyzed.ResultsSeventeen cases of eosinophilic ascites were included in the study. The main presenting manifestations were abdominal pain (47.1%), and abdominal pain with distension (29.4%). Two patients presented with a picture of intestinal obstruction. Moderate ascites was found in 10 patients (58.8%) by ultrasound. Eosinophilia in the peripheral hemogram was detected in 76.5% of the study population. Endoscopic examination showed gastro-duodenitis in 9 patients (52.9%) and duodenitis in 4 patients (23.5%). All patients showed complete improvement and disappearance of ascites after starting steroids within two weeks. Eleven patients (64.7%) relapsed after discontinuation of steroids.ConclusionEosinophilic ascites is an uncommon cause of ascites that is often underdiagnosed. The relapse rate after stopping treatment is high but with excellent response to retreatment.

Haemorrhagic ascites: An atypical presentation of endometriosis

Abstract Haemorrhagic ascites is primarily associated with perforated abdominal viscera, malignancies and tuberculosis or hepatic pathologies. However, its presentation due to ovarian endometriosis is a rare finding. We report the rare occurrence of haemorrhagic ascites due to ovarian endometriosis in a 26-year-old multiparous female presentingwith severe abdominal pain. The other probable causes of ascites were excluded and computed tomography of abdomen and pelvis revealed moderate ascites with bulky left ovarian cyst. Abdominal paracentesis revealed haemorrhagic ascitic fluid which on cytopathology did not reveal evidence of malignancy. Diagnostic work-up including magnetic resonance imaging and diagnostic laparoscopy confirmed the diagnosis. She was treated with oral dienogest which caused regression of the mass and pain. This case highlights that endometriosis may be included in the differential diagnosis while treating haemorrhagic ascites in women in reproductive age.

Juvenile granulosa cell ovarian tumors: Report of a case

Juvenile granulosa tumors of the ovary are rare tumors. We report the case of juvenile granulosa cell tumor affecting a 33-year-old woman operated on for pain pelvic, the tumor was located in the left ovary with moderate ascites. The purpose of this work is to present the anatomoclinical and radiological characteristics of this tumor in order to allow an early diagnosis and to improve its prognosis, to establish a therapeutic chronology for this tumor. Different prognostic factors for ovarian granulosa cell tumor are being studied; the treatment is surgical.

Renal Manifestation of Mixed Connective Tissue Disease

A young female presented with facial puffiness and swelling in both lower limbs for 3 months, distension of the abdomen, and breathlessness on exertion for 1 month with a history of hypertension and hypothyroid on regular treatment. On general physical examination, there were pallor, bilateral pitting edema, tachycardia, and blood pressure of 190/100 mmHg. Abdominal examination revealed shifting dullness. Respiratory and cardiovascular systems were normal. Fundoscopy revealed Grade 1 papilledema, and the rest of the neurological examination was unremarkable. Investigations showed normocytic normochromic anemia, serum creatinine of 1.6 mg/dl, and hypoalbuminemia; urine R/E showed significant proteinuria; and anti-U1 ribonucleoprotein particle antibodies were positive. Two-dimensional echocardiography showed mild concentric left ventricular hypertrophy and mild pericardial effusion. Ultrasonography abdomen showed bilateral renal parenchymal disease and moderate ascites. Renal biopsy revealed diffuse proliferative glomerulonephritis and lupus nephritis Class IV. Renal manifestation is very rare in mixed connective tissue disease as an initial presentation.

Prognostic value of moderate or massive ascites in patients with advanced gastric cancer.

Advanced gastric cancer is a highly aggressive malignancy. The available literature does not provide the prognostic value of ascites based on their degree, because most clinical trials exclude patients who present with massive ascites. Therefore, this study examined whether the presence or degree of ascites has a prognostic value in 124 patients with advanced gastric cancer. The degree of ascites was assessed using computed tomography and classified as none, small, moderate or massive. The overall survival (OS) was compared based on the presence or degree of ascites. Furthermore, a Cox proportional hazards analysis was performed to ascertain the predictors of OS. The cumulative 1-year and 2-year OS rates in patients without ascites were 43.5 and 20.2%, respectively, whereas those in patients with ascites were 29.1 and 13.6%, respectively (P=0.116). The cumulative 1-year and 2-year OS rates in patients without moderate or massive ascites were 39.5 and 20.9%, respectively; however, those in patients with moderate or massive ascites were 28.0 and 4.0%, respectively (P=0.027). Multivariate analysis showed that diffuse-type [hazard ratio (HR), 1.532; 95% confidence interval (CI), 1.002-2.343; P=0.049], moderate or massive ascites (HR, 2.153; 95% CI, 1.301-3.564; P=0.003) and chemotherapy (HR, 0.189; 95% CI, 0.101-0.352; P<0.001) were significant predictive factors of OS. In conclusion, the present study indicated that moderate or massive ascites may influence the OS of patients with advanced gastric cancer.

Giant hepatic hemangioma in a patient with cirrhosis: challenging to manage.

Giant hepatic hemangiomas are occasional in patients with cirrhosis. It remains a challenge to decide on the need for treatment and choose the most appropriate intervention. A 62-year-old woman was recently diagnosed with cirrhosis and complained of upper abdominal fullness, reduction in oral food intake, and weight loss of 6 kg over the last three years. Upper digestive endoscopy evidenced thin-caliber esophageal varices and significant extrinsic compression of the lesser gastric curvature. Abdominal computed tomography revealed an exophytic tumor in the left hepatic lobe, measuring 11.5 cm, which had progressive centripetal contrast enhancement from the arterial phase, compatible with hepatic hemangioma. Serum tumor markers were negative, and her liver function was unimpaired. The patient underwent surgical resection (non-anatomical hepatectomy of segments II and III) which had no immediate complications, and the histopathological evaluation confirmed cavernous hepatic hemangioma. Two weeks later, she was admitted to the emergency room with jaundice, signs of hepatic encephalopathy, and moderate ascites, and was further diagnosed with secondary bacterial peritonitis. As no perforations, abscesses, or fistulas were observed on subsequent imaging tests, clinical management was successfully carried out. This case highlights that giant hepatic hemangiomas may be symptomatic and warrant treatment. In the setting of cirrhosis and portal hypertension, physicians should be aware of the risk of hepatic decompensation following surgical resection, even in patients with Child-Pugh class A.

Extraordinary cause of abdominal pain in sickle-cell disease patient: a case report

Background: The coexistence of extrahepatic portal vein thrombosis (EHPVT) and sickle-cell disease (SCD) was documented in a young adult patient who was presented with vague gastrointestinal symptoms, including right upper quadrant abdominal pain associated with fever and jaundice. Diagnosing EHPVT in children can be challenging due to ambiguous presentation and the lack of sufficient literature, particularly in those with SCD. Case Presentation: A five-year-old boy with homozygous sickle-cell (SS) disease presented to the emergency department with subjective fever and abdominal pain. The patient was managed conservatively with intravenous (IV) fluids, antibiotics, and analgesics. After admission, the patient was found to have hypoalbuminemia, anemia, and thrombocytopenia. Abdominal ultrasound showed moderate ascites with bowel loop thickness and preserved vasculature. Later, the boy developed increased abdominal pain. Abdominal computed tomography (CT) with contrast showed hepatic, portal, superior mesenteric and splenic veins thrombosis. Conclusion: Venous thrombosis is rare in SS disease, and its occurrence in this disease raises the possibility of a common pathogenesis and adds another pathology to the causes of abdominal pain in sickle-cell disease.

Life-threatening Haemoperitoneum from a Simple Ovarian Cyst

Ovarian enlargement of non-neoplastic origin is due to the accumulation of fluid in the functional unit. Follicular cysts are the most common physiological functional ovarian cysts. Definitive diagnosis is often difficult to establish as the clinical symptoms may be similar to acute appendicitis, acute cholecystitis, ovarian torsion or ectopic pregnancy. Spontaneous hemoperitoneum secondary to follicular cysts are rare but may be life-threatening. The case: The following case study is of a 20 year old female who presented to the emergency ward with severe right lower abdominal pain. On pelvic ultrasound a thick-walled cystic space occupying lesion (SOL) of size 70mm x 56mm was noted in the right side with peripheral vascularity and peripheral tiny follicles. Mild to moderate ascites was also seen. An emergency laparotomy was performed. The histopathology of the ovarian cyst was reported as follicular cyst with no evidence of malignancy. Conclusion: This case study emphasizes the optimal management of ruptured ovarian cyst and the elimination of differential diagnoses.

Association of serum sodium and 24-hour urinary sodium level with the severity and complications of ascites in cirrhotic patients.

Hyponatremia is an independent predictor of mortality in cirrhotic patients but little is known regarding the relationship between the level of serum sodium and 24-hour urinary sodium with the development of severity and complications of cirrhotic ascites. To observe the association of serum sodium and 24-hour urinary sodium levels with different grades of ascites and its complications in cirrhotic patients. In the department of Gastroenterology in a tertiary care hospital, this cross-sectional study was conducted from April 2019 to September 2020. A total of 96 admitted cirrhotic patients with ascites were enrolled in this study by consecutive sampling. Out of 96 patients with cirrhotic ascites, 48 patients had mild, moderate, and severe ascites and 48 patients had complications of ascites like refractory ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome. The mean serum sodium level was 131.69 ± 4.90 and 124.88 ± 5.67 mmol/L and the 24-hour urinary sodium level was 76.82 ± 45.64 and 35.26 ± 22.57 mmol/L in uncomplicated and complicated ascites groups respectively with P value < .001. In grade 1, grade 2, and grade 3 ascites, there was a significant (P = .001), association between mean serum sodium (mmol/L) level (R -0.777) and 24-hour urine sodium (mmol/L) level (R -0.704) but no significant difference was seen when refractory ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome were considered. In our finding, low serum sodium and low 24-hour urinary sodium levels were associated with the development of severe complications of cirrhotic ascites. Hence, Serum sodium and 24-hour urinary sodium levels can be good predictors of grading and complications of cirrhotic ascites.

FRI506 Severe Dilated Cardiomyopathy As First Manifestation Of Thyrotoxicosis- A Case Report

Abstract Disclosure: Z. Saeed: None. C. Labib: None. W. Althunibat: None. M. Varatharajah: None. Introduction: Hyperthyroidism is a common metabolic disorder with prominent cardiovascular manifestations ranging from palpitations, angina-like chest pain, exercise intolerance and dyspnea to high-output heart failure and dilated cardiomyopathy. Approximately 6% of patients with hyperthyroidism/thyrotoxicosis develop symptoms of heart failure and less than 1% develop dilated cardiomyopathy with reduced left ventricular systolic function. Here we present a case of a 55-year-old man who presented with symptoms of heart failure and was diagnosed with dilated cardiomyopathy due to thyrotoxicosis. CASE PRESENTATION: 55-year-old man with a past medical history of vitiligo and cirrhosis presented to the emergency department with complaint of lower extremity swelling, cough, dyspnea on exertion, chest discomfort, palpitations and lethargy for two weeks. He also had a weight gain of 14 lbs. in this period. In the emergency department he had a heart rate of 118 beats/minute, physical exam revealed bilateral fine hand tremors, bibasilar crackles and a 2/6 holosystolic murmur on chest auscultation as well as hyperactive deep tendon reflexes. EKG showed atrial fibrillation with a rate of 184 beats/min. Initial chest imaging showed cardiomegaly, perihilar congestive changes and small right pleural effusion. CT abdomen &amp; pelvis demonstrated moderate volume ascites. Lab work showed a TSH of 0.00 mIU/L (0.5-5.0. mIU/L), T4 Free 5.3 ng/dL (0.9-2.3 ng/dL), Troponin T 36 ng/L, pro BNP 3150 pg/ml. He was given furosemide, propranolol, hydrocortisone, a bolus of diltiazem and was started on diltiazem and heparin drip and admitted to the hospital. Endocrinology was consulted and he was started on methimazole and methylprednisolone. Transthoracic echocardiogram showed an ejection fraction of 15%. Thyroid ultrasound was negative for any nodules or mass. Cardiac catheterization was done which revealed moderate pulmonary hypertension, non-ischemic dilated cardiomyopathy. Patient was discharged home on methimazole and guideline directed medical therapy for heart failure. He followed outpatient with Endocrinology and Cardiology. Six months after his hospital admission, repeat TSH was 1.71 mIU/L after treatment. Repeat echocardiography showed an improvement in ejection fraction from 15% to 35-40%. DISCUSSION: Prolonged untreated hyperthyroidism leads to high output heart failure characterized by an increase in heart rate, cardiac contractility and cardiac output which in some cases progresses to dilated cardiomyopathy with impaired left ventricular systolic function. Heart failure with reduced ejection fraction is a frequently encountered problem, most commonly due to ischemic cardiomyopathy. Thyrotoxicosis is one of the rare and reversible causes of nonischemic dilated cardiomyopathy which must be promptly diagnosed and treated in order to prevent life threatening complications. Presentation: Friday, June 16, 2023

Nodular Lymphocyte-Predominant Hodgkin Lymphoma: A Rare Lymphoma with Isolated Hepatic Presentation.

Differential diagnosis of fever, especially in young patients, is very complex and complete investigation takes time, which can delay the diagnosis of malignancies such as primary hepatic lymphoma (PHL).PHL is very rare, and overlapping symptoms with other liver diseases can make the diagnosis very challenging.When the suspicion of PHL is very high, only the hepatic biopsy can lead to the correct diagnosis because the disease has no extrahepatic involvement.

Wilson’s Disease and Autoimmune Hepatitis Coexistence: A Cause of Diagnostic Delay

This case report describes a 27-year-old housewife who presented with a progressive and insidious onset of abdominal distension, loss of appetite, and fatigue which started 3 months before her presentation. The physical assessment showed moderate ascites and small liver size, and no other peripheral evidence of chronic liver disease was observed. A diagnosis of liver cirrhosis and was confirmed by investigations and imaging, where ascites responded well to therapy with diuretics. Investigations for the cause of cirrhosis was established through the diagnosis of autoimmune hepatitis, and she was started on steroids and azathioprine with partial improvement in liver biochemistry. She presented 8 months later with neuropsychiatric symptoms in the form of slurred speech and difficulty walking. Accordingly, Wilson’s disease was suspected to be the cause and further investigations confirmed this. A chelating agent, D penicillamine, was added to her immunosuppressive treatment. Nine months later she showed slow improvement in her neurological symptoms and was referred for assessment for liver transplantation. Wilson’s disease, although rare, should be suspected in patients with decompensated liver disease. The dominance of clinical and epidemiological features of autoimmune hepatitis as a common causative pathology for chronic liver disease in young and middle-aged ladies may hide the presence of other serious different pathologies such as Wilson’s disease.