Murphy's Sign Research Articles

Endoscopic treatment including a single-operator peroral cholangioscopy-guided electrohydraulic lithotripsy and endoscopic nasogallbladder drainage combined laparoscopic cholecystectomy for Mirizzi syndrome

Mirizzi Syndrome (MS) is rare among gallbladder diseases and may be difficult to treat. In particular, endoscopic treatment often fails owing to unable to access or capture the impacted cystic duct stone. We report a case of MS grade III that were successfully managed by an endoscopic treatment and interval laparoscopic cholecystectomy. A 59-year-old women was admitted our hospital presenting with upper abdominal pain and fever up to 38.5℃. She was mildly jaundiced with scleral icterus with a positive Murphy's sign. An abdomen computed tomography scan and T2-weight magnetic resonance cholangiopancreatography image demonstrated about 1.4cm stone at junction of the cystic duct and mid-common bile duct with cholecysto-choledochal fistula, compatible with MS type III and acute calculus cholecystitis. A digital single-operator cholangioscopy (DSOC)-guided eletrohydraulic lithotripsy (EHL) was performed. Elective laparoscopic cholecystectomy was performed after the stones were completely removed. The patient was discharged without any complications on the 5th day after surgery. The treatment of MS is mainly surgical and consists of partial or complete cholecystectomy with or without common bile duct exploration. However, in the era of minimal invasive treatment, laparoscopy treatment for low grade MS is being tried steadily. In our case, through preoperative intervention using DSOC guided EHL, the effect of downgrading MS could be achieved, and this resulted in a safe laparoscopic surgical approach. In conclusion, DSOC guided EHL with ENGBD may allow a minimally invasive approach for management of high grade MS.

Hepatobiliary and Pancreatic: Right upper quadrant pain and positive Murphy's sign

Hepatobiliary and Pancreatic: Right upper quadrant pain and positive Murphy's sign

Severe gastrointestinal bleeding secondary to cholecystitis: a case report and our handling experience

The patient was male, 57 years old, who was treated for "upper abdominal pain and discomfort for 4 hours". The pain was severe, with back radiation, without cold fever, nausea, vomiting, chest tightness, shortness of breath, skin or yellow eyes, also without hematemesis or black stool. Physical examination: without yellow skin and sclera, with right upper abdomen tenderness and positive Murphy sign. There were no other obvious positive signs. Abdominal CT：cholecystitis with possible occupancy, and multiple common bile duct stones. Laboratory tests: White blood cells was 10.88×109/ L, neutrophilic granulocyte was 84%, Glutamic transaminase was 666 IU/L. Past medical history: hypertension and diabetes. Preliminary diagnosis: Acute cholecystitis, Common bile duct stones, Abnormal liver function, High blood pressure, Diabetes, Admitted to hospital. Handling measures: fasting, pain relief, anti-infection, liver protection, fluid replacement treatment, and monitor blood sugar, blood pressure, and further improve the inspection.

Complete gallbladder duplication – Seventh report in world literature

Gallbladder duplication results from a rare abnormality of embriogenesis1 and is twice as common in women as in men2 .The signs and symptoms of double gallbladder cholecystitis are the same as those of single gallbladder cholecystitis: strong pain in the epigastric region and right hypochondrium, which may irradiate to the back and be accompanied by nausea and/or vomiting, Murphy positive sign, and pain on palpation of these regions; plastron may also be present3 . For this reason, many cases are still diagnosed intraoperatively, making surgery difficult and increasing the possibility of biliary tract injury. We report the case of a female patient with epigastric and dorsal pain for 4 days, which worsened with the ingestion of salty and fatty foods and was accompanied by nausea and vomiting. Physical examination showed a positive Murphy sign. A complete abdominal ultrasound examination showed gallbladder duplication, both lithiasic. Magnetic resonance cholangiography confirmed the duplication of the gallbladder and cystic ducts, with a single main biliary tract and acute lithiasic cholecystitis in both gallbladders. A laparoscopic cholecystectomy of both vesicles was performed without complications, and the patient was discharged 3 days after the procedure.

Acute acalculous cholecystitis in a child with hepatitis A infection

Abstract Acute acalculous cholecystitis (AAC) is more common than acute calculus cholecystitis in children, especially critically ill patients. A rare cause of AAC is hepatitis A virus infection. Here, we report the case of a 5-year-old girl who presented with abdominal pain, nausea, vomiting, tenderness of the right upper quadrant of the abdomen and positive Murphy's sign. Laboratory results showed elevated liver enzymes, positive hepatitis A IgM titre, and direct hyperbilirubinemia. Radiological tests showed all signs of AAC including increased gallbladder wall thickening, pericholecystic fluid, and absence of stones. The diagnosis of hepatitis A-induced AAC was confirmed by clinical evaluation, laboratory results, and radiology. The patient was treated successfully by conservative management.

Prospective validation of the bedside sonographic acute cholecystitis score in emergency department patients.

Acute cholecystitis can be difficult to diagnose in the emergency department (ED); no single finding can rule in or rule out the disease. A prediction score for the diagnosis of acute cholecystitis for use at the bedside would be of great value to expedite the management of patients presenting with possible acute cholecystitis. The 2013 Tokyo Guidelines is a validated method for the diagnosis of acute cholecystitis but its prognostic capability is limited. The purpose of this study was to prospectively validate the Bedside Sonographic Acute Cholecystitis (SAC) Score utilizing a combination of only historical symptoms, physical exam signs, and point-of-care ultrasound (POCUS) findings for the prediction of the diagnosis of acute cholecystitis in ED patients. This was a prospective observational validation study of the Bedside SAC Score. The study was conducted at two tertiary referral academic centers in Boston, Massachusetts. From April 2016 to March 2019, adult patients (≥18years old) with suspected acute cholecystitis were enrolled via convenience sampling and underwent a physical exam and a focused biliary POCUS in the ED. Three symptoms and signs (post-prandial symptoms, RUQ tenderness, and Murphy's sign) and two sonographic findings (gallbladder wall thickening and the presence of gallstones) were combined to calculate the Bedside Sonographic Acute Cholecystitis (SAC) Score. The final diagnosis of acute cholecystitis was determined from chart review or patient follow-up up to 30days after the initial assessment. In patients who underwent operative intervention, surgical pathology was used to confirm the diagnosis of acute cholecystitis. Sensitivity, specificity, PPV and NPV of the Bedside SAC Score were calculated for various cut off points. 153 patients were included in the analysis. Using a previously defined cutoff of≥4, the Bedside SAC Score had a sensitivity of 88.9% (95% CI 73.9%-96.9%), and a specificity of 67.5% (95% CI 58.2%-75.9%). A Bedside SAC Score of < 2 had a sensitivity of 100% (95% CI 90.3%-100%) and specificity of 35% (95% CI 26.5%-44.4%). A Bedside SAC Score of≥7 had a sensitivity of 44.4% (95% CI 27.9%-61.9%) and specificity of 95.7% (95% CI 90.3%-98.6%). A bedside prediction score for the diagnosis of acute cholecystitis would have great utility in the ED. The Bedside SAC Score would be most helpful as a rule out for patients with a low Bedside SAC Score < 2 (sensitivity of 100%) or as a rule in for patients with a high Bedside SAC Score≥7 (specificity of 95.7%). Prospective validation with a larger study is required.

Acute Cholecystitis as a Diagnosis of Mucinous Cystic Neoplasia of the Gallbladder. A Literature Review

Purpose: Mucinous cystic neoplasms (MCNs) of the gallbladder are extremely rare, benign, unilocular or multilocular cystic tumors that contain septations. We present a case diagnosed incidentally after emergency cholecystectomy for acute cholecystitis. Method: 69-year-old woman with epigastric pain of 24 hours of evolution associated with nausea and fever. No jaundice. 14,000 leukocytes, CRP: 33. Normal bilirubin, gamma-GT, and alkaline phosphatase. Positive Murphy's sign. Abdominal ultrasound: acute cholecystitis. Surgical treatment: laparoscopic cholecystectomy, showing acute edematous cholecystitis. No complications in the postoperative period. AP: mucinous cystic neoplasm (MCN) with low-grade dysplasia. Results and conclusions: MCNs of the gallbladder are rare, and no established guidelines for appropriate management have been developed. It´s benign cystic proliferations of the hepatobiliary epithelium. Lesions originate in the liver in 85% of cases and affect women more frequently, with a mean age at presentation of 45 years. Its origin remains unclear. Previous studies have hypothesized that originate from ectopic remnants of embryonal gallbladder tissue and aberrant hamartomatous bile ducts. Discrepancies across the literature exist regarding the malignant potential. Some authors believe that approximately 13% of cystadenomas have dysplastic changes that can progress to a malignant form. If suspected, ultrasound or CT-guided fine needle aspiration for biopsy is generally not recommended as it increases the chances of tumor spread in the peritoneal cavity. The only consistent consensus across the literature is that all suspected MCNs originating in the gallbladder should be imaged, surgically removed, and evaluated under the microscope to determine the nature of the disease.

Cholelithiasis and chronic cholecystitis in a ten-year-old-boy: a case report

Background: Cholelithiasis in children is uncommon and challenging to diagnose because the patient is often asymptomatic and the clinical feature doesn't clearly depict cholelithiasis or cholecystitis. This case study aims to describe a rare case of cholelithiasis with chronic cholecystitis in a ten-year-old boy.Case Presentation: A ten-year-old boy presented with umbilical pain, nausea, and emesis. Physical examination showed there is no tenderness in all abdominal quadrants with a negative Murphy sign. Laboratory results revealed elevated white blood cell count 20.42x103/?L, elevated erythrocyte sedimentation rate 47.2 mm/hour, normal liver function tests, urine, and stool analysis. He underwent transabdominal ultrasound twice. The latest transabdominal ultrasound showed cholelithiasis, free fluid around the pelvic region due to suspected visceral organ perforation. Laparoscopic cholecystectomy was performed without complication. The result of pathology anatomy examination was chronic cholecystitis. The patient was discharged 3 days after surgery in good condition. The long-term prognosis of the patient was good.Conclusion: Even though the patient is male with good nutritional status (not obese), the patient was in the mean age that was identified as a key contributor to this disease. Ultrasonography examination is a screening modality that is still an excellent diagnostic tool with 95% accuracy even though it is highly operator dependent. Laparoscopic cholecystectomy is a gold standard for management even in children with decreased pain and shorter lengths of stay in the hospital.

S1415 Granulomatosis With Polyangiitis Presenting as Acute Cholecystitis

INTRODUCTION: Granulomatosis with Polyangiitis (GPA) is a systemic autoimmune disease that mainly affects small vessels and can affect any organ system. It is one of the ANCA associated vasculitides, defined by vascular inflammation associated with autoantibodies known as ANCA. Although rarely seen, GPA can affect the GI system and present with GI complications. CASE DESCRIPTION/METHODS: A 27-year-old female initially presented to the ED with lower extremity weakness, joint pain and swelling, then returned a month later after recent diagnosis of rheumatoid arthritis (RA) with epigastric and right upper quadrant pain. CT abdomen/pelvis and labwork were insignificant. She returned the following day for persistent symptoms. Abdominal ultrasound confirmed cholelithiasis and possibly cholecystitis. She underwent cholecystectomy and was subsequently discharged but soon returned with fevers, nausea, chills, sweats and epigastric pain radiating to the right shoulder. EGD showed findings of gastritis. MRCP and ERCP were unremarkable. Gallbladder pathology showed cholelithiasis and findings consistent with small vessel vasculitis. Further workup was positive for protease 3 antibody, consistent with GPA. She was treated with pulse dose steroids, plasmapheresis and started on Rituxan infusion. Non-opioid pain medications were given while opioids and steroids were tapered. Her abdominal pain improved and she was discharged with outpatient follow up. DISCUSSION: In a retrospective review, GI involvement, most commonly abdominal pain, was found in varying percentages of patients with polyarteritis nodosa, ANCA vasculitides including GPA and RA associated vasculitis. Biopsies from 36 patients via EGD found no signs of vasculitis. Four of five patients with cholecystectomy for cholecystitis were shown to have vasculitis. In an analysis of case records of 34 patients with GPA, nine of 34 had GI complications. EGD samples revealed nonspecific inflammation. The insignificant findings on EGD in the patient cases as well as the unremarkable ERCP and MRCP on our patient show that it is worthwhile to question the necessity of continuous procedures in patients with GPA who present with persistent abdominal pain. It is important to consider systemic vasculitis in patients with unclear causes of GI symptoms especially in those with history of rheumatological disorder. Benefits include avoiding unnecessary imaging and procedures as well as decreased hospital stay thereby utilizing high value care and improving patient experience.Figure 1.: Ultrasound showing cholelithiasis without any wall thickening. There was positive Murphy's sign while obtaining the imaging.Figure 2.: Images show a small artery with fibrinoid necrosis of the vessel wall. There is infiltration in the vessel wall and in the surrounding tissue by neutrophils and lymphocytes. Each image shows varying degrees of obliteration of the vessel lumen with Figures 2.1 and 2.2 showing complete obliteration.

Porcelain Gallbladder

An 86-year-old woman with a 3-month history of intermittent epigastric pain presented to our outpatient clinic. She was diagnosed as having mild hypertension, but had no significant medical history. On physical examination, she exhibited mild tenderness of her epigastrium and right upper quadrant without guarding or rebound tenderness. Abdominal ultrasonography revealed a calcified gallbladder with sonographic Murphy sign. Abdominal radiograph and computed tomography showed rim calcification of the gallbladder wall (Figures A–C).

The Importance of Universal Preprocedural Testing for the Novel Coronavirus 2019

The Importance of Universal Preprocedural Testing for the Novel Coronavirus 2019

Gallbladder Hydatid Cyst: A Review on Clinical Features, Investigations and Current Management.

BackgroundGallbladder hydatid cyst (GBHC) is highly uncommon with an incidence of 0.3–0.4% of all atypically located hydatid cysts. Our personal experience of one case of primary GBHC (PGBHC) managed laparoscopically motivated this systematic review. This study aimed to analyze the demographic characteristics, types [whether primary GBHC (PGBHC) or secondary GBHC (SGBHC)], clinical presentation, laboratory investigations, imaging studies, operative procedure, hospital stay, follow-up and recurrence.MethodsA systematic review was performed using preferred reporting items for systematic reviews and meta-analyses guidelines.ResultsTwenty studies, including 22 cases plus one more case managed by us, were included in the review. For PGBHC, the mean age was 48.61 years while for SGBHC it was 47.9 years. PGBHC was more common in females (69.23%) while SGBHC was more common in males (55.55%). Overall, GBHC was more common in females (56.52%). The most common presentation overall was abdominal pain (100%) followed by nausea/vomiting (43.47%). The other common symptoms were nausea/vomiting (61.53%) and Murphy’s sign (38.46%) in PGBHC, but jaundice (50%) and fever (30%) in SGBHC. In PGBHC, 50% patients had normal liver function while this was deranged in 66.66% patients with SGBHC. Serology was positive in 50% of PGBHC and 100% in SGBHC. Ultrasonography was positive in 50%, while CT-scan showed 70%. CT-scan was better at detection of SGBHC (100%). The most common operation was open cholecystectomy (78.26%) either isolated or combined. Isolated open cholecystectomy was commonly done in PGBHC (69.23%). Overall, only 56.52% of patients received albendazole, but no recurrence was reported. The average hospital stay was 7.25 days and follow-up ranged from 1 month to 10 years.ConclusionGBHC mostly affects females with abdominal pain being the most common symptom. Ultrasonography is expedient though CT-scan is more sensitive. Albendazole monotherapy has questionable value. Open cholecystectomy is the most common operation. However, laparoscopy is safe in experienced hands.

Unusual gastrointestinal manifestations of COVID-19: two case reports.

As of December 2019, a new strain of coronavirus named severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was discovered in Wuhan, China, following an epidemic of a fast-spreading viral respiratory disease, later called Coronavirus Disease 2019 (COVID-19), which then lead to the present pandemic the world has come to know. Patients who tested positive for COVID-19 are mostly asymptomatic or present with mild self-limiting symptoms. While GI symptoms occur with less prevalence, they are increasingly being reported. A diagnosis of Covid-19 has increased dramatically in patients presenting with gastrointestinal symptoms suggesting that GI symptoms should be taken into serious consideration with patient diagnosis. Case 1: A 65-year-old man presented to the hospital emergency room with abdominal pain, Murphy's sign and chills without fever, subsequently diagnosed as acute acalculous cholecystitis with a positive COVID-19 rRT-PCR. Case 2: A 78-year-old woman presented to the hospital emergency room complaining of severe positional epigastric pain precipitated by lying supine, chills with no fever, being later diagnosed as acute pancreatitis and a positive COVID-19 rRT-PCR. It has become evident that the ACE2 receptor plays a significant role as the entry site into human cells for the virus. This receptor is generally expressed in respiratory cells, as well as the gastrointestinal tract, corresponding with extrapulmonary manifestations of COVID-19. Studies concluded that the origin of gastrointestinal symptoms could be caused by the interaction of the SARS-CoV-2 virus with cells through the ACE2 receptor. The findings of the present study support this theory, as both patients presented with symptoms regarding tissues with high ACE2 expression.

Intrahepatični holangiokarcinom sa fudroajantnim tokom

Cholangiocarcinoma is a malignant tumor originating from the ductal epithelium. It is divided into intrahepatic, gallbladder carcinoma and peripheral cholangiocarcinoma. The prevalence depends on the region, ethnicity, gender, and localization of the tumor. The most common symptoms are jaundice, pain, nausea, weight loss. The tumor is mostly found in the advanced stage when local and distant metastases are detectable. Median survival rate in patients who are in an advanced inoperable stage is 3.9 months. A 60-year-old patient came in January 2018 with pain in the epigastrium, weight loss and nausea. Objectively positive Murphy sign and enlarged liver were found. The ultrasound showed a lobulated, heterogeneous, fatty liver with a tumor mass in the right liver lobe, measuring more than 12 cm in diameter. Laboratory findings: Alpha-fetoprotein 13.0 ng/mL, carcinoembryonic antigen 7.25 mg/ml, carbohydrate antigen 19-9 56.7 U/ml, erythrocyte sedimentation rate 29, bilirubin 24.7 mmol/L, alanine aminotransferase 32.0 U/L, aminotransferase 56 U/L, alkaline phosphatase 181 U/L, C-reactive protein 43.1 µg/mL, uric acid 561 µmol/L. Computerized tomography showed an enlarged, lobular, non-homogeneous liver and non-homogeneous, as well as hetero-dense changes of indistinct contours, measuring 98x90x80 mm and 8x16 mm. All these findings were confirmed by magnetic resonance. Chest x-ray showed multiple metastases. Liver biopsy confirmed primary malignancy of the bile. The patient was treated palliatively and passed away in March, two months after the initially occurrence of disease symptoms.

Laparoscopic Cholecystectomy of Gallbladder Stone Presenting as Empyema in a 9 Years-Old Boy: A Case Report

Background: The gall bladder stones (GBS) are common disease related to diet habit, obesity, hematological diseases, diabetes mellitus and receiving total parenteral nutrition. GBS is a rare cause of hospitalization of pediatric patients, but have been increasingly diagnosed in recent years due to widespread use of ultrasonography. The aim of this case report study is to determine the clinical presentation, risk factors, valuable diagnostic procedures and outcome of laparoscopic management of cholelithiasis in children. Case report: Our case is a 9 years-old boy with empyemic gallbladder complaining of attacks of colicky epigastric pain associated with recurrent vomiting. On abdominal palpation, there is positive sign of deep tenderness at hypochondrium area and positive murphy sign. He has central obesity with BMI 29.9, skin folds more than 3.5 cm and waist circumference more than 90 cm. He has History of high cholesterol and fatty diet and fast food habit, prolonged intake of vitamin D and positive family history. While, no other associated risk factors was detected in our patient. All laboratory investigations was within normal ranges even for his lipid profile. Although, empyema was present, no leukocytosis was detected. Abdominal ultrasound showed the gall bladder wall is slightly thick surrounded by pericholycystic fluid, solitary gall bladder stone of 3 cm size and normal CBD. While, post-operative histopathological examination revealed thick wall gallbladder with multiple tiny stones of cholesterol type. The patient was treated with laparoscopic cholecystectomy with promising outcome and no complications. Conclusion: Pediatric surgeons should consider cholecystolithiasis as from differential diagnosis of abdominal pain associated with vomiting in children. Empyema of gallbladder should be considered once murphy sign is positive in such child patients. Child obesity, fatty diet, vitamin D deficiency and family history are possible risk factors. Ultrasonography is the mainstay of diagnosis. Laparoscopic cholecystectomy is the appropriate management for symptomatic cholelithiasis in children.

1275 Intestinal-Type Intracholecystic Papillary Tubular Neoplasm (ICPN) Presenting as Acute Hemorrhagic Cholecystitis

INTRODUCTION: The term Intracholecystic Papillary Tubular Neoplasm (ICPN) was coined by Adsay et al (2012). ICPN includes mass-forming (papillary or polypoid), intramucosal and preinvasive gallbladder neoplasms larger than one cm in size. CASE DESCRIPTION/METHODS: A 73-year-old man presented with acute and sharp right upper quadrant abdominal pain for one day. He denied nausea, vomiting, diarrhea, fever or chills. Past medical history included COPD, non-Hodgkin lymphoma in remission and hypertension. He was not receiving anticoagulants or antiplatelet medications. On abdominal examination, there was marked tenderness in the right upper quadrant area with a positive Murphy's sign. Laboratory testing revealed leukocytosis of 22,000/µL with neutrophilia and normal liver chemistry tests and a serum lipase level. Abdominal ultrasonography showed a markedly distended gallbladder with mural thickening of up to 1.0 cm and numerous gallstones with a positive sonographic Murphy's sign. Non-contrast CT showed mixed attenuation suggesting hemorrhage into the gallbladder lumen and suggestive of acute hemorrhagic cholecystitis. He underwent open cholecystectomy. Surgical findings were a distended gallbladder with a thickened and inflamed wall. Half of the gallbladder lumen was occupied by stones and the remainder was filled with detached, friable, tan-red hemorrhagic material. Microscopic examination of several of detached fragments and intact mucosa showed an abundant ICPN of intestinal-type origin and a tubular-papillary growth pattern. There was marked acute and chronic inflammation of the gallbladder wall without mural perforation. DISCUSSION: ICPNs are usually seen in middle-aged individuals, with a 2- fold higher prevalence in women. Macroscopically, ICPNs are exophytic tumors: tubular/lobulated types are soft, friable and can get easily detached appearing as sludge or debris, while granular or papillary types are sessile and feathery filling the gallbladder lumen. ICPN exhibits a variety of cell lineages such as biliary (50%), gastric (25%), intestinal (8%, as in our patient), oncocytic (6%) and mixtures of lineages (∼10%). In our patient, the two most plausible pathogenic processes are either diagnosis of an incidental ICPN due to the associated acute calculus hemorrhagic cholecystitis or acute “acalculous” cholecystitis from tumor shedding and bleeding into the gallbladder lumen and causing cystic duct obstruction associated with asymptomatic (incidental) cholelithiasis.

1348 The Ketamine Connection: Ulcerative Cystitis and Biliary Dilatation in the Setting of Chronic Ketamine Abuse

INTRODUCTION: Recreational ketamine abuse can present with a unique constellation of symptoms, and limited literature on this topic makes this case a rare learning opportunity. CASE DESCRIPTION/METHODS: A 37-year-old male with diffuse psoriasis and a one-year-history of ketamine inhalation presented to the ER complaining of recurrent episodes of epigastric pain. The pain was described as colicky, non-radiating, and 10/10 in intensity; he related the pain acutely worsened in the 3 days prior to admission. He also had a remote history of cocaine and marijuana abuse. He denied vomiting, diarrhea, melena, dysphagia, odynophagia, fevers, or chills. Physical exam findings were negative for a Murphy's sign. Laboratory studies were significant for eosinophilia and an elevated lipase. A CT of the abdomen revealed hypodensities in the liver parenchyma and dilatation of the intrahepatic biliary ducts, common bile duct, gallbladder, and pancreatic duct. These findings suggested an obstructing stone or mass lesion at the ampulla. Furthermore, a pelvic CT also revealed an asymmetric, markedly thickened anterior urinary bladder wall and bladder dome; these findings were concerning for underlying malignancy of the bladder. A urinalysis revealed elevated white blood cells and red blood cells, but cytology was negative. A re-evaluation of the patient revealed symptoms of difficulty urinating, with sensation of having to push to void and dysuria at the end of micturition. Of note, the patient denied any history of freshwater swimming or exposure to factory chemicals. The patient underwent an EUS, which revealed a dilated common bile duct without stones, an acalculous gallbladder, and a deformed ampulla. A bedside cystoscopy was performed, revealing no tumors or strictures, but revealed a high-riding median lobe of the prostate at the bladder neck. Additionally, the posterior dome showed a thickened, erythematous area, and another rounded area consistent with ulcerative cystitis. Urology scheduled the patient for a repeat cystoscopy with biopsy, but unfortunately he left against medical advice as his pain and other symptoms had resolved. DISCUSSION: Ketamine, known for its hallucinogenic effects, is used recreationally among various populations. Hepatic-dominant metabolization, with urinary (90%) and biliary (10%) excretion leave these organs exposed to ketamine metabolites and their effects. This case emphasizes the importance of drug history in patients presenting with biliary colic and urinary symptomatology.

1396 Viral Acalculous Cholecystitis: A Rare Extrahepatic Manifestation of Hepatitis A

INTRODUCTION: Hepatitis A (HAV) is the most common form of acute viral hepatitis worldwide with an incidence of 0.6 reported cases per 100,000 population in the United States. Typical clinical symptoms include nonspecific prodromal symptoms such as fever, malaise, weakness, anorexia, nausea, vomiting and abdominal pain. Atypical features of HAV include recurrent hepatitis, prolonged cholestasis and extrahepatic manifestations. Acalculous cholecystitis (ACC) is an extremely rare extrahepatic manifestation of HAV. We present a unique case of acute hepatitis A presenting as ACC in an adult male with IV drug use. CASE DESCRIPTION/METHODS: A 50 year old male with a history of active IV heroin use and treated hepatitis C presented with nausea and RUQ abdominal pain for 3 days. On admission, laboratory findings were remarkable for AST of 2574 U/L, ALT of 3214 U/L, ALP 321 U/L and total bilirubin of 4.0 mg/dl. On physical examination patient was afebrile and hemodynamically stable with normal bowel sounds, soft abdomen, mild RUQ tenderness to deep palpation and Murphy's sign negative. CT abdomen demonstrated an edematous gallbladder wall with mild pericholecystic fluid and fat stranding, CBD diameter 4.0 mm (Figures 1 and 2). General Surgery believed his overall clinical picture to be due to acalculous cholecystitis and recommended non-operative management. Patients IgM Hepatitis A returned positive, Hepatitis B and C non-reactive. Thus, his findings were attributed to an active hepatitis A viral infection. He was treated conservatively with intravenous fluids and pain control. On discharge the patient remained afebrile, abdominal pain had resolved and liver function tests had normalized. DISCUSSION: Acute Hepatitis A with gallbladder involvement has been described in approximately 50 to 98% of adults. Although the etiology remains unclear, the invasion of the gallbladder by HAV and cell-mediated immunologic response have been proposed in the pathogenesis of HAV induced cholecystitis. The treatment is mainly conservative, as ACC due to HAV is transient and improves with resolution of viremia. Thus, patients do not require surgical interventions, unless they develop severe complications from ACC including gangrene and empyema. Our case demonstrates the importance of having a high clinical suspicion for HAV, especially in patients with known risk factors. Physicians should be cognizant of Hepatitis A and its rare extra hepatic manifestation, such as acalculous cholecystitis in order to avoid unnecessary surgical interventions.

3027 Lipase Stands Out: Is It Sufficient to Diagnose Acute Pancreatitis?

INTRODUCTION: Acute pancreatitis is defined when two out of the three diagnostic criteria are present such as abdominal pain often radiating to the back, characteristic imaging findings, and amylase and/or lipase levels that are three times or more the upper limit of normal (ULN). We present the case of an elderly male with abdominal pain and isolated raised lipase concentrations treated as acute pancreatitis. CASE DESCRIPTION/METHODS: A 96-year-old male with a history of dementia, coronary artery disease, hyperlipidemia, presented with sudden onset right-sided abdominal pain and six episodes of vomiting that started a few hours prior. He denied constipation, diarrhea, and fever. The patient does not drink alcohol or smoke. On arrival, he had a pulse of 77 beats/minute, blood pressure of 165/88 mm Hg, respiratory rate of 16 breaths/minute and oxygen saturation of 93% on room air. Physical exam revealed bilateral pedal edema along with significant tenderness in the right lower quadrant with mild tenderness in the right upper quadrant with negative Murphy's sign. Laboratory investigations revealed white blood cell count of 13 K/ul, sodium of 131 mmol/l, chloride of 95 mmol/l, calcium of 9.4 mg/dl, triglyceride levels of 60 mg/dl, aspartate aminotransferase of 65 U/l, alanine transaminase of 36 U/l, and alkaline phosphatase of 123 U/l, and lipase of 4450 U/l. Ultrasound of the gall bladder and computed tomography of the abdomen revealed diffuse gallbladder wall thickening with pericholecystic fluid without any significant pancreatic abnormality. A provisional diagnosis of acalculous cholecystitis was made and he was started on intravenous (IV) ceftriaxone one gm, once a day and IV metronidazole 500 mg, thrice a day with IV pantoprazole 40 mg, once a day. Magnetic resonance cholangiopancreatography done after two days revealed the absence of gall bladder wall thickening. Cholecystitis was thus ruled out and the patient was diagnosed with acute pancreatitis owing to the raised levels of lipase. A resolution of abdominal symptoms and a decreasing trend was seen in serum lipase levels on day four of hospitalization but the levels still remained above the ULN (Figure 1). The patient was discharged with surgical follow-up on an outpatient basis. DISCUSSION: The cut-off set for lipase levels in acute pancreatitis has a specificity of &gt;99%. Clinicians should have a high suspicion of pancreatitis in patients with abdominal pain and isolated hyperlipasemia but be wary of alternative diagnosis too.

3189 Portal Vein Thrombosis Without Cirrhosis: A Case Report

INTRODUCTION: PVT is a rare entity in the absences of liver cirrhosis, malignancy, prothrombotic disorder or an intra-abdominal inflammatory state. In some cases, no clear etiology can be found and it can be triggered by a combination of factors. We report a case of non-cirrhotic woman with a symptomatic and progressive PVT in the setting of low antithrombin activity and liver lesions. CASE DESCRIPTION/METHODS: 48 year old female without past medical or family medical history, was brought to the ED with diffuse abdominal pain. For the past ten weeks, she has experienced post-pandrial abdominal pain associated with nauseas and two episodes of non-bloody vomiting. She denied diarrhea, recent abdominal infections, drug use or OCP use. Patient has not undergone abdominal surgery. Her physical exam was unremarkable except for mild diffuse abdominal pain, no Murphy's sign, no guarding or rebound signs. CBC, BMP, lipase and liver function panel was unremarkable. Recent mammography, EGD and colonoscopy displayed no signs of malignancy or portal hypertension. MRA showed no stenosis or obstruction of arteries. CAT-scan of abdomen and pelvis with IV contrast showed extensive thrombosis of main portal vein, right portal vein, left portal vein and the portosplenic confluence. Also showed collateral vessels extending from the portosplenic confluence into the bilateral retroperitoneum, bilateral renal hilum and extending across the ovarian veins into the pelvis. There were multiple indeterminate hypodense liver lesions. Additional laboratory tests were ordered and samples collected before starting anticoagulation. Laboratory tests showed decrease antithrombin activity, which is a risk factor for PVT. She was admitted on low-molecular weight heparin (LMWH) until stabilization, and then discharged on oral anticoagulation. In this case, outpatient follow up evaluation by hemato-oncology was scheduled to rule out other coagulation disorders and malignancy. DISCUSSION: PVT in a healthy and young patient is not common. The prevalence of PVT is low in patients with cirrhosis; it is even lower in patients non-cirrhotic and without malignancy. It has been estimated that in non-cirrhotic PVT, hypercoagulable states account for 40%-60% of cases. The American Association for the Study of Liver Diseases (AASLD) guidelines recommend treatment with anticoagulation to prevent thrombi extension and to restore blood flow in occluded vessels. The outcome for non-cirrhotic, non-malignant PVT is good if the diagnosis and treatment occurs early.