Pain In Right Upper Quadrant Research Articles

EGS SO05 - Improving the Flow of Patients Attending Surgical Assessment Unit: Introduction of Ambulatory USS Slots - Closed Loop Audit

Abstract Background Modern emergency surgical service recognises that a significant proportion of patients presenting with acute abdomen can be diagnosed and treated in the ambulatory fashion. However, this approach requires multidisciplinary cooperation between the general surgery team and radiology department. We aimed to assess and improve the flow of patients presenting to Surgical Assessment Unit (SAU) with complaints of right iliac fossa (RIF) and right upper quadrant (RUQ) pain. Method We performed a retrospective analysis of all ambulatory patients returning to SAU of a District General Hospital with RUQ and RIF pain in January 2023. We measured the waiting time between the arrival to SAU and the time of USS. We presented the results in a local meeting and negotiated the introduction of two daily USS slots for SAU patients. We re-assessed the impact of the USS slots on waiting times in July 2023. Results In January 2023, 13 patients returned to SAU for USS. The minimum waiting time for this cohort was 59 minutes and the maximum waiting time was 3 hours and 39 minutes. The median was 2 hours and 15 minutes. In July 2023, 18 patients returned to SAU for USS. The minimum waiting time for this cohort was 4 minutes and the maximum waiting time was 2 hours and 20 minutes. The median was 1 hour and 5 minutes. There was an average reduction of 1 hour and 10 minutes in waiting time for USS. Conclusion The introduction of two USS slots per day for patients returning to SAU with RUQ and RIF pain resulted in a 48% reduction in waiting times. This improved the flow of patients, sped up the diagnosis and timely access to treatment, as well as significantly improved patients experience and satisfaction. We would recommend close co-operation between general surgery and radiology to allow timely access to imaging for patients presenting with acute abdomen to SAU.

Impact of Intraoperative Nefopam on Postoperative Pain, Opioid Use, and Recovery Quality with Parietal Pain Block in Single-Port Robotic Cholecystectomy: A Prospective Randomized Controlled Trial.

Background and Objectives: This study explored how nefopam, a non-opioid analgesic in a multimodal regimen, impacts postoperative pain, opioid use, and recovery quality in single-port robot-assisted laparoscopic cholecystectomy (RALC) patients with a parietal pain block, addressing challenges in postoperative pain management. Materials and Methods: Forty patients scheduled for elective single-port RALC were enrolled and randomized to receive either nefopam or normal saline intravenously. Parietal pain relief was provided through a rectus sheath block (RSB). Postoperative pain was assessed using a numeric rating scale (NRS) in the right upper quadrant (RUQ) of the abdomen, at the umbilicus, and at the shoulder. Opioid consumption and recovery quality, measured using the QoR-15K questionnaire, were also recorded. Results: The 40 patients had a mean age of 48.3 years and an average body mass index (BMI) of 26.2 kg/m2. There were no significant differences in the pre- or intraoperative variables between groups. Patients receiving nefopam reported significantly lower RUQ pain scores compared to the controls, while the umbilicus and shoulder pain scores were similar. Rescue fentanyl requirements were lower in the nefopam group in both the PACU and ward. The QoR-15K questionnaire scores for nausea and vomiting were better in the nefopam group, but the overall recovery quality scores were comparable between the groups. Conclusions: Nefopam reduces RUQ pain and opioid use post-single-port RALC with a parietal pain block without markedly boosting RSB's effect on umbilicus or shoulder pain. It may also better manage postoperative nausea and vomiting, underscoring its role in analgesia strategies for this surgery.

FRI229 Bilateral Adrenal Hemorrhage Following Deep Tissue Body Massage

Abstract Disclosure: M. Antony: None. S. Gundlapally: None. P. Russell: None. S. Storm: None. S. Patel: None. V. Verma: None. R. Kant: None. Introduction: Adrenal hemorrhages have been reported in patients undergoing ACTH stimulation test using bovine- source ACTH. It can also be seen in severe stressful situations such as septicemia and extensive thermal burns due to sudden and profound adrenocortical stimulation by endogenous ACTH. Idiopathic spontaneous adrenal hemorrhage and motor vehicle accident induced adrenal hemorrhage have also been rarely reported. Coagulopathy, thromboembolic disease, and postoperative state are 3 major risk factors associated with bilateral adrenal hemorrhage. We present a unique case of a patient who presented with bilateral adrenal hemorrhage following deep tissue body massage. Clinical Case: A 44-year-old male with a past medical history of recurrent pulmonary embolism (PE) and deep venous thrombosis (DVT) due to lupus anticoagulant disorder status-post inferior vena cava (IVC) filter and recent change from Coumadin to Xarelto presented to the ED with a chief complaint of right upper quadrant (RUQ) pain extending to the right flank. Patient experienced unrelenting pain after a deep-tissue massage one week prior to presentation. Patient was seen two days prior to admission for similar complaints, but was discharged after reassuring CT abdomen/pelvis, ultrasound, and labs. He returned after pain worsened, and a repeat CT showed right adrenal hemorrhage and enlargement. Patient denied all other symptoms except pain. Vitals included BP of 144/84 mmhg, RR 20/min, HR 89/min, temp of 98.1°F, and SpO2 of 99%. Physical exam was notable only for RUQ pain and right CVA tenderness. Initial labs showed normal CBC including HGB 13.6g/dL (13-17 g/dL), HCT 37.5% (38.5-52%), and PLT 181K/microL (150-450 K/microL). Glucose 120mg/dL (70-99mg/dL), Na 129mmol/L (135-146 mmol/L), K 3.3mmol/L (3.5-5.2 mmol/L), Cl 87mmol/L (98-107 mmol/L), anion gap 17mmol/L (4-15mmol/L). LFT, serum lipase and CPK were non-contributory. PT was elevated at 24.7s (10-13s) and INR was 2.1 (0.9-1.2). Anticoagulation was stopped for three to four weeks, and nonsurgical management was recommended. Potassium supplementation was given, and the patient was continued on his hypertension medications. On further investigation, origin of the hemorrhage was determined to be traumatic secondary to the massage during which the masseuse walked on the patient. The patient was discharged after three days but was readmitted after continued abdominal pain and hyponatremia. He was diagnosed with a left-sided adrenal hemorrhage on repeat CT scan twelve days after identification of the first. Medical management was successful. Conclusion: Adrenal hemorrhage is a potentially life-threatening condition often caused by trauma, severe burns, or septicemia. Anticoagulant therapy and thromboembolic disease, as seen in our patient, are also risk factors. The atypical trauma induced by the patient's massage likely initiated the hemorrhagic event. Presentation: Friday, June 16, 2023

Double closed loop small bowel obstruction due to right diaphragmatic hernia after transcatheter arterial chemoembolization and microwave ablation for hepatocellular carcinoma.

64-Year-old male patient with hepatocellular carcinoma (HCC), liver cirrhosis, chronic hepatitis C infection, and glottic cancer presented with acute progressive abdominal pain and palpable mass in right upper quadrant of the abdomen. Despite treatment with hyoscine and tramadol, the symptoms persisted. He had received three sessions of Transcatheter arterial chemoembolization (TACE) and two sessions of microwave ablation (MWA) for HCC treatment, with the last session being TACE 11months prior. Plain film abdomen showed bowel gas pattern in the right hemithorax compatible with bowel obstruction. CT imaging revealed a right diaphragmatic hernia containing closed loop small bowel obstruction. An emergency exploratory laparotomy was performed. The patient improved and was discharged. There was no recurrence of diaphragmatic hernia or abdominal mass or pain at the 6-month follow-up visit. We herein demonstrate a catastrophic complication of TACE by using an IPA and MWA which leads to right diaphragmatic hernia.

Effectiveness of ultrasound screening in right upper quadrant pain: A comparative study in a basic emergency service.

The use of ultrasound screening is primarily facilitated by point-of-care ultrasound (POCUS) and its integration into healthcare systems is a result of the versatility of this imaging technique. This study intends to compare the accuracy and pertinence of sonographic findings obtained by a sonographer in a Basic Emergency Service (BES) with that of radiologists at referral hospital (RH) in Portugal. Twenty patients with right upper quadrant (RUQ) pain and suspected cholecystitis or biliary pathology underwent sonography screening using POCUS in the BES. They were then forwarded to the RH where a radiologist performed a conventional ultrasound exam on the same patients. The results of both exams were compared to determine if the findings obtained in the BES were confirmed by the radiologist in the RH. In our sample, 60% of cases were related to biliary pathology, 20% were liver-related, 10% had hepatopancreatic biliary etiology, and 10% had unknown etiology. A strong association between the sonographic findings in the BES and the RH was found in the variables "Sonographic Murphy sign" (V = 0.859; p = 0.001), "Cholelithiasis/Gallbladder sludge" (V = 0.840; p = 0.001), and "Intrahepatic biliary tract dilatation" (V = 0.717; p = 0.006). Adequate measures of agreement between the findings of the radiographer and radiologist were obtained for the "Sonographic Murphy sign" (k = 0.664; p = 0.001) and the presence of "Cholelithiasis/Gallbladder sludge" (k = 0.712; p = 0.000). Major biliary abnormalities were detected in patients with RUQ pain in BES using sonography. The correlation between the sonographic findings obtained by the sonographers at BES and those obtained by radiologists at the RH in Portugal was strong, showing that POCUS screening could be extended to other similar settings; however, more studies are needed.

Cholecystalgia: An Atypical Presentation of Congestive Heart Failure in a New Diagnosis of Alcohol-Induced Cardiomyopathy

Right upper quadrant (RUQ) pain is a frequent presenting symptom in the emergency department, and gallstone-induced acute cholecystitis is one of the main causes; in addition, RUQ pain can be a consequence of several other conditions. Although rare, it may also indicate cholecystalgia from gallbladder edema, which is usually related to other conditions, such as congestive heart failure (CHF), alcoholic and nonalcoholic liver cirrhosis, acute viral or drug-induced hepatitis, renal failure, and hypoproteinemia. We present a case of cholecystalgia resulting from gallbladder edema in a patient with a newly diagnosed alcohol-induced cardiomyopathy without the common CHF signs and symptoms.

STUDY OF ETIOLOGY OF LIVER ABSCESS AND IT'S DIFFERENT WAYS OF MANAGEMENT

Background: Liver abscess are cystic, space occupying lesion within liver parenchyma. It has become one of the most common disease with more prevalence in underdeveloped and developing countries. Pyogenic liver abscess more common in western world while amoebic liver abscess are more common in underdeveloped countries and people living with lower socio-economic conditions. Liver abscess, undiagnosed and untreated, has a very high mortality rate. With early diagnosis and prompt institution of specic therapy, the prognosis is good and the mortality is very low. Surgical management was the mainstay for treating liver abscess earlier. However, USG guided percutaneous needle aspiration and percutaneous drainage procedure shown a favorable outcome with less average length of stay in hospital. In this study we aimed to study etiology of liver abscess and its different ways of management. To study the etiology of liver abscess Aim: Materials And Methods: and its different ways of management. This is a prospective, observational study was conducted in GSVM Medical College, LLR & Associated Hospitals, Kanpur (UP).Study was done on 100 patients with different types of liver abscess. Patient with ruptured liver abscess were not included. Outcomes were assessed on the basis of recurrence (with regular follow ups at one month, three months, six months and one year); relieving of symptoms and length of stay in hospital. Results: Out of 100 patients majority of patients were in the age range of 31-45 (56.0%) followed by 46-60 (22.0%) with mean age of 40.74±10.53 years. Most of the cases were males (98%), and females (2.0%). Majority of patients were with lower socioeconomic status (96%). Most of the patient having amoebic liver abscess (66%) with positive ELISA for antibodies, while 34 % of patient having pyogenic liver abscess with 10% having bacterial growth on culture examination having E.coli . 84% of cases having liver abscess in right lobe and were single (66.0%). On the basis of their personal history, comorbidities and clinical features, 14.05 were diabetic, 44.0% were alcoholic, 98% were having fever with 60% cases have chills and rigor and 100% having pain in right upper quadrant. Majority of cases undergone pigt Conclusion: ail treatment were pyogenic (76.4%) and majority of amoebic abscess were treated with aspiration (72.7%) and difference was found statistically signicant with p value of 0.001. Reduction in size of abscess cavity was observed in all the cases but recurrence was higher in conservative treatment (p=0.007) and length of stay was higher in pigtail (p<0.001).

An Exceptional Case of Cobalamin Deficiency that Presented with Extremely High Indirect Bilirubin Levels

Cobalamin deficiency anemia is a type of anemia that present with weakness, fatigue, icteric sclera and neuropathy. Main causes of cobalamin deficiency are low intake or decreased absorption (gastric and intestinal causes). In present case, we report a 65-year-old male who presented to the emergency department with signs and symptoms of cobalamin deficiency including bilateral peripheral neuropathy, icteric skin and sclera, and abdominal pain in right upper quadrant. He had low cobalamin and extremely high bilirubin levels (8mg/dL) in serum. After the diagnosis of cobalamin deficiency established, 1mg daily cobalamin treatment initiated for five days which would follow weekly and monthly intramuscular injections consequently. Hemolysis and other causes of elevated indirect bilirubin levels were excluded in differential diagnosis. Clinical and laboratory improvements were achieved after the treatment. In conclusion, physicians should kept in mind cobalamin deficiency even in subjects with unusual high levels of indirect bilirubin.

S3238 A Case of Concurrent Cholecystitis and Stauffer Syndrome

Introduction: Stauffer syndrome (SS) is a paraneoplastic syndrome seen in some malignancies, most commonly 4-15% of primary renal cell carcinomas, resulting in nephrogenic hepatic dysfunction. SS commonly results in elevated alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and prothrombin time (PT) as well as decreased albumin in the absence of liver metastasis. The etiology of SS is unknown, although three have been suggested: elevated interleukin-6, elevated colony stimulating factor or, least likely, autoimmune. We describe a case of a woman presenting with right upper quadrant (RUQ) pain who was found to have indirect predominant hyperbilirubinemia and acute cholecystitis and renal mass on ultrasound. Case Description/Methods: An 81-year-old female presented to an outside hospital for RUQ and epigastric pain that worsened after fatty meals. Imaging showed acute cholecystitis as well as a right renal mass. Physical exam at the time was remarkable only for diffuse tenderness to abdominal palpation, most notably in the RUQ. There was no scleral icterus or costovertebral angle tenderness on exam. Labs on presentation can be seen in Table 1. Given the elevated indirect bilirubin, gastroenterology was consulted and suggested Gilbert syndrome (GS) or SS given their concern for renal cell carcinoma (RCC). The next day the patient underwent a laparoscopic cholecystectomy notable for acute gangrenous cholecystitis with cholelithiasis, and had rapid normalization of bilirubin over 48 hours. The patient followed with outpatient urology for renal biopsy, which was positive for clear cell RCC. Follow up imaging revealed scattered pulmonary nodules up to 1.1cm, with concern for metastasis. Surgery was deemed inappropriate and the patient was conservatively managed, given her wishes to prioritize quality of life and not undergo chemotherapy. (Figure) Discussion: This case illustrates an interesting clinical picture where a patient with confirmed cholecystitis also has a new renal mass, with elevated indirect bilirubin and PT, consistent with SS. The diagnosis of SS is made clinically, with hopeful resolution of abnormal lab values upon RCC resection. In this case, surgery was not indicated, hemolysis was ruled out with stable hemoglobin and normal peripheral smear, and the diagnoses of acute cholecystitis and RCC causing SS was made. In addition to hemolysis, GS, and Criggler-Najjar when working up indirect hyperbilirubinemia, it is imperative to include SS on the differential diagnosis.Figure 1.: CT abdomen with right renal mass. Table 1. - Patient labs on presentation and 2 days post-cholecystectomy Lab Admission Post-Op Day 2 Normal WBC Count (103 cells/uL) 17 14 4.1-9.3 Platelet (103/uL) 246 248 130-350 Hemoglobin (g/dL) 10.6 9.8 11-14.7 Albumin (g/dL) 3.3 2.7 3.5-5.2 Total Bilirubin (mg/dL) 2.8 0.9 0.1-1.2 Indirect Bilirubin (mg/dL) 2.4 0-0.9 Alkaline Phosphatase (IU/L) 96 102 30-115 AST (IU/L) 23 20 5-45 ALT (IU/L) 12 16 5-60 Lipase (U/L) 12 11-82 Prothrombin Time (s) 14.3 9.4-12.9 INR 1.2 0.83-1.14 AST = aspartate transaminase, ALT = alanine transaminase.

S2473 A Case of Familial Mediterranean Fever Diagnosed by Abdominal CT Scan in a Patient Previously Diagnosed With Functional Abdominal Pain

Introduction: Familial Mediterranean fever (FMF) is a hereditary autoimmune disease in which patients present with periodic, self-limited episodes of fever and serositis. It is prevalent in individuals of Middle Eastern origin. Since no definitive diagnostic test is available, FMF is suspected based on clinical symptoms; there are major and minor criteria to aid in making the diagnosis. Imaging modalities are not included in these criteria. We present a patient whose only symptom was recurrent abdominal with no family history of FMF. At the time he was diagnosed with Functional Abdominal Pain. FMF was suspected based on unexplained focal peritonitis on computerized tomography (CT). Case Description/Methods: A 45-year-old male of Middle Eastern descent was seen in clinic complaining of episodic right upper quadrant (RUQ) abdominal pain since he was 17 years old. The pain occurred once or twice per month. Over the years he had multiple visits to the emergency department and extensive work up including endoscopic evaluation and imaging studies. He underwent cholecystectomy, and bilateral inguinal hernia repair without benefit. He was diagnosed with Functional Abdominal Pain then. When evaluated in our clinic, lab work showed mild iron deficiency anemia; otherwise, unremarkable. Upper endoscopy, colonoscopy, small bowel series and capsule endoscopy were normal. 3 months later he presented to our ER with an acute episode of severe RUQ pain. He was afebrile; abdominal exam was remarkable for localized tenderness in the RUQ. Lab work was remarkable for an elevated erythrocyte sedimentation rate of 31. Abdominal CT was only remarkable for fat stranding around the hepatic flexure and the proximal half of the transverse colon. Colonoscopy was normal with no evidence for segmental colitis to explain the inflammatory changes. Given the history of recurrent abdominal pain, ethnicity, and focal unexplained peritonitis on CT scan, FMF was suspected, and treatment with colchicine was initiated without recurrence of symptoms for now several years since the diagnosis, meeting diagnostic criteria for FMF. Discussion: If not considered, FMF can remain misdiagnosed for many years leading to unnecessary procedures and surgeries. This was an unusual presentation with afebrile episodes of intermittent RUQ pain with the diagnosis ultimately suspected by CT imaging and confirmed by response to colchicine. Clinicians should consider FMF in patients of high-risk ethnic origin presenting with unexplained focal peritonitis on CT scan.

S3162 Subcapsular Hepatic Hematoma: A Rare Complication of Hemolysis, Elevated Liver Enzymes, and Low Platelet Count (HELLP) Syndrome in Pregnancy

Introduction: Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is seen in 0.1-1.0% of pregnant people overall, with the risk increased by preeclampsia. Common complications of HELLP include bleeding, disseminated intravascular coagulation (DIC), and abruptio placentae. Here we present a rare case of subcapsular liver hematoma that occurs in only 1% of HELLP patients. Case Description/Methods: A 29-year-old woman, gravida 4, para 3 with a history of preeclampsia during prior pregnancies presents with acute onset epigastric and pelvic pain for one day at 27th-week gestation. The severe, intermittent epigastric pain radiates laterally down to the pelvis and is aggravated with laying down. The review of systems and vitals were normal. Mild tenderness in the right upper quadrant (RUQ) was noted. Labs showed high ALT 233 U/L, AST 378 U/L, low platelet 108,000/microL, and high LDH 519 IU/L. The rest of the labs were normal. She underwent an emergent C-section at admission for HELLP syndrome. An ultrasound showed two complex hypoechoic hepatic mass-like areas measuring 9.3cm and 3.5 cm in the setting of hepatomegaly and diffuse hepatic steatosis suggestive of focal fatty sparing or cavernous hemangioma. Biliary sludge without cholecystitis or cholelithiasis was also noted. An MRI with IV contrast with the liver mass protocol was obtained which showed hepatic subcapsular hematoma of dimensions 24 cm x 9.2 cm x 3.9 cm at the level of the right hepatic lobe. The pain continued to worsen with a drop in hemoglobin from 12.8 gm/dl at admission to 7.1 gm/dl on day 4. IR was consulted for rupture concern and recommended CT angiography of abdomen and pelvis with and without arterial/venous phase that showed similar appearing subcapsular hematoma without an active bleed. Underwent image-guided hepatic angiography that showed large perihepatic hematoma along the right lateral abdominal wall without active contrast extravasation. Right hepatic artery embolization was done with a reduction in peripheral hepatic arterial blood flow by 25%. Later hemoglobin stabilized, liver enzymes improved, and the patient was discharged home 6 days later in a clinically stable state (Figure). Discussion: Early diagnosis of subcapsular hematoma is challenging due to nonspecific signs and symptoms but crucial for improved outcomes. Physicians should evaluate for a subcapsular hematoma in patients with HELLP and RUQ pain or hypotension. Therapeutic options for ruptured hematomas include laparotomy and hepatic artery embolization.Figure 1.: Coronal section of MRI with IV contrast (Liver mass protocol) of abdomen and pelvis demonstrates subcapsular hepatic hematoma involving the hepatic dome and right hepatic lobe approximately measuring 24 cm in craniocaudal dimension.

S2945 Check Point SOS! A Case of Cemiplimab-Associated Sinusoidal Obstruction Syndrome

Introduction: Hepatic veno-occlusive disease (VOD) or sinusoidal obstruction syndrome (SOS), is a clinical syndrome characterized by hepatomegaly, right-upper quadrant pain, and ascites that occurs most commonly in the setting of high-dose chemotherapy or hematopoietic stem cell transplantation (HSCT). The diagnosis can be confirmed on biopsy. Cemiplimab is an immune checkpoint inhibitor recently approved for the treatment of cutaneous squamous cell carcinoma. There are currently no known reports of immune checkpoint inhibitor-related VOD/SOS. Case Description/Methods: A 58-year-old female with a history of locally advanced basal cell carcinoma of the left eye treated with six months of Cemipilimab presented with ascites. On admission, labs were notable for a total bilirubin of 1.2, mildly elevated liver function tests, alkaline phosphatase 884, and international normalized ratio 2.1. A diagnostic tap revealed a high SAAG ascites that was negative for infection. A comprehensive serological workup for viral, metabolic and autoimmune causes was unrevealing. A transjugular liver biopsy demonstrated a hepatic venous pressure gradient of 18mmHg, nodular regenerative hyperplasia (NRH), and portal venopathy. The patient was discharged on steroids but returned one month later for recurrent ascites and worsening bilirubin to 12.6 (direct 7.3); COVID PCR was negative. A full rheumatologic and vasculitis workup was unremarkable. Repeat biopsy (Figure 1) demonstrated moderate NRH changes, prominent central vein sclerosis with fibrous obliteration, signs of SOS/VOD and central venulitis with fibrotic changes with sinusoidal portal hypertension. Discussion: VOD occurs most often with hematopoietic stem cell transplantation, and chemotherapeutic agents. Here we present the first case of checkpoint inhibitor-induced VOD/SOS. Despite discontinuation of the offending agent and a trial of steroids, the patient’s clinical course continued to deteriorate. She eventually developed refractory ascites and portosystemic encephalopathy. She was deemed not a candidate for liver transplant given her underlying malignancy. She was transitioned to home hospice before further treatment, such as Defibrotide could have been pursued. VOD associated with immune checkpoint inhibition should be considered in the differential of patients who develop new onset liver dysfunction and ascites while receiving these medications.Figure 1.: Sinusoidal dilatation and congestion alongside central vein sclerosis. These are common findings of sinusoidal obstruction syndrome on liver biopsy.

S2843 How Many Stones Are Too Many Stones?

Introduction: Gallstones disease or cholelithiasis has become one of the most prevalent diseases of the developed world in the last few decades. Certain populations, including pregnant females, have been identified to be at increased risk. Gallstones can be present in 1-3% of all pregnancies and acute cholecystitis is the second cause of non-obstetric indication for surgery in pregnancy. In pregnancy, there is an influx of estrogen, which increases cholesterol secretion. By the other side, increased progesterone levels reduce bile secretion and delay gallbladder emptying. These changes result in super-saturation of bile with cholesterol and a predisposition to gallstone formation. We present the case of a postpartum female that presented with cholelithiasis and choledocholithiasis. Case Description/Methods: A 28-year-old female with past medical history significant for hypothyroidism and recent pregnancy, presented to the hospital with complaints of right upper quadrant (RUQ) abdominal pain. She had gone out of the country in order to seek medical attention and was prescribed Flagyl and Ketorolac, with no symptomatic relief. She had worsening RUQ pain described as “colicky”, worse in the epigastric region, in addition to significant pruritus. Patient’s review of systems was positive for nausea, dark urine, and jaundice for the last 4 days. In the hospital, she had abnormal liver enzymes. Ultrasound and abdominal CT presented with significant biliary dilation. Magnetic resonance cholangiopancreatography (MRCP) demonstrated “innumerable gallstones”, measuring between 3 to 6mm, located in the cystic and common bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincteroctomy resolved patient symptomatology. (Figure) Discussion: Despite the increased frequency of gallstone disease in pregnancy, there is no consensus on the management of symptomatic cholelithiasis and/or choledocholithiasis, in this setting. Conservative management with symptomatic treatment has been the gold standard for decades. However, the risk for recurrent symptoms and subsequent hospital admission is high, at times up to 72%. The Society of American Gastrointestinal and Endoscopic Surgeons recommend laparoscopic cholecystectomy as the treatment of choice for symptomatic cholelithiasis, regardless of pregnancy state. Developing a standard guide to manage symptomatic cholelithiasis and choledocholithiasis in pregnancy would save both time and cost to the patient and healthcare system.Figure 1.: Shows the magnetic resonance cholangiopancreatography (MRCP) of our patient with numerous stones on the common bile duct Panel 1 and 2). Endoscopic retrograde cholangiopancreatography (ERCP) showing some of the multiple stones that came out after sphincterotomy was performed (Panel 3).

An Unusual Cause of a Cecal “Seesaw” and Pneumatosis Intestinalis

Question: A 66-year-old woman with history of stroke, previous hernia surgery with mesh placement, and obstructive cholestasis due to choledocholithiasis presented with 3 days of right-sided abdominal pain, 15-lb weight loss over 1 month, and 3 weeks of constipation with thin stools. Colonoscopy was normal a few months prior. Her prior episode of choledocholithiasis in 2017 led to endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and placement of a double pig-tail stent. She was recently admitted 1 month ago for jaundice and right upper quadrant (RUQ) pain at which time magnetic resonance cholangiopancreatography showed severe intrahepatic and extrahepatic biliary duct dilation but no liver or pancreatic lesions. The cecum was nonspecifically distended and fluid filled. Esophagogastroduodenoscopy revealed a benign-appearing intrinsic duodenal stricture felt to be related to scar tissue from the previous hernia mesh surgery. ERCP revealed an occluded biliary stent that had migrated to the major papilla and a severe burden of choledocholithiasis. The occluded stent was removed, and partial removal of stones was achieved via basket extraction. A new biliary stent was placed with a plan to follow up in 4 weeks for repeat ERCP for further stone extraction and stent removal. Before this appointment she was readmitted for worsening RUQ pain. A computed tomography scan revealed dilated loops of distal small bowel and a dilated cecum that had folded anteriorly and superiorly with extensive pneumatosis. The ascending colon was also dilated up to a decompressed hepatic flexure, where nonspecific bowel wall thickening was visualized, suggesting a transition point. No obvious mass or lesion was noted at the hepatic flexure (Figure A). Despite clinical improvement with conservative management, a lower gastrointestinal series performed a few days later showed persistent severe obstruction at the hepatic flexure with bird-beak appearance (Figure B). What is the most likely explanation for these imaging findings and how should it be managed? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. The patient’s imaging findings are consistent with cecal bascule (type III cecal volvulus). Cecal bascules are the rarest variant of cecal volvulus that involve upward folding of the cecum, without axial twisting or sigmoid involvement.1Rabinovici R. Simansky D.A. Kaplan O. et al.Cecal volvulus. Dis Colon Rectum. 1990; 33: 765-769Crossref PubMed Scopus (119) Google Scholar Bascule in French means “seesaw,” describing the pathophysiology of the cecal presentation. Surgical management was indicated given the persistent and severe hepatic flexure stricture seen on lower gastrointestinal series. Exploratory laparotomy revealed numerous omental nodules and a mass was discovered in the RUQ involving the gallbladder and liver that was causing extrinsic compression of the hepatic flexure. The largest nodule was excised and confirmed a diagnosis of metastatic cholangiocarcinoma. A distal loop ileostomy was created to decompress the colon and prevent ongoing colonic obstruction. No colonic resection was necessary. The patient began cancer staging and treatment planning, but unfortunately passed 1 month after diagnosis. This is a unique case of an extrinsic malignant obstruction causing cecal bascule. The development of a cecal bascule is usually attributed to an abnormally mobile cecum due to improper development and insufficient fixation of the mesentery to the posterior parietal peritoneum. A mobile cecum may also be acquired in pregnancy due to enlargement of the uterus or after abdominal surgery, such as open appendectomies, which require extensive division of peritoneal attachments to the cecum. Clinical presentation varies with abdominal pain, distention, and nausea being the most common symptoms but can progress to an acute abdomen and perforation.2Lung B.E. Yelika S.B. Murthy A.S. et al.Cecal bascule: a systematic review of the literature.Tech Coloproctol. 2018; 22: 75-80Crossref PubMed Scopus (14) Google Scholar Diagnosis of type III cecal volvulus requires computed tomography imaging confirming a distended cecum lying anterior to ascending colon. Treatment generally involves surgical resection of the affected bowel because colonoscopic detorsion may lead to recurrence.3Le C.K. Nahirniak P. Qaja E. Cecal volvulus. StatPearls Publishing. StatPearls Website, 2021Google Scholar

Comparison of Diagnostic Accuracy of CT scan and USG in Right Upper Quadrant Pain: A Review Analysis

Purpose: Acute right upper quadrant (RUQ) pain is a common presenting symptom in emergency departments and outpatient medical practices, and is most commonly attributable to biliary and hepatic pathology. The main objective of the study is to systematically analyse the comparison of diagnostic accuracy of ultrasound and computed tomography in right upper quadrant pain. Material and methods: This study was conducted using a systematic search on Google scholar, Pubmed and Web of science published until 20th June 2020. The cited references of retrieved articles and previous reviews were also manually checked to identify any additional eligible studies with indexed search terms for cholecystitis, US, cholescintigraphy, CT, and MR imaging. Results: After excluding duplicates and articles that did not meet the inclusion criteria, we obtained 30 articles with full-texts which were read for further evaluation, where another 60 were excluded as irrelevant. Overall, we included 30 articles that directly match on the inclusion criteria. Conclusion: It is concluded that RUQ pain were not as good as sensitivities reported in prior studies. CT was statistically significantly better for the diagnosis of RUQ pain than US, most likely because of an unclear clinical picture, the patient population, and a high proportion of poor-quality US examinations. However, US is still our first test of choice if RUQ pain is suspected clinically, whereas CT is performed when the clinical picture is unclear.

Clinical diagnosis of cholecystitis in emergency department patients with cholelithiasis is indication for urgent cholecystectomy: A comparison of clinical, ultrasound, and pathologic diagnosis

BackgroundBiliary pathology is a common reason for emergency department visits with discharge and outpatient follow up if sonographic evaluation does not reveal evidence of cholecystitis. This retrospective review was conducted to assess the sensitivity of clinical versus sonographic evaluation for indication of urgent cholecystectomy. MethodsRetrospective chart review of 308 patients who presented to the emergency department (ED) with right upper quadrant (RUQ) pain and cholelithiasis whom underwent cholecystectomy. The history and physical exam, laboratory values, ultrasound (US), and final surgical pathology were compared for accuracy of clinical to pathologic diagnosis. Results95.5% of our patients that presented to the ED secondary to RUQ pain with cholelithiasis had pathologic cholecystitis. Sensitivity of clinical diagnosis was superior to US findings as compared to pathologic diagnosis of cholecystitis at 96% vs 44% and 87% vs 18% for acute (AC) and chronic cholecystitis (CC) respectively. ConclusionRUQ pain with known cholelithiasis lasting longer than 4 hours is sensitive for pathologic cholecystitis. This finding, even with the absence of sonographic evidence of cholecystitis, is indication for index encounter urgent cholecystectomy.

Sonographic findings in patients with an acute pain in Right Upper Quadrant

Abdominal pain is a common presentation in the outpatient setting. Patients presenting to the emergency department with RUQ pain are often diagnosed with acute cholecystitis. The spectrum of diseases is also associated with RUQ pain including choledocholithiasis, biliary colic and liver pathologies. Ultrasoundis the first-line imaging modality opted to diagnose the cause of RUQ pain. More than one-third of patients suspected of having acute cholecystitis and right upper quadrant pain after the initial clinical evaluation are ultimately proved to have a different diagnosis.The objective of this study is to find sonographic findings in patients with acute RUQ pain and establish reasons of using Ultrasound in these circumstances. Material and Method: A total of 385 cases who were presented with RUQ pain in Sanabil Health Services Hospital were included in this descriptive observational study. 190 were female and 195 were male with a mean age of 44.7±13.4 years. A thorough scan of complete abdomen was done and results were analyzed through IBM SPSS statistics 28.0 version 2021. Results:Out of total 385 patients, 91 patients (23.6%) were suffering from cholelithiasis and only 19 (5.0%) of them had cholecystitis which are major causes of right upper quadrant pain. Majority of patients (26.8%) were diagnosed with Fatty liver disease, Obstructive kidney disease (17.4%) and a significant number of patients (14.5%) were also normal on Ultrasound scan. Conclusion:The Ultrasonographic diagnosis of majority of patients who are presented with right upper quadrant pain is fatty liver disease and other pathologies which are known to not cause any pain in right upper quadrant

A hypervascular liver mass

A 49-year-old woman—on remission 7 years after the surgical resection of a lower left limb melanoma—presented with persistent right-upper quadrant pain associated with nausea and vomiting. Physical examination was unremarkable. Laboratory tests were within normal range, except for an elevated gamma-glutamyl transferase of 73 U/L (normal <38). An abdominal ultrasonography revealed a right liver mass. Magnetic resonance imaging (MRI) of the liver showed a 10 × 9 × 7.5 cm heterogeneous mass located within segment VII, with central necrosis (Figure 1).

Carcinoma of Breast Expressing Human Epidermal Growth Factor Receptor 2: Case Report

Introduction: Breast carcinoma is a systemic disease in which micro metastasis of abnormal cells which can form the secondary malignant cells. Breast carcinoma is the rapid and uncontrolled growth of abnormal cells. Breast cancer is cancer of breast that develop from breast tissue.&#x0D; Case History: Clinical findings – patient 49 years old female, having pain in right upper quadrant of right breast, irritation and discomfort in breast, swelling in lower area of breast. Biochemical, Hematological and rediological investigation are decrease.&#x0D; Investigation: Physical examination -lump is found on right breast which is non tender and slightly movable. USG and Mammography shows A suspicious retroareolar lump in the right breast and two foci pleomorphic macro calcification in right breast, Histopathology – shows both the masses are malignant but in biopsy metastasis not detected.&#x0D; Therapeutic Intervention: Symptomatic treatment -tab acetaminophen -tab – hydrocortisone. Lumpectomy On the left breast and mastectomy done on right breast. Radiation therapy and Chemotherapy is given before and after surgery and Chemotherapy was continue after the surgery. Hormonal therapy also given for HER2 + receptor .all the complications of chemotherapy is managed by quality nursing care.&#x0D; Outcome: After all pharmacological, surgical and medical intervention and quality nursing care, patient is now in stable condition. During treatment her treatment response is good and she can very effectively cope up with her disease condition and she is able to do her daily activities effectively.

S2613 Management and Outcomes of Complex Cystic Masses With Malignant Transformation

Introduction: Liver cysts are generally simple and benign; we describe the presentation and outcomes of 3 patients with rare complex cystic tumors that emphasize the broad differential diagnosis for this condition. Case Description/Methods: The records of 3 patients were reviewed with respect to presenting symptoms, their management and clinical outcomes. A 47 year old male with a history of pancreatic neuroendocrine tumor and liver metastases underwent a multivisceral transplant including the liver. Three years later he complained of postprandial right upper quadrant (RUQ) and chest pain. A new 13 cm cystic lesion was found in his liver. Surgical resection of the mass was performed revealing an angiosarcoma with epithelioid features. The patient’s condition rapidly deteriorated with weakness and muscle wasting. Given the aggressive nature of the tumor and patient debility, the patient was admitted to hospice. A 38 year old female presented with postprandial RUQ pain and CT showed a 2.5 cm complex cystic liver mass with growth compared to prior imaging. The mass was surgically removed. Pathology showed a mucinous cystic tumor with a few foci of high grade neoplasia. Follow-up imaging shows continued resolution of disease without need for adjuvant therapy. The third case, a 63 year old female, has a history of hypothyroidism and an asymptomatic 4 cm complex liver cyst for a decade until it rapidly started growing to 7.6 cm with RUQ pain. Laparoscopic marsupialization with fenestration revealed a biliary cystadenoma. Follow up imaging showed a 4 cm cystic area secondary to residual inflammation. Discussion: The majority of hepatic cysts are benign and less than 5 % are malignant. Imaging characteristics may provide insight into discerning benign epatic cysts from malignant ones. Complex cysts have many septations and contain hemorrhagic or proteinaceous fluid. Biliary cystadenoma, which is premalignant, and biliary cystadenocarcinoma usually present as complex cysts. Mucinous cystic neoplasms of the liver are very rare, usually complex, premalignant, yet definitive diagnosis is challenging. Primary hepatic angiosarcomas are seen in middle aged patients; these have a propensity for local recurrence and malignant change. These cases emphasize the importance of the follow up and an early intervention of incidentally found hepatic large complex cysts.