Pelvic CT Scan Research Articles

Changes of Fixed Anatomical Spinopelvic Parameter in Patients with Lumbosacral Transitional Vertebrae: A Matched Pair Analysis.

Functional spinopelvic parameters are crucial for describing spinal alignment (SA), but this is susceptible to variation. Anatomically fixed pelvic shape is defined by the parameters pelvic radius (PR), pelvic incidence (PI), and sacral table angle (STA). In patients with lumbosacral transitional vertebrae (LSTV), the spinopelvic alignment may be altered by changes of these parameters and influences of SA. There have been no reports studying the relation between LSTV, four (4 LV) and six (6 LV) lumbar vertebrae, and fixed anatomical spinopelvic parameters. A retrospective analysis of 819 abdomen–pelvis CT scans was performed, identifying 53 patients with LSTV. In a matched-pair analysis, we analyzed the influence of LSTV and the subgroups 4 LV (n = 9) and 6 LV (n = 11) on PR, PI, and STA. LSTV were classified according to Castellvi classification. In patients with 6 LV, measurement points at the superior endplates of S1 and S2 were compared. The prevalence of LSTV was 6.5% (53/819), 6 LV was 1.3% (11/819), and 4 LV was 1.1% (9/819) in our study population. PI significantly increased (p < 0.001), STA significantly decreased (p < 0.001), and PR (p = 0.051) did not differ significantly in the LSTV group (n = 53). Similar findings were observed in the 4 LV subgroup, with an increase in PI (p < 0.021), decrease in STA (p < 0.011), and no significant difference in PR (p < 0.678). The same results were obtained in the 6 LV subgroup at measuring point S2 (true S1) PI (p = 0.010), STA (p = 0.004), and PR (p = 0.859), but not at measuring point S1 (true L6). Patients with LSTV, 4 LV, and 6 LV showed significant differences in PI and STA compared to the matched control group. PR showed no significant differences. The altered spinopelvic anatomy in LSTV patients need to be reflected in preoperative planning rebalancing the sagittal SA.

Unusual Cause of Dysuria: A Large Primitive Retrovesical Hydatid Cyst

Hydatidosis is endemic in Morocco. Pulmonary and hepatic localisations are the most frequent. The primary retrovesical location is exceptional. It is considered an “aberrant” or “ectopic” location and represents less than 1% of all cases of hydatid disease. Its diagnosis is sometimes difficult, requiring radiological and serological examinations. The aim of this case report is to present a specific management of a primitive retrovesical hydatid cyst and to compare it with the review of literature. We report an exceptional case of a large primary retrovesical hydatid cyst in a 45-year-old patient with no significant pathological history, of rural origin with a notion of contact with stray dogs. Symptoms are of late onset and represented essentially by voiding disorders associated with episodes of constipation and a feeling of heaviness. Abdominal and pelvic Ultrasound and CT scan identified a rounded, multivesicular retrovesical cystic mass. Because of the existence of intimate adhesions with neighboring organs, we opted for treatment with a partial cysto-pericystectomy. The post-operative follow up was without incident with a good long term evolution. There was no local recurrence and the patient did not complain of any urinary disorder. In order to reduce the incidence of hydatid disease in endemic countries, the best treatment remains primary prevention.

Topical Capsaicin for Treating Cannabinoid Hyperemesis Syndrome

Introduction Cannabinoid hyperemesis syndrome (CHS), associated with chronic cannabis use, presents with cyclic abdominal pain, nausea, and vomiting. With increasing use of marijuana, the incidence of CHS is expected to increase. Most patients with CHS make frequent visits to the emergency room and are usually refractory to conventional treatment. We, therefore, present a case of CHS successfully treated with topical capsaicin application. Case Presentation. A 41-year-old female with a recent excess use of cannabis presented to the emergency department for evaluation of recurrent excruciating epigastric pain accompanied by severe nausea and vomiting. She had similar, milder symptoms a year ago and underwent endoscopic evaluation which was negative except for mild reflux esophagitis for which she was started on a proton pump inhibitor. On this presentation, basic laboratory workup, EKG, and CT scan of abdomen and pelvis were unremarkable. A detailed abdominal exam was only positive for mild epigastric tenderness. She was instructed to continue pantoprazole and pain medication and outpatient repeat esophagogastroduodenoscopy. The patient returned the next day with extreme retching, nausea, and vomiting and was admitted for further evaluation. Intravenous fluids, antiemetics, and morphine were started for pain control with no symptomatic improvement. A diagnosis of cannabis hyperemesis syndrome was made based on history of chronic marijuana use and otherwise negative workup. A trial of topical capsaicin, over the epigastric region, was tried that provided dramatic relief within 24 hours. Repeat endoscopic evaluation had no evidence of ulcers, celiac disease, or esophagitis. She was discharged on topical capsaicin and counselled on marijuana abstinence, with no return of symptoms. Conclusion Based on the dramatic resolution of symptoms with topical capsaicin, our case supports this promising intervention and provides an alternate approach to antiemetics and narcotics routinely used in patients with cannabis hyperemesis syndrome.

Cytomegalovirus Colitis Leading to Recto-vaginal Fistula in Immunocompetent Patien

Cytomegalovirus (CMV) is a double-stranded DNA virus member of Herpesviridae family. Majority of the population is exposed to CMV, based on sero-prevalence. CMV establishes latent infection and may re-activate later and cause significant clinical manifestations, especially in immunocompromised patients, like those on immunosuppressant drugs and chemotherapy, post organ transplantation and acquired immunodeficiency syndrome. The clinical manifestations of CMV in immunocompetent people are due to primary infection and vary from mild and self-limiting to severe and debilitating. CMV colitis in immune-competent people is uncommon. The complication of CMV infection leading to colonic perforation and recto-vaginal fistula is rare in immunocompetent subjects. We report case 67 year old female who was admitted with road traffic accident with tibia and T10 vertebral fracture without any abdominal injury. She underwent spinal fixation. She later developed diarrhea with abdominal pain. Whilst investigations were underway, she developed signs of intestinal obstruction. Urgent CT scan of abdomen and pelvis confirmed intestinal obstruction with rectal perforation. Urgent laparotomy was done which confirmed diagnosis of recto-vaginal iula. Adhesiolysis and Hartmann’s procedure was performed. Intraoperative biopsy specimen of the rectum confirmed the diagnosis of CMV. She recovered after undergoing rehabilitation and treatment with Ganciclovir. She is awaiting reversal of colostomy.

Refractory pelvic fracture-associated hemorrhage after preperitoneal packing: now what?

A male patient in his 50s presented after a high-speed motorcycle crash. On arrival to the trauma bay, his primary survey was intact with normal vital signs. He had an...

Characteristics of abdomen and pelvis CT scan's evaluation of patients with malignancies

Characteristics of abdomen and pelvis CT scan's evaluation of patients with malignancies

Characteristics of abdomen and pelvis CT scan's evaluation of patients with malignancies

According to the American Cancer Center, cancer causes about 1 in 6 deaths worldwide, more than AIDS, tuberculosis and malaria taken together, it is the second leading cause of death, after cardiovascular disease. Imaging examinations to examine the abdomen and pelvis are the methods of choice in detecting neoplastic formations with the provision of information that is essential for the subsequent management of these patients. From the PubMed databases and the Google Scholar search engine, the articles published during 2010-2020 were selected, according to the keywords: oncology statistics, oncology imaging, computed tomography, abdominal neoplasms, pelvic neoplasms, oncology staging, post-processing programs in computed tomography, follow-up of cancer patients, diagnostic algorithms. Information on international scientific studies on oncological pathology statistics has been selected and processed globally, according to data from the American Cancer Center and the International Agency for Research on Cancer, innovative methods for assessing the staging of patients with abdominal and pelvic neoplasms, and modern post processing in the case of examination by computed tomography of abdominal and pelvic neoplasms patients. After processing the information in the Google Scholar and PubMed database, according to the search criteria, 346 articles on the proposed topic were found. The final bibliography contains 176 relevant sources, of which 77 were considered representative for the elaboration of this synthesis article. We must aim to justify, optimize and customize each imaging procedure for patients with neoplasms, as they are frequently exposed to imaging examinations.

Relationship between calcifications and structural lesions on hand radiography and axial calcifications on CT-scan: A retrospective study in systemic sclerosis.

The objectives of this study were to describe the prevalence and characteristics of radiographic lesions of the hands, and calcifications of the spine on computer tomography scans (CT-scans), and to investigate the relationships between radiographic and CT-scan abnormalities and clinical features in a population of patients with systemic sclerosis (SSc).Subjects underwent X-ray examination of the hands, and thoracic or thoraco-abdominal and pelvic CT scan or lumbar CT scan in the year. Structural lesions on hand X ray was scored and spinal calcifications were evaluated in the anterior, intracanal and posterior segments. Intra and inter-reliability was tested for radiography and CT- scan. Prognostic factors considered were interstitial pulmonary lesions on the CT scan, pulmonary arterial hypertension (PAH) and death.This study involved 77 SSc patients, 58 (75%) with limited cutaneous SSc (lcSSc) and 19 (25%) with diffuse SSc (dSSc). The prevalences of radiographic lesions of the hand were 28.6% for periarticular calcifications and 26% for calcinosis. On CT scan, 64 (83%) patients exhibited at least 1 calcification. Spine calcifications were depicted in 80.5%, 27.3%, and 35.1% at the anterior, intracanal and posterior segments respectively. Calcifications were mainly localized on thoracic spine. Inter reader reliabilities were good for hands and moderate for spine respectively. Spine calcifications and periarticular calcifications in the hands were associated (P = .012). Calcinosis in the hands was related to PAH (P = .02). Posterior calcification segment and foraminal calcifications were associated with interstitial lung disease (ILD) (P = .029) and death (P = .001).More than 80% of systemic sclerosis patients presented spine calcifications. A significant association between hands and spinal calcifications were confirmed and some localization in the posterior segment considered as a bad prognostic factor.

Abdominal pelvic CT findings compared between COVID-19 positive and COVID-19 negative patients in the emergency department setting.

PurposeManifestations of COVID-19 are primarily respiratory based, however, gastrointestinal symptoms are now recognized as an important component of the disease. The purpose of this study is to evaluate differences in abdominal pelvic CT findings in the emergency department by COVID-19 test result.MethodsThis retrospective study identified patients tested by PCR for COVID-19 infection who underwent abdominal pelvic CT scan in the ED across an academic health system from March 15 to April 15, 2020. Radiology reports were reviewed for the presence of ground glass opacity in the lungs and acute abdominal pathology. A subset of patients with acute abdominal pathology were identified with inflammatory pathology in organs with high ACE2 receptor expression including bowel, pancreas, urinary bladder, and kidney. CT findings for COVID positive versus negative patients were compared with Chi-square test.Results597 patients tested by PCR for COVID-19 infection underwent abdominal pelvic CT scan, 44% were COVID-19 positive. COVID-19 positive patients demonstrated significantly more ground glass opacity at the lung bases, 65.1%, (222/341) versus 12.4% (33/266), p < 0.001), and significantly less acute abdominal findings, 23.8% (81/341) versus 45.5% (121/266), p ≤ 0.001). When abdominal pathology was present, COVID-19 positive patients had higher rate of inflammatory pathology 58% (47/81) versus 29.8% (36/121).ConclusionsIn patients undergoing abdominopelvic CT from the ED, COVID-19 positive patients are more likely to have ground glass opacities at the lung bases and less likely to have acute abdominal pathology compared with COVID-19 negative patients. Further, COVID-19 positive patients are more likely to have inflammation of organs with high expression of ACE2 receptors than other types of acute abdominal pathology.

Ultra-low-dose CT versus radiographs for minor spine and pelvis trauma: a Bayesian analysis of accuracy.

To compare diagnosis performance and effective dose of ultra-low-dose CT (ULD CT) versus radiographs in suspected spinal or pelvic ring or hip fracture for minor trauma. ULD CT, in addition to radiography, was prospectively performed in consecutive patients admitted to the emergency department for minor traumas, during working hours over 2 months. Presence of a recent fracture was assessed by two blind radiologists independently. Sensitivities and specificities were estimated using the best valuable comparator (BVC) as a reference and using a latent class model in Bayesian inference (BLCM). Dosimetric indicators were recorded and effective doses (E) were calculated using conversion coefficient. Eighty areas were analyzed in 69 patients, including 22 dorsal spine, 28 lumbar spine, and 30 pelvic ring/hip. Thirty-six fractures (45%) were observed. Applying the BVC method, depending on location, ULD CT sensitivity was 80 to 100% for reader 1 and 85 to 100% for reader 2, whereas radiographic sensitivity was 60 to 85% for reader 1 and 50 to 92% for reader 2. With BLCM approach for reader 2, ULD CT sensitivity for all locations/dorsal spine/lumbar spine and pelvic ring-hip was 87.1/75.9/84.2/76.9% respectively. Corresponding radiograph sensitivity was 73.8, 54.8, 80.4, and 68.7%. Effective doses of ULD CT were similar to radiographs for dorsal and hip locations whereas for lumbar spine, ULD CT effective dose was 1.83 ± 0.59 mSv compared with 0.96 ± 0.59 mSv (p < 0.001). Sensitivity for fracture detection was higher for ULD CT compared with radiographs with an effective dose comparable to radiographs. • Ultra-low-dose spine and pelvis CT demonstrates better fracture detection when compared with radiographs. • The effective dose of ultra-low-dose spine and pelvis CT scan and radiographs is comparable. • Replacement of radiographs by ULD CT in daily practice for trauma patients is an option to consider and should be evaluated by a randomized trial.

Reduction of Ovarian Radiation Dose and Image Quality Disruptive Effects: New Constructed Shields for CT Scanning of Abdomen and Pelvis

Background: Cumulative dose of ovary as a radiosensitive organ during abdominal and pelvic CT scan imaging is still a controversial challenge that requires practical dose reduction strategies. Although bismuth shields can reduce the dose in the right proportions, their use is controversial due to the reduced image quality. Objectives: The aim of this study was to investigate the performance of a new combination of X-ray absorber structures that have less effect on image quality parameters. Methods: First, various shields with different weight percentages of Cu and Bi were made, then the percentage of dose reduction and image quality were evaluated via phantoms. Finally, Shield with the least effect on image quality was evaluated for clinical evaluation on 20 patients. Results: Shielding with thicknesses of 1T and 3T reduced the Entrance skin dose of ovarian by about 52% and 73%, respectively. Shields with 90% cu-10% Bi and 100% Bi structures had the least and most destructive effects on image quality, respectively, and also have the same image quality. The 10% Bi-90% Cu shield provided a 21% greater dose reduction than the bismuth shield. Also, this 1T thick shield did not create an artifact in the reconstructed images. Conclusions: Shields are flexible, inexpensive, and user-friendly for ovarian shielding in abdominal and pelvic CT scans. Unlike bismuth shields, shields do not have the detrimental effects of image quality degradation.

S1960 An Atypical Presentation of Duodenal Neuroendocrine Tumor as Black Esophagus

INTRODUCTION: Acute esophageal necrosis (AEN) or “black esophagus” is characterized by diffuse circumferential black esophageal mucosa that abruptly stops at the gastroesophageal (GE) junction. Etiology of AEN is unclear but ischemia, infection, prolonged vomiting, toxin injury, and malignancy are thought to be associated with AEN. We present a patient with vomiting, diarrhea, and weight loss, found to have AEN and a duodenal neuroendocrine tumor (NET) on endoscopy. This case is an atypical presentation of duodenal NET as AEN in the setting of chronic acid exposure. CASE DESCRIPTION/METHODS: A 60-year-old male with past medical history of hypertension and atrial fibrillation presented with vomiting 5 times per day, burning abdominal pain, acute on chronic diarrhea, and 25 pound weight loss. Patient had chronic diarrhea for multiple years and reported having a negative endoscopy and colonoscopy 3 years prior. CT scan of chest, abdomen, and pelvis showed diffuse thickening of esophagus but no mass. An endoscopy revealed severe pan-esophagitis with black ulcerations and necrosis that spared the GE junction. Endoscopy also showed a duodenal mass and numerous duodenal ulcers. Esophageal biopsy showed completely eroded mucosa with granulation tissue, acute/chronic inflammation, and fibrinopurulent surface exudates. Pathology of duodenal mass was consistent with a well-differentiated NET (Ki-67 < 2%). Patient underwent robotic distal gastrectomy and gastrojejunostomy. A follow up endoscopy showed resolution of AEN; however, severe esophageal stenosis had developed and required balloon dilation. DISCUSSION: Although the incidence of AEN is low (0.2%), it is associated with high mortality rate (up to 35%) and complications such as esophageal perforation and stricture. Management is supportive and correcting of the underlying condition. Therefore, it is important to recognize AEN and identify its underlying cause. This patient’s vomiting and injury to the esophagus was secondary to his NET. Duodenal NET accounts for 2-3% of all neuroendocrine tumors and < 2% of all gastrointestinal malignancies in the United States. Although duodenal NETs are often indolent, Zollinger Ellison Syndrome occurs in 10% of patients. Symptomatic patients present with abdominal pain, diarrhea, and heartburn. Complications of severe acid hypersecretion can occur with findings of bleeding (32%), esophageal strictures (2%) and perforation (3%). Five-year overall survival is 60-70%.Figure 1.: Initial endoscopy showing multiple areas of black colored ulcers in the background of severe pan-esophagitis.Figure 2.: Initial endoscopy showing a large frond-like/villous and polypoid lesion with no bleeding in the duodenal bulb.Figure 3.: Follow up endoscopy showing LA Grade D esophagitis and intrinsic severe stenosis but resolution of necrotic lesions.

S2281 CMV Colitis Mimicking as IBD Flare-Up in Immunocompetent Patient

INTRODUCTION: Although almost 70 % of human beings are likely to be infected with CMV, the majority, being immunocompetent, are unlikely to manifest. Cytomegalovirus (CMV) colitis rarely occurs in immunocompetent patients. Usually, CMV colitis occurs in immunocompromised individuals but there have been reports in immunocompetent individuals as well. Here, we present a case of a 64 year old female initially presenting as IBD flare-up but later getting diagnosed with CMV colitis. CASE DESCRIPTION/METHODS: A 64-year-old woman, with a past medical history of HTN, type II diabetes, and GERD, IBD - Crohn's type on mesalamine, with recently done EGD and colonoscopy, presented to the hospital for abdominal pain and bloody stools for one month. When she came to the hospital, her WBCs were elevated, and she also had elevated lactate, ferritin but the rest of her labs were unremarkable. Subsequently, a CAT scan of Abdomen and Pelvis showed non-specific colitis. Gastroenterology service recommended starting the patient on Solu-Medrol for a possible Crohn’s Disease Flare Up. Other stool studies were negative. Over the course of her hospitalization, the patient underwent colonoscopy which showed severe inflammation and was also started on Infliximab due to unresponsiveness to treatment. Strongyloides serologies were checked and came back negative as well. The pathology results from colonoscopy came back and the findings were consistent with Cytomegalovirus (CMV) colitis. CMV IgG Ab checked came back positive and viral load came back at 7400 U/L. It was decided to treat the patient with Ganciclovir. The patient reported improvement and was able to tolerate her diet. She was subsequently discharged on valganciclovir. On subsequent follow up reported the resolution of her signs and symptoms. DISCUSSION: CMV colitis occurs in immunocompromised individuals but there have been reports in immunocompetent individuals as well. The mechanism is unclear but it has been hypothesized that CMV superinfects already inflamed mucosa. It is also stated that MHC proteins are upregulated leading to an autoimmune response. The treatment of choice for CMV colitis remains ganciclovir. The association between cytomegalovirus infection and inflammatory bowel disease challenges both the clinicians and the pathologists to establish the correct diagnosis and to prescribe the most appropriate form of therapy, therefore a high suspicion should be there for CMV colitis in Immunocompetent IBD patients as well who are not responding to treatment.Figure 1.: CT Scan of Abdomen and Pelvis showing prominent diffuse colonic wall thickening.

S1640 Primary Colonic Lymphoma Manifesting as Colovesical Fistula

INTRODUCTION: Gastrointestinal (GI) tract is the most common extranodal site of Non-Hodkin lymphoma (NHL) and constitutes about 4% of all GI malignancies. The most common sites of involvement in the GI tract are stomach followed by the small intestine. We report a case of primary colonic lymphoma manifesting with colovesical fistula in a patient with human immunodeficiency virus (HIV) infection. CASE DESCRIPTION/METHODS: A 50-year-old male with a history of HIV on antiretroviral therapy with undetectable viral load and a CD4 count of 260 cells/µL, presented with burning micturition, intermittent passage of air and feculent material in urine, on and off for one year. He has chronic nonbloody diarrhea and noticed thirty-pound weight loss over the past three months. At admission, he was afebrile, hypotensive, and had sinus tachycardia (114/min). Physical examination was significant for palpable, tender left lower quadrant mass but no hepatosplenomegaly, bowel distention, or peripheral lymphadenopathy. Laboratory data revealed anemia (HB 8.5 g/dl), leukocytosis (WBC 14000/µl), mildly elevated platelet count (422,000/µl), acute kidney injury (serum creatinine 2.50, baseline 0.81 mg/dL) and normal CEA level. Urine was brown, turbid with microscopy showing RBC and WBC ( >180/hpf). CT scan of abdomen and pelvis with contrast revealed a large circumferential mass measuring 14.5 cm × 10 cm in sigmoid colon with a fistulous communication to the urinary bladder suggestive of colovesical fistula. Colonoscopy confirmed a partially obstructing, large circumferential, ulcerated mass within the proximal sigmoid colon. Pathology was consistent with diffuse large B-cell lymphoma (+BCL2, +MYC). PET-CT scan showed increased FDG uptake in the sigmoid colon along with adrenal gland and bone but no involvement of lymph nodes, liver, or spleen. A diverting colostomy was performed and subsequently, he was started on dose-adjusted R-EPOCH Regimen. The patient received 5 cycles of chemotherapy and a repeat PET-CT scan showed resolution of activity in the sigmoid colon, bone, and adrenal gland. Retroperitoneal ultrasound during chemotherapy showed persistence of colovesical fistula. DISCUSSION: HIV-AIDS predisposes patients to different malignancies including NHL in about 10% of patients. Colonic involvement of primary NHL is exceedingly rare. High viral load and low CD4 counts (< 100) are risk factors for NHL in HIV patients. We describe here an unusual presentation of NHL manifesting as colovesical fistula, in a patient with HIV.Figure 1.: Computed tomographic scan of abdomen & pelvis in sagittal view showing large sigmoid mass (long arrow). Air-fluid level of orally administered contrast noted in the urinary bladder. (short arrow).Figure 2.: Colonoscopy shows a fungating, ulcerating mass in the sigmoid colon, nearly obstructing the lumen.Figure 3.: Initial PET tumor imaging whole body.

S1615 Primary Rectal Lymphoma: A Rare Entity of Lower Gastrointestinal Bleeding

INTRODUCTION: Primary rectal lymphoma is an extremely rare gastrointestinal neoplasm. The diagnosis can be delayed with varied presentations depending on the site of the colonic involvement. We present a case of acute onset of hematochezia from primary diffuse large B-cell lymphoma at the rectum. CASE DESCRIPTION/METHODS: A 54-year-old Caucasian man who has sex with men presented with constipation for 3 weeks and rectal bleeding for one week. He reported rectal pain associated with having bowel movements and tenesmus. He denied fever, chills, night sweats, or weight loss. Physical examination was unremarkable. Laboratory showed WBC 11.1 K/MM3, Hb 14.6 g/dL, platelet count 325 K/MM3, and negative serum HIV screening. CT scan of the abdomen and pelvis revealed circumferential rectal wall thickening with mesorectal fat stranding and enlarged mesorectal lymph nodes (Figure 1). The patient underwent flexible sigmoidoscopy which demonstrated circumferential deep ulcerations, linear erosions, and loss of vascularity of mucosa from the anus to the recto-sigmoid colon up to 20 cm and hypertrophied anal papillae (Figure 2). Biopsy of the rectum up to 20 cm revealed diffused large B-cell lymphoma with germinal center origin. A whole-body PET-CT scan showed disease activity localized in the rectum. Bone marrow biopsy showed slightly hypocellular bone marrow but negative for lymphoma. He underwent R-CHOP chemotherapy and radiation with a good response. Repeat colonoscopy at 3 months after treatment did not show evidence of recurrence. Follow-up PET-CT and CT chest/abdomen/pelvis were without recurrence of the disease. He remains in remission for 15 months since the diagnosis. DISCUSSION: Gastrointestinal (GI) non-Hodgkin lymphoma accounts for 1-4% of primary GI neoplasms. The stomach is the most commonly involved site followed by the small intestine and colon. Primary colorectal lymphoma only accounts for 6-12% of GI non-Hodgkin lymphomas. Diffuse large B-cell lymphoma (DLBCL) is the most common histopathology. Symptoms are varied depending on the location of the disease. Rectal lymphoma can present with rectal bleeding and obstructive symptoms, for example, constipation, small stool caliber, or tenesmus, as in this case. DLBCL is sensitive to chemoradiation. The estimated median survival of patients with localized disease is approximately 23 months. A high index of suspicion is required to prevent delays in diagnosis.Figure 1.: CT scan of abdomen and pelvis showed circumferential wall thickening at the rectum (arrows).Figure 2.: Flexible sigmoidoscopy showed circumferential deep ulcerations, linear erosions, and loss of vascularity of mucosa at the rectum (A) and hypertrophied anal papillae in retroflection view (B).

S1788 A Rare Case of an Adult Ingesting a Disk Battery With Impaction in the Lower Gastrointestinal Tract

INTRODUCTION: Disk battery ingestion is commonly seen in the pediatric population and rarely in adults. There are no guidelines on how to manage these in the lower GI tract. We present a rare case of a disk battery impacted in the lower GI tract in an adult patient. CASE DESCRIPTION/METHODS: A 96 year-old-male with a history of Alzheimer's disease presented for concerns that he had ingested a battery. Physical examination was remarkable for altered mental status. Abdominal x-ray revealed a coin like lesion in the RLQ (Figure 1). CT scan of abdomen and pelvis confirmed a radiopaque object at the ileo-cecal junction (Figure 2), believed to be a disk battery. Colorectal surgery was consulted for colonoscopic removal with possible surgical conversion but the health care proxy refused and instead opted for conservative management/non-invasive measures. Multiple trials of bowel regimens including polyethylene glycol were initiated to induce dislodgement without success as serial abdominal x-rays revealed that the battery remained impacted in the same location (Figure 3). At this point, the health-care proxy opted for discharge to a nursing home with supportive measures. DISCUSSION: Current guidelines recommend removal if the battery is lodged in the esophagus, if the battery is in the stomach and is less than 2 cm in size, conservative management is advised as it will likely pass through the GI tract. Progression should be followed with serial abdominal x-rays every 3 days and if impaction is suspected, the battery should be removed. Currently no guidelines on impacted objects in the lower GI tract exist, but we hypothesize that if the object is less than 2 cm, it will likely be evacuated. The major risk of foreign body ingestion is perforation. This occurs from penetration of the mucosa or via pressure injury from impaction. Lithium-Ion batteries have a high risk of electrical thermal injury leading to liquefaction necrosis and Nickel-Cadmium batteries can cause caustic injuries. Regardless, they both carry an increased risk of perforation, especially with impaction. In our case, the patient was given multiple bowel regimens to induce dislodgement. Although serial imaging did not show progression of the battery, to our knowledge, there are no other cases in which bowel regimens have been used for managing lower GI tract foreign objects and this creates a need for further investigation.Figure 1.: Abdominal X-Ray showing radiopaque object in RLQ (Red Arrow).Figure 2.: CT Abdomen and Pelvis showing radiopaque object at the Ileocecal Valve (Red Arrow).Figure 3.: Abdominal X-Ray showing unchanged location of radiopaque object in RLQ (Red Arrow).

S2444 Diagnosis of a Grave Disease in a Seemingly Asymptomatic Woman: Budd-Chiari With Portal Vein Thrombosis in Setting of Polycythemia Vera

INTRODUCTION: Vascular disorder of the liver are rare in the general population with increased prevalence in patients with cirrhosis and MPD. Up to 50 % of patients with BCS have an associated MPD while 10–15% are classified as idiopathic. Coincidence of BCS and PVT has been reported in 10–15% cases but rarely documented as the presenting finding of PV in the setting of an extensive splanchnic thrombosis. CASE DESCRIPTION/METHODS: A 35-year-old female with a past medical history of one spontaneous miscarriage presented with 1 week of epigastric pain and early satiety. On examination she had marked hepatosplenomegaly with diffuse dull percussion note and shifting dullness. On presentation, the patient was hemodynamically stable. Labs showed ALT 810, AST 499, Tb9.4, Db7.1, ALP 272, IINR 2.6, Albumin 2.9, Hemoglobin/Hct 14.3/42. CT of abdomen/pelvis showed hepatosplenomegaly, markedly enlarged left lobe of the liver, and diffuse ascites suggestive of PVT (Figure 1). Patient was started on heparin however course was complicated by worsening of symptoms, repeat imaging two days afterwards showed extension of the clot to involve hepatic vein and SMV thrombosis extending into the IVC with concerns for early signs of bowel necrosis. Patient underwent an emergent successful extended TIPS, IVC stent, and thrombectomy/thrombolysis of SMV and portal vein with no complications post procedure (Figure 2). Work-up showed positive hypercoagulability workup for JAK2 21%, no further mutations detected. Patient underwent bone marrow biopsy which confirmed the diagnosis of PV. Her symptoms improved over the course of 10 days, was transitioned to oral anti-coagulant. DISCUSSION: Acute PVT can sometimes remain with non-specific symptoms however, the extension of thrombosis is usually what depicts the clinical progression, in addition to use of systemic anti-coagulation which is seldom used in chronic forms of PVT. Several studies showed that JAK2 mutation to be found in almost 35% of all splanchnic vein thrombosis forms, and in 41-59% of patients with BCS. However, it is uncommon to see PV in young patients <40 years of age, in whom only a minority will develop BCS. In our case, the symptoms were imperceptible, yet the diagnosis was severe, which raises the possibility of likely a chronic picture of portal vein thrombosis or BCS. It was extremely challenging given the unclear symptom presentation and critical radiographic findings to provide adequate therapy to control extent of thrombosis without thrombolysis and TIPS.Figure 1.: CT scan of the abdomen pelvis in portal venous phase. (A) Coronal view showing pre TIPS hyper-enhancement of the caudate lobe (red). Thrombus in portal vein (orange). Ascites (blue). (B) After TIPS and IVC placement showing heterogeneous liver nutmeg (black/0 and resolution of ascites (blue).Figure 2.: A) Hepatic venogram showing Classical spider-web appearance of Budd-Chiari (blue arrow). B) percutaneous access of splenic vein doing portal venogram showing occluded/thrombosed portal vein (red arrow). C) stent extending from IVC to PV connected via splenic vein catheterization. D) TIPS (blue arrow) and IVC stent (red arrow).

RARE CAUSE OF FATAL LIVER DISEASE: A CASE OF ACUTE LIVER FAILURE IN A PATIENT WITH RECENTLY DIAGNOSED METASTATIC OVARIAN CARCINOMA

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Metastatic liver disease is a relatively common finding in autopsies of adults with aggressive tumors. In a majority of cases, affected patients do not have signs or symptoms of liver failure. CASE PRESENTATION: A 41-year-old previously healthy Caucasian female presented to our ED with worsening abdominal pain and shortness of breath. Her symptoms started about a week prior to the ED visit. Her PCP ordered a CT scan of chest, abdomen, and pelvis which showed an ovarian mass concerning for carcinoma with multiple hepatic and pulmonary metastases. In the ED, vital signs were normal. A distended non-tender abdomen was appreciated during the physical exam. Laboratory workup revealed leukocytosis (WBC 31.1K/UL), abnormal LFTs (AST 1525U/L, ALT 396U/L, bilirubin 3.6MG/DL, alkaline phosphatase 366U/L), renal failure (Crea 1.76MG/DL, BUN 47MG/DL), elevated lactic acid (8.1MEQ/L), INR (1.6). A repeat CT scan of the chest, abdomen, and pelvis was unchanged. The patient was started on broad-spectrum antibiotics. On day 2, the patient was noted to have the worsening of liver function (AST 4652U/L and ALT 907U/L) as well as the development of respiratory failure. She was placed on BiPAP for increased work of breathing. She was started on CRRT for refractory metabolic acidosis and the worsening of renal failure. On day 3, the patient became confused with visible jaundice, asterixis, worsening of LFTs with AST and ALT (20845U/L and 2441U/L, respectively), elevated ammonia level as well as coagulopathy. Her MELD score was 46. Unfortunately, the patient suffered a cardiac arrest (PEA) twice within an hour with ROSC. The family made the decision to proceed with the withdrawal of care. The patient expired soon after that. DISCUSSION: Acute (also known as fulminant) liver failure is characterized by severe acute liver dysfunction (INR ≥1.5 and hepatic encephalopathy) in the absence of preexisting liver disease within less than 26 weeks. The two most common causes of acute liver failure are viral and drug-induced hepatitis. Malignant infiltration is a rare cause of liver failure which has been increasingly recognized in recent years. Patients with acute liver failure in the setting of metastatic liver disease have a very poor prognosis. CONCLUSIONS: In patients with signs and symptoms of acute liver failure, it is important to rule out metastatic liver disease as a potential etiology. Unfortunately, no definitive treatment is available at this point in affected individuals since liver transplant is contraindicated in patients with metastatic liver disease not meeting oncologic criteria for cure. Reference #1: Polson J, Lee WM. AASLD position paper: The management of acute liver failure. Hepatology. 2005;41(5):1179-1197. Reference #2: Nazario HE, Lepe R, Trotter JF. Metastatic breast cancer presenting as acute liver failure. Gastroenterology & hepatology. 2011;7(1):65. DISCLOSURES: No relevant relationships by Vincent Chan, source=Web Response No relevant relationships by Artem Minalyan, source=Web Response No relevant relationships by Qian Zhang, source=Web Response

S1422 COVID-19-Associated Pancreatitis: It's Not All About the Lungs

INTRODUCTION: Acute pancreatitis resulting from COVID-19 infection has rarely been reported in the literature. We describe a case series of two patients with COVID-19 infection who presented with gastrointestinal (GI) symptoms and COVID-19 associated acute pancreatitis. CASE DESCRIPTION/METHODS: CASE 1 An 18-year-old hispanic male presented to the hospital with acute onset of epigastric pain and vomiting. Blood tests on admission: leukocytosis 10.6K, lymphopenia 5.2%, and elevated lipase of 9916 unit/L. A CT scan of abdomen and pelvis showed enlargement of the pancreas with surrounding fat stranding, consistent with acute interstitial pancreatitis. He had persistent fevers with negative septic work up but confirmed COVID-19 infection. Other causes of acute pancreatitis were ruled out. He was diagnosed with COVID-19 related pancreatitis, and on a follow-up outpatient he had resolution of pancreatitis. CASE 2 A 66-year-old white male presented to the hospital with fever, shortness of breath, vomiting, and watery diarrhea. Laboratory tests on admission showed lymphopenia and elevated D-dimer of 287 ng/ml. CT scan of the chest showed bilateral patchy ground-glass opacities (Figure 1). COVID-19 RT-PCR nasopharyngeal swabs testing were negative four times. However, a stool sample was positive for COVID-19 RT-PCR. He clinically improved and was discharged home. Unfortunately, he was readmitted for abdominal pain and obstipation. His abdomen was distended with diffuse tenderness. Laboratory studies showed an elevated lipase of 9542 unit/L and amylase of 796 unit/L. Abdominal x-ray showed distended loops of bowels, suggesting ileus (Figure 2). Ultrasound of the abdomen showed ascites and non obstructive IVC thrombus. A CT scan of the pancreas showed diffuse peripancreatic edema, consistent with acute pancreatitis (Figure 3). He was started on therapeutic Lovenox, tolerated diet and was discharged home. DISCUSSION: COVID-19, is a novel virus that has caused a pandemic since it was first reported in Wuhan, China, in December 2019. Although respiratory symptoms are common presenting symptoms, more recent literature described patients presenting with GI symptoms. However, patients rarely can develop COVID-19 associated pancreatitis. Pancreatic injury can manifest as a spectrum ranging from an asymptomatic elevation of amylase and lipase to severe acute pancreatitis. Theories including cytokine response and susceptibility to ACE-2 receptor for COVID-19 have been proposed as possible mechanisms for acute pancreatitis.Figure 1.: CT chest findings.Figure 2.: Abdominal xray findings.Figure 3.: CT pancreas findings.

S2553 Endometriosis: A Rare Cause of Ascites

INTRODUCTION: Ascites is the pathological accumulation of fluid within the peritoneal cavity. These are mostly due to portal hypertension resulting from cirrhosis but there are non cirrhotic rarer causes of ascites. It is important to investigate the etiology of non-cirrhotic ascites as treatment of the underlying etiology can reverse it. CASE DESCRIPTION/METHODS: A 34-year-old female with history Cerebral Palsy presented to the clinic with 3 months of increasing abdominal distention. No associated jaundice, changes in urine color or constitutional symptoms. Examination revealed 10 cm reducible umbilical hernia along with abdominal fullness. No signs of portal hypertension or cirrhosis noted. Labs showed normal metabolic panel, blood counts and coagulation profile. Abdominal ultrasound revealed moderate to large ascites with nodular liver suggesting developing cirrhosis. She underwent paracentesis with removal of 5 liters of black-brown colored fluid showing many RBCs, 500 WBCs, Albumin of 3.5, Protein of 5.8, LDH of 978, SAAG of 0.6 and negative cytology. CT scan showed large abdominal and pelvic ascites, nodular liver and a 7 × 7 cm pelvic mass. MRI showed multiseptated pelvic collection with solid component in the right adnexal region. She underwent an exploratory laparoscopy with a right salpingo-oophorectomy and adnexal mass biopsy. Pathology showed ovarian fibroma with endometriosis. Follow up 3 months into the surgery, the patient was doing well and had no ascites. DISCUSSION: Cirrhosis is the most common cause of ascites. Ovarian fibroma and endometriosis are some of rare non cirrhotic causes as seen in this case. Ascites related to endometriosis was first described in 1954. A systematic review noted 63 cases with endometriosis related ascites between 1950 to 2010 who were mostly nulliparous women of African origin of ages 19 to 51 years. Diagnosis of endometriosis is usually delayed as it mimics gynecological malignancy and requires surgical exploration. Bilateral oopherectomy is the definite treatment. Here, right salpingo-oophorectomy was considered per patient preference. Ovarian fibromas are benign sex cord-stromal tumours seen in postmenopausal women which can present with ascites as a component of Meigs syndrome. Atypical causes such as these need to be considered especially in the young nulliparous females. Peritoneal fluid analysis and imaging may be misleading as they both can mimic malignancy, hence surgery is diagnostic. Therefore a broader differential is critical in evaluating ascites.Figure 1.: Initial CT scan of abdomen and pelvis with IV contrast showing soft tissue density structure within the anterior midline pelvis measures 6.5 × 7.5 × 7 cm.