Peripancreatic Fat Stranding Research Articles

Abstract #1385190: Empagliflozin Induced Acute Pancreatitis

Acute pancreatitis is a rapid onset inflammatory process of the pancreas which may have local and systemic manifestations. The most common causes of acute pancreatitis are gallstones and alcohol use. Other causes include drug-induced. Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a class of oral hypoglycemic agents which is approved by the FDA for treating diabetes and for heart failure. 56-year-old, female patient known to have uncontrolled type 2 diabetes. Presented with a complaint of acute epigastric pain radiating to the back and then become a generalized abdominal pain, moderate in severity, not relieved by analgesic, associated with nausea and vomiting. The patient denied any history of alcohol, smoking use. A review of her medication list included sitagliptin 100 mg, metformin 2g, gliclazide 60 mg and more recently, empagliflozin 10 mg which was started seven weeks prior to symptoms onset. Physical examination was significant for tenderness in epigastric area. Laboratory workup revealed an elevated serum lipase 3851 units/L, serum amylase 3755 units\L abdominal CT scan shows mild fatty atrophy and mild peri-pancreatic fat stranding and free fluid adjacent to the tale and body suggesting evidence of acute pancreatitis. Abdominal ultrasound shows the gall bladder was without stones. The patient was admitted with diagnosis of mild acute pancreatitis and underwent conservative management. Patient condition was improved and discharged on same pre-admission antidiabetic medication with OPD follow-up. 3 weeks later she presented to the emergency department complaining from acute epigastric pain radiating to the back and association of nausea and vomiting. With tenderness in epigastric area laboratory workup revealed an elevated serum lipase and amylase. Abdominal CT scan confirmed acute interstitial pancreatitis. After 3 days of conservative management she was improved and discharged but this time her diabetologist discontinue empagliflozin and she was started on insulin. She was following up with her diabetologist in outpatient clinic and there was no history of recurrence of pancreatitis. Drug induce pancreatitis are rare cause but must be considered. It is therefore important to determine the underlying etiology of acute pancreatitis to prevent occurrence, recurrence, and the complications of pancreatitis. FDA and Health Canada have identified a potential safety issue and possible association between SGLT-2 inhibitors and acute pancreatitis but Further studies are required to investigate this association. This case report emphasized the possible association between SGLT2 inhibitors and acute pancreatitis. Physicians must be aware about this side effect as a possible cause of acute pancreatitis after exclusion of most common etiologies. Also, physician should inform the patient about the side effects of SGLT2 and the symptoms of acute pancreatitis and advised them to stop SGLT-2 inhibitors use in case such symptoms occur. Further studies are required to investigate this association.

Rim Enhancement and Peripancreatic Fat Stranding in Preoperative MDCT as Predictors for Occult Metastasis in PDAC Patients

To identify the radiological features and clinical biomarkers that could predict the occult metastasis (OM) of pancreatic ductal adenocarcinoma (PDAC). This retrospective study included PDAC patients who were radiologically diagnosed resectable (R) or borderline resectable (BR) and underwent surgical exploration from January 2018 to December 2021. Depending on whether distant metastases were found during the exploration, patients were divided into OM and non-OM groups. Univariate and multivariable logistic regression analyses were performed to determine the radiological and clinical predictive factors for occult metastasis. Model performance was determined by discrimination and calibration. A total of 502 patients (median age, 64 years; interquartile range, 57-70 years; 294 men) were enrolled, among which 68 (13.5%) patients were found with distant metastases, with 45 liver-only, 19 peritoneal-only, four patients had both liver and peritoneal metastases. Rim enhancement and peripancreatic fat stranding were more frequent in the OM group than in the non-OM group. Tumor size (p = 0.028), tumor resectability (p = 0.031), rim enhancement (p < 0.001), peripancreatic fat stranding (p < 0.001) and level of CA125 (p=0.021) were independent predictors of occult metastasis according to the multivariable analyses, and the areas under the curve (AUCs) of these characteristics were 0.703, 0.594, 0.638, 0.655, 0.631, respectively. The combined model showed the highest AUC of 0.823. Rim enhancement, peripancreatic fat stranding, tumor size, tumor resectability and level of CA125 are risk factors for OM of PDAC. The combined model of radiological and clinical features may help the preoperative prediction of OM in PDAC.

Gastroinstestinal Fistula in Acute Necrotising Pancreatitis with Septicaemia: A Case Report

Acute Pancreatitis (AP) is an inflammatory condition with cumbersome side effects. Gastropancreatic (GI) fistula is a rare complication seen in cases with infected pancreatic or peripancreatic necrosis. GI fistulas can result in severe haemorrhage and septicemia. Hereby, the authors present a case of 36-year-old male with a chief complaint of abdominal pain associated with abdominal distension and non bilious vomiting after binge consumption of alcohol for the past 10 days. Computed Tomography (CT) scan showed the presence of free gas in the abdomen. Contrast-Enhanced CT (CECT) imaging revealed diffuse enlargement affecting the head, uncinate process, body, and tail of the pancreas. There were also a few necrotic peripancreatic fluid collections with extensive peripancreatic fat stranding. Based on these findings, the diagnosis of acute necrotising pancreatitis was suggested. Despite treatment with antibiotics and necrosectomy with drainage of the abscess collection, the patient showed no improvement. A repeat CECT examination was performed due to the deterioration of the patient’s clinical condition, which showed a complete non enhancing pancreas. Additionally, a large defect measuring approximately 16 mm was observed in the posteroinferior wall of the stomach at the middle third of the body, with extravasation of contrast material into the pancreatic collection, suggestive of fistula formation. Subsequently, the patient underwent pancreatic necrosectomy with closure of the gastric perforation using feeding jejunostomy. A follow-up CT examination was performed four days later due to the deteriorating status of the patient, as well as new onset haematemesis and bloody discharge from the surgical drain. The CT scan revealed a few peripancreatic soft tissue infiltrates adjacent to the pancreatic head. Persistent collections were noted along the anterolateral surface of the right psoas, extending to the adjoining right anterior pararenal space and the left anterolateral abdominal wall in the left hypochondriac region. Thickening of the bilateral lateroconal fascia and anterior and posterior renal fascia was observed, likely due to inflammation. Following this, the patient underwent another surgery, and percutaneous drainage was performed with antibiotic coverage. The patient showed a significant reduction in the collection and improved clinical condition after 10 days. Imaging plays a crucial role in diagnosing such complications, enabling early detection and reducing mortality in these patients.

S1681 Pancreatitis Secondary to Paxlovid-Induced Tacrolimus Toxicity

Introduction: Pancreatitis is a very common gastrointestinal disease that results in hospital admission. Early detection and treatment leads to better outcomes. This is the first reported case of pancreatitis secondary to elevated tacrolimus in a patient with prior renal transplantation after receiving Paxlovid for a COVID-19 infection. Case Description/Methods: A 57-year-old male with past medical history of 4 renal transplants secondary to posterior urethral valves who presented to the emergency room with acute onset epigastric pain for 24 hours. He was on tacrolimus 5 mg every 48 hours monotherapy for his immunosuppression. 10 days prior to his presentation he had developed chills and anxiety. He tested positive for COVID-19 at that time on a home rapid test. His symptoms had not significantly improved and given his immunosuppressed state he was given Paxlovid (Nirmatrelvir/ritonavir). He took 2 days of Paxlovid, however after his second day of treatment he developed severe epigastric pain requiring him to go to the emergency room. On admission his labs were notable for a lipase of 150 U/L (ULN 63 U/L). He underwent a CT scan was notable for an enlarged pancreatic head and neck with peripancreatic fat stranding (Figure). He also had a right upper quadrant ultrasound without any cholelithiasis and only trace sludge noted. His creatinine was noted to be 1.81 mg/dl which was above his baseline of 1.2 mg/dl. His tacrolimus trough level resulted at a level 45.6 ng/ml and later peaked at 82.2 ng/ml. His liver enzymes were normal. He was treated as acute pancreatitis with hydration and his tacrolimus was held with overall clinical improvement. Discussion: Tacrolimus is one of the most common medications used in solid organ transplantation. It is a calcineurin inhibitor that inhibits both T-lymphocyte signal transduction and IL-2 transcription. It is metabolized by the protein CYP3A and levels are monitored closely. Paxlovid is currently prescribed as an antiviral therapy for COVID-19 infection. The ritonavir compound in Paxlovid is potent inhibitor of CYP3A. Currently the guidelines do not recommend Paxlvoid as a therapeutic in patients taking tacrolimus as there is concern about increased drug levels. There have been several case reports of pancreatitis in setting of tacrolimus. This case report helps to demonstrate the need for close monitoring of therapeutics levels, especially in medications with high risk of drug to drug interaction to help prevent serious side effects such as tacrolimus induced pancreatitis.Figure 1.: Axial image of acute pancreatitis. Noted enlarged pancreatic head and neck with peripancreatic fat stranding

S1905 A Rare Case of Acute Pancreatitis With Normal Lipase

Introduction: Acute pancreatitis (AP) is an inflammatory disease of the pancreas that usually presents with epigastric pain radiating to the back. AP is a critical condition that can lead to multi-organ failure if not diagnosed early. It is diagnosed with 2 of the following: characteristic abdominal pain, imaging consistent with acute pancreatitis, and lipase levels greater than 3 times the upper limit of normal. The negative predictive value of lipase for diagnosing acute pancreatitis is between 94% and 100%. We present a rare case of acute pancreatitis with normal serum lipase levels. Our findings highlight the vital utility of imaging for diagnosing acute pancreatitis in the setting of normal lipase levels. Case Description/Methods: An 80-year-old female presented with a 1-day history of epigastric pain radiating to her back associated with nausea, vomiting, and loss of appetite. Her past medical history was significant for hypertension, NIDDM II, and atrial fibrillation. She had no recent medication changes and took amlodipine, metformin, metoprolol, and apixaban. Previous surgeries included cholecystectomy and appendectomy. She abstained from alcohol, tobacco, or recreational drug use. She reported abdominal trauma from bicycle collision one week prior to arrival. Vital signs were remarkable for T 101.2 F. She did not appear in acute distress. Her physical exam was remarkable for epigastric tenderness on palpation. Murphy, Cullen, and Grey-Turner signs were absent. Laboratory evaluation revealed WBC 12.8 k/uL, lipase 29 U/L, amylase 52 U/L, AST 13 U/L, ALT 21 U/L, ALP 58 U/L (Table). Lipid profile and EtOH levels were within normal limits. CT of the abdomen and pelvis revealed interstitial edematous pancreatitis (Figure). She was started on aggressive intravenous fluid resuscitation, metoclopramide for nausea, and intravenous acetaminophen for pain. Her abdominal pain progressively resolved, and she tolerated a full diet by day 3. Discussion: AP is a critical condition that requires early diagnosis. The negative predictive value of elevated lipase levels for diagnosing AP ranges from 94% to 100%. Our patient was diagnosed with acute pancreatitis due to trauma in the setting of normal lipase levels. We demonstrate the utility of imaging in diagnosing acute pancreatitis in the setting of normal serum lipase levels.Figure 1.: CT scan of the abdomen revealed peripancreatic fat stranding and interstitial edema consistent with findings of pancreatitis. Table 1. - Laboratory trends are displayed here. Lipase remained within normal limits through the 4 days measured. Admission Day 1 Day 2 Day 3 Day 4 Normal Range Hemoglobin 8.8 7.8 9.3 8.6 9.0 12.0 - 15.0 g/dL WBC 12.8 7.4 5.9 5.7 6.2 3.4 - 11.0 10*3/uL Amylase 52 39 29 - 103 U/L Lipase 29 12 13 - 60 U/L Calcium 8.9 8.1 8.9 8.8 8.4 8.4 - 10.2 mg/dL Alkaline Phosphatase 58 44 46 59 54 40 - 129 U/L ALT 21 16 29 17 11 10 - 50 U/L AST 13 10 14 12 16 13 - 39 U/L

S1675 Blame It on the Bamboo Stump: A Pancreatic Ductal Disruption Successfully Managed With Two-Step Endoscopic Therapy

Introduction: Non-penetrating, isolated pancreatic injuries are rare, and the management is not well-established and challenging. Most injuries are managed by surgery, but recently several case reports discuss endoscopic therapy for treatment of main pancreatic duct disruption. We report a case of pancreatic injury from falling on a bamboo stump with complete pancreatic ductal disruption and complete pancreas divisum with a dominant dorsal duct that was successfully nonoperatively managed through endoscopic therapy. Case Description/Methods: An 18-year-old male transferred for worsening abdominal pain from a grade IV pancreatic injury complicated by pancreatic ascites and massive pancreatic fluid collections (PFCs) sustained a month prior after a non-penetrating fall onto a bamboo rod in the Caribbean. He had failed conservative therapy and 2 attempts with ERCP for pancreatic duct (PD) stent placement. CT A/P and MRCP showed a 13cm cyst consistent with hemorrhagic pancreatic pseudocyst (Figure A-B). Labs showed leukocytosis, elevated lipase and LFTs, but he was hemodynamically stable. US-guided paracentesis drained 250mL of fluid consistent with pancreatic ascites. To allow for pancreatic edema reduction, we elected for a 2-step procedure with separate EUS and ERCP. EUS showed multiple PFCs s/P endoscopic cyst-gastrostomy with Axios stent (Figure C-D). Repeat CT A/P showed decrease in size of the PFCs (Figure E). He was discharged and returned in one week for ERCP that revealed a surprising complete pancreas divisum and total disrupted main dorsal PD, which was endoscopically treated with sphincterotomy of the minor papilla and a long PD stent across the disruption (Figure F-H). The Axios stent was removed a week later, and 4 weeks later we successfully removed the PD stents from both the major and minor papillae. He made an uneventful recovery and remains well. Discussion: Pancreatic disruption syndrome or Disconnected Pancreatic Duct Syndrome (DPDS) is an interruption of pancreatic duct continuity, usually from necrotizing pancreatitis, but can occur with blunt or penetrating abdominal injury, as in our patient. Endoscopic management is a minimally invasive option for DPDS and pancreatic ascites. Our patient had severe pancreatic injury managed using 2-stage endoscopic therapy, demonstrating a successful treatment strategy for pancreatic injury with total main DPDS. Further studies are required regarding the selection of patients, safety, and long-term outcomes.Figure 1.: Image A: CT A/P (coronal) demonstrating edematous pancreas with significant peripancreatic fat stranding, with a peripherally enhancing hypodense fluid collection near the body and tail of the pancreas measuring approximately 4.0 x 4.8 x 13 cm in the maximum AP, RL and SI dimensions (red arrow). Image B: MRCP (coronal) Abutting the pancreatic body is a multilobulated rim-enhancing complex fluid collection that extends from the level of the diaphragmatic hiatus to just above the level of the aortoiliac bifurcation and measures 6.8 x 9.7 x 19.1 cm (AP by TR by SI, red arrow). Image C-D: EUS demonstrating large pancreatic fluid collection (PFC, left) and s/P Axios cyst-gastrostomy (right). Image E: CT A/P (coronal) demonstrating cyst-gastrostomy placement with interval decrease in PFC. Image F-H: Pancreatogram showed extravastion of contrast material at the junction of proximal 2/3 and distal1/3 of the dorsal PD c/w disrupted dorsal PD (Complete Pancreas divisum, left). Placement of a 5 Fr 9 cm Zimmon PD stent with pigtail crossing the disruption at the minor papilla (center). Pancreatogram showing no extravasation of contrast material s/P PD stent placement.

S1665 Hypertriglyceridemia Independent Propofol-Induced Acute Pancreatitis—A Rare and Unusual Complication

Introduction: Propofol is a widely utilized lipophilic sedative anesthetic. Common side effects include hypotension, apnea, and rash. While rare, acute pancreatitis (AP) is a documented complication of propofol administration. Though the exact mechanism has yet to be established, current theories include propofol-induced hypertriglyceridemia (HTG) or idiosyncratic hypersensitivity reaction. We present a rare case of HTG-independent propofol-induced AP after an elective rhytidectomy. Case Description/Methods: A 75-year-old woman with hypertension and hypothyroidism, presented with 4 days of worsening mentation, abdominal distention and pain after an outpatient rhytidectomy. She was a former smoker, but denied alcohol or illicit drug use. On arrival, vital signs were significant for fever of 100.4F and tachycardia to 106 beats/min. Physical exam was significant for abdominal distension and epigastric tenderness. Laboratory studies revealed leukocytosis of 12,200 mm3 with 10.4% bandemia, alkaline phosphatase of 143 U/L, serum calcium of 8.9 mg/dL, lipase of 222 U/L, and triglycerides of 111 mg/dL. Abdominal ultrasound was unremarkable without evidence of gallstones or biliary dilatation. A computed tomography of the abdomen revealed extensive peripancreatic fat stranding and fluid with homogenous parenchymal enhancement consistent with severe interstitial edematous AP. An infectious workup was unremarkable for a concomitant source. Medication reconciliation revealed no confounding medications known to cause pancreatitis. She received intravenous fluids, proton pump inhibitor and pain regimen. Her diet was gradually advanced and she clinically improved over the next 48 hours with mentation returning to baseline. She was subsequently discharged home. Discussion: AP is responsible for over 230,000 hospitalizations annually in the US, with drug-induced AP comprising 0.5-2% of all cases. Propofol-induced AP has been sparsely reported in the setting of HTG, though exceedingly rare without this lab abnormality. The Badalov classification system differentiates association and causality of drug-induced AP by evaluating latency, rechallenge, and published evidence (Figure). Within this system, propofol has traditionally been characterized as a class II drug. However, recent published evidence has shown recurrence of AP upon propofol rechallenge, suggesting a more causal relation and a reclassification to class Ib. We present this case to raise awareness of the possible complications of propofol administration.Figure 1.: The Badalov Classification System of Drug-Induced Acute Pancreatitis.

489 Imaging of Acute Pancreatitis in a UK District General Hospital

Abstract Aim Imaging should not be routinely used in the diagnosis of Acute Pancreatitis unless there is: diagnostic uncertainty; failure to responding to conservative management; severity confirmation needed. It is suggested that optimal timing for CT assessment should be at least 72 hours after the onset of symptoms. We aimed to benchmark our unit and assess the imaging of Acute Pancreatitis and compare this against the standards set up by the Royal College of Radiologists (RCR). Method Patients with a CT proven diagnosis of Acute pancreatitis were included with data retrospectively collated and analysed over a 5-month period in 2021. Results 30 consecutive patients with CT confirmed Acute Pancreatitis were included (57% male, 43% female; mean age: 53 years). 50% had optimal timing of scans (72 hours after onset of symptoms), 67% of scans were deemed appropriate (diagnostic uncertainty, assessing severity). 40% of CT reports did not comment on all 3 prognostic factors (presence of pancreatic necrosis; free intraperitoneal fluid; extensive peripancreatic fat stranding). Only 27% of patients had an ultrasound of the gallbladder within 24 hours of Acute Pancreatitis diagnosis. Conclusion The findings of this snapshot study is in line with the existing literature. Our unit does not meet the targets set out by the RCR (95%). There remains a need to standardise the approach to imaging and we aim to aid this by disseminating the study findings to the relevant departments and increasing knowledge amongst the clinicians. Re-audit is planned in the coming months.

Drug-induced acute pancreatitis in a bodybuilder: a case report

BackgroundUnregulated use of a variety of drugs and supplements by bodybuilders and athletes is common and can lead to severe adverse complications. Only a small proportion of acute pancreatitis cases are drug induced, and case reports are essential for identifying potential drug-related risks for pancreatitis. Here we present the first case report published of acute pancreatitis linked to recreational use of anabolic–androgenic steroids, subcutaneous growth hormone, and clenbuterol in a previously healthy male after excluding all other causes of pancreatitis.Case presentationA 31-year-old Arab male bodybuilder presented with acute abdominal pain associated with nausea and sharp pain radiating to the back. The patient was not using tobacco or alcohol but was using multiple drugs related to bodybuilding, including anabolic–androgenic steroids, subcutaneous growth hormone, clenbuterol, and multiple vitamin supplements. Laboratory studies revealed a normal white blood cell count, elevated C-reactive protein, minimally elevated aspartate aminotransferase and total bilirubin with normal remaining liver tests, and elevated amylase and lipase. The patient had no hypertriglyceridemia or hypercalcemia, and had had no recent infections, abdominal procedures, trauma, or scorpion exposure. Imaging and laboratory investigations were negative for biliary disease and IgG4 disease. Abdominal computed tomography revealed hepatomegaly and diffuse thickening and edema of the body and tail of the pancreas with peripancreatic fat stranding. An abdominal ultrasound showed slight hepatomegaly with no evidence of cholelithiasis. Genetic testing for hereditary pancreatitis-related mutations was negative. A diagnosis of drug-induced acute pancreatitis was made, and he was treated with aggressive intravenous hydration and pain management. The patient has avoided further use of these drugs and supplements and had no further episodes of pancreatitis during 1 year of follow-up.ConclusionsThis case describes a patient with drug-induced acute pancreatitis after the intake of anabolic–androgenic steroids, subcutaneous growth hormone, and clenbuterol, where all other common causes of acute pancreatitis were excluded. Clinicians should be alert to the possibility of drug-induced acute pancreatitis occurring in bodybuilders and athletes using similar drug combinations.

Pancreatic Injury in Patients with SARS-Cov-2 (COVID-19) Infection: A Retrospective Analysis of CT Findings.

Objective To determine the association between COVID-19 infection and peripancreatic changes on CT as a sign of acute pancreatic injury. Methods Retrospective analysis of CT examinations in patients with confirmed COVID-19 infection yielded 103 instances. An age- and gender-matched cohort of patients without COVID-19 was found. CT examinations were evaluated for peripancreatic stranding or edema, fluid collection, or necrosis, without any other explanation. Depicted pulmonary parenchyma was evaluated for possible COVID-19-related changes. Clinical and laboratory data were retrieved from the clinical database. Results Peripancreatic fat stranding (n = 8) or fluid collection (n = 2) without any other cause was found in 10 (10%) patients. Abdominal complaints were reported in 4 (40%) patients. Elevated serum amylase or lipase levels were documented in 5 (50%) patients who also satisfied the diagnostic criteria for acute pancreatitis. From the study sample of 103 patients with COVID-19, pulmonary parenchyma was depicted in 102 (99%), and from these, 57 (55%) had an evidence of pulmonary changes compatible with COVID-19 pneumonia. This proportion was not significantly different between patients with and without peripancreatic changes (p = 0.35). In the matched cohort, we found peripancreatic changes in 2 (2%, p = 0.033) patients. Patients with pancreatic injury and elevated amylase levels were more likely to require orotracheal intubation (35% vs. 12%, p = 0.021). Conclusions We showed that the prevalence of peripancreatic stranding or fluid collection is higher in patients diagnosed with COVID-19 infection compared to an age- and gender-matched cohort. Patients with pancreatic injury and elevated amylase levels are more likely to require orotracheal intubation. Our findings corroborate the link between COVID-19 infection and pancreatic injury from the perspective of imaging.

S1662 Unusual Etiology of Papillary Stenosis Resulting in Pancreatitis

Introduction: Celiac Disease (CD) is known as chronic inflammation characteristically affecting the proximal small bowel. Although pancreatitis has been found to be related to CD, no specific etiology has been identified. Several cases have been reported describing CD resulting in papillary stenosis, but few have been due to duodenal scalloping causing obstruction and furthermore, stenosis. Case Description/Methods: A 74-year-old female with a past medical history of type 2 diabetes mellitus, hypertension, hyperlipidemia, stroke, celiac sprue, hypothyroidism and psoriatic arthritis presented to the emergency department (ED) with epigastric pain associated with nausea and abdominal distention. In the ED the patient was given morphine for pain control, ondansetron and a liter normal saline bolus. Patient was noted to have transaminitis with AST 480, ALT 255, elevated total bilirubin at 1.4 with a direct bilirubin of 0.7. Lipase was 54. CT abdomen showed diffuse diverticulosis without diverticulitis as well as questionable peripancreatic fat stranding. The patient underwent an MRCP which revealed no intra hepatic biliary dilatation, with mild extra hepatic biliary dilatation, and the common bile duct measuring 12 mm. No bile duct stones or biliary stricture was identified. She subsequently underwent an EGD which prompted an ERCP, with EGD revealing esophageal protruding lesions. On ERCP, scalloping was noted in the duodenum in close proximity to the ampulla, and a biopsy was consistent with celiac disease. She was suspected to have papillary obstruction and stenosis from duodenal scalloping. Of note, TTA was found to be high for CD at 27 indicating CD which was not well controlled. A stent was placed, and the patient was subsequently discharged a few days later after improvement of symptoms. Discussion: Pancreatico-biiliary diseases have been well documented in association with CD. Postulated mechanisms include reduced gallbladder emptying due to impaired cholecystokinin release, and pancreatitis due to malnutrition. It is likely that mucosal inflammation seen in CD involving the papilla and surrounding duodenal area is the likely contributing factor to predisposing these patients to pancreatitis. Several cases have been reported of specifically papillary stenosis secondary to CD inflammation, but few have been due to anatomical obstruction resulting from the disease. It is well known that patients with CD are at increased risk of developing acute and chronic pancreatitis, but most commonly idiopathic.

English

BACKGROUND Since the outbreak of coronavirus disease (Covid-19) many patients have presented with a variety of other symptoms along with primary respiratory symptoms. The increased reporting of these extra-pulmonary symptoms has made it necessary for the clinicians to establish a proper cause and relation between coronavirus disease 2019 (Covid-19) and extra-pulmonary symptoms. This study was undertaken to assess if the cause of elevated lipase levels in Covid-19 patients was due to acute pancreatitis. METHODS A retrospective observational study was performed at a local critical care ICU facility in Bathinda, India (MediWin Hospital, Bathinda, Punjab). RT - PCR, Rapid antigen test, CT scans were done to establish the Covid-19 status. Clinical signs and symptoms, CT scans were used to confirm the diagnosis of acute pancreatitis. MRI was preferred in patients with deranged renal function test. RESULTS Lipase test was done in 62 patients and the levels were found elevated in 52 patients. 40 patients were found to have symptoms of the spectrum of acute pancreatitis. 10 patients had symptoms along with signs of1 severe inflammatory response syndrome. Imaging was advised in these 10 patients with1 moderate to severe presentation of acute pancreatitis. 9 patients were advised CT scans which had no significant findings. 1 patient with deranged renal function test was advised2 MRI scan which showed mildly diffusely bulky pancreas. Mild peripancreatic fat stranding and fluid collection, suggestive of acute interstitial pancreatitis. It was associated with poor outcomes and lead to the patient’s death eventually. CONCLUSIONS Hyperlipasemia led to acute pancreatitis in 1 (1.6 %) patient. It was associated with poor outcome and caused eventual death of the patient. The prospects of a Covid-19 patient developing Hyperlipasemia due to acute pancreatitis were found to be statistically insignificant. KEY WORDS Coronavirus, Hyperlipasemia, Pancreatitis, Lipase, RT - PCR, Rapid Antigen Test.

CT severity indices derived from low monoenergetic images at dual-energy CT may improve prediction of outcome in acute pancreatitis

To determine whether imaging features and severity indices using low monoenergetic DECT images improve diagnostic conspicuity and outcome prediction in acute pancreatitis compared to conventional images. A retrospective study of patients with clinical and radiographic signs of acute pancreatitis who underwent 50 contrast-enhanced CT exams conducted on a single-source DECT was performed. Representative conventional and 50 keV-monoenergetic images were randomized and presented to four abdominal radiologists to determine preferred imaging for detecting fat stranding and parenchymal inflammation. Contrast and signal-to-noise ratios were constructed for necrotic, hypoattenuated, inflamed, and healthy parenchyma. These parameters and the CT severity index (CTSI) were compared between conventional and low monoenergetic images using paired t tests and correlated to clinical outcome. Although preference for conventional images was noted for subtle peri-pancreatic fat stranding (169/200 (85%) reads), there was clear preference for low monoenergetic images among all readers for pancreatic inflammation evaluation (188/200 (94%) reads). Moreover, identification of small, hypoattenuating inflammatory foci on monoenergetic images alone in 13/50 (26%) cases resulted in upstaged CTSI from mild to moderate in 7/50 (14%), associated with longer hospitalization (16 ± 17 days vs. 5 ± 2 days; p < 0.05), ICU admission, and drainage. Quantitatively, a twofold difference between normal and inflamed parenchyma attenuation was identified for monoenergetic (44.8 ± 27.6) vs. conventional (25.1 ± 14.7) images (p < 0.05). Significant increases were seen in the monoenergetic SNR and CNR compared to the conventional images (p < 0.05). DECT low monoenergetic images afford better tissue assessment and demarcation of inflamed pancreatic parenchyma. Additionally, they provide improved characterization of the extent parenchymal necrosis, enabling better classification that may better predict severe clinical outcomes. • DECT low monoenergetic images afford better tissue assessment and demarcation of inflamed pancreatic parenchyma and provide improved characterization of the extent parenchymal necrosis. • Qualitatively, low monoenergetic images were preferred over conventional DECT images for the evaluation of pancreatic inflammation; and quantitatively, there is a twofold difference between normal and inflamed parenchyma attenuation, SNR, and CNR between monoenergetic vs. conventional images. • Monoenergetic imaging identified additional small, hypoattenuating inflammatory foci in 26% resulting in an upstaged CT severity index in 14% associated with longer hospitalization, ICU admission, and drainage, thereby enabling better classification and better prediction of severe clinical outcomes.

Ascaris Lumbricoides Infestation as an Unexpected Cause of Acute Pancreatitis

Ascariasis is the most common helminthic infection. It is most common in children of tropical and developing countries where the transmission is by contamination of soil by human feces or use of untreated feces as fertilizer. Transmission in most endemic areas is via person to person contact. We hereby present a case report of acute pancreatitis due to ascariasis. Twenty-five-year-old male patient presented to us with chief complaint of acute epigastric pain radiating to back and associated with vomiting. Initial lab investigations revealed increased serum amylase and lipase. Probable diagnosis of acute pancreatitis was made. CT scan was done and report revealed bulky pancreas, and significant peri-pancreatic fat stranding. He was managed symptomatically with intravenous fluids, analgesics, anti-emetics and enteral nutrition. However, the cause remained undetermined as we ruled out the possible etiologies of acute pancreatitis until one day the patient vomited a 15-cm round worm. Thereafter, his condition improved dramatically. This is one of the first few case reports of ascariasis-induced pancreatitis from Pakistan and the first one from Baluchistan province of Pakistan. Thus it highlights ascariasis as possible etiology of acute pancreatitis in regions where ascariasis is geographically endemic.

S1459 Immune Checkpoint Inhibitor-Induced Pancreatic Injury: An Atypical Presentation

INTRODUCTION: Immune checkpoint inhibitors (ICI) are effective in the treatment of several advanced cancer types. ICI-pancreatic injury (ICI-PI) is uncommon and often asymptomatic with incidentally elevated pancreatic enzymes. We present a case of ICI-PI mimicking autoimmune pancreatitis (AIP) with obstructive jaundice. CASE DESCRIPTION/METHODS: A 60-year-old male with acral melanoma metastatic to the liver was treated with four cycles of nivolumab and ipilimumab. After three cycles of maintenance nivolumab, surveillance positron emission tomography (PET) revealed diffuse fluorodeoxyglucose (FDG)-avidity of the pancreas with peripancreatic fat stranding (Image 1). He endorsed mild abdominal discomfort with an elevated lipase 10x the upper limit of normal (Table 1). He had no gallstones on imaging and socially drank alcohol. ANA was negative with normal IgG4. He was given a diagnosis of ICI-PI and treated with intravenous fluids and discharged on a 14-day steroid taper and lab monitoring. Three weeks after completing the steroid taper, he presented with worsening abdominal pain and gray colored stool. Labs showed elevated liver tests consistent with a cholestatic obstructive pattern. Computed tomography (CT) revealed diffuse mild enlargement of the pancreas. MRCP showed dilated extrahepatic bile duct up to 11mm with an intrapancreatic stricture. Endoscopic ultrasound (EUS) showed diffusely lobular pancreas with hypoechoic areas and intervening hyperechoic standing. The pancreatic duct was not dilated. The bile duct was dilated and abruptly narrowed as it entered the pancreatic head. Fine needle aspiration (FNA) of the pancreatic head with 25G needle revealed pancreatic acini and focal findings suggestive of chronic pancreatitis without metastatic melanoma (Image 2). A diagnosis of ICI-PI mimicking AIP was made. He received high dose oral steroids with a long taper. His liver enzymes normalized. Repeat PET showed interval resolution of pancreatic FDG-avidity and peripancreatic fat stranding with continued remission of melanoma. DISCUSSION: This is a unique case of ICI-PI evolving into obstructive jaundice and resolving with steroids. Although he had negative serologies, his imaging and clinical course mimicked AIP. Both ICI related adverse events and AIP are T-cell driven processes suggesting a possible similar pathogenesis. The incidence of ICI-PI will likely rise with the increasing use of ICIs; thus, awareness of ICI-PI and its variable presentation are clinically salient.Table 1.: Liver enzymes, total bilirubin and lipase from the last cycle of nivolumab therapy through both hospitalizations. Normal aspartate aminotransferase (AST) is 0–40 IU/L. Normal alanine aminotransferase (ALT) is 0-32 IU/L. Normal alkaline phosphatase (ALP) is 39-117 IU/L. Normal total bilirubin is 0–1.2 mg/dL. Upper limit of normal lipase is 51 U/LFigure 1.: Image 1. Positron emission tomography (PET) imaging. A. Prior to nivolumab therapy. B. After three cycles of maintenance nivolumab. C. After high dose oral steroids and normalization of liver enzymes.Figure 2.: Image 2. Biopsy obtained during endoscopic ultrasound (EUS). A. Benign pancreatic acini and focal findings suggestive of chronic pancreatitis on hematoxylin and eosin (H&E) stain. B. SOX10 stain with control. SOX10 is a melanoma marker and thus no metastatic melanoma identified.

S1575 A Case of Acute Pancreatitis Associated With the Novel Severe Acute Respiratory Syndrome Coronavirus-2

INTRODUCTION: Acute pancreatitis is a frequent cause of hospital admissions. The most common causes are gallstones and alcohol, while 10% are infectious. To our knowledge, we present the 4th case of acute pancreatitis caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS CoV2). CASE DESCRIPTION/METHODS: A 60-year-old African American male with uncontrolled hypertension presented with weakness and nausea for one week. He denied alcohol use, herbal medications and reported non-compliance to his prescribed medications. Vitals: BP 188/98 mmHg, HR 110/min. Physical exam revealed epigastric tenderness. Labs were significant for positive SARS-CoV-2, T bili:0.3mg/dl, IGG:1145mg/dl, IGM: 77mg/dl, calcium:8.3mg/dl, triglyceride:440mg/dl, Lipase 4800U/L and D-Dimer 2418 ng/ml. Ultrasound abdomen was negative for gallstones.CT abdomen revealed peripancreatic fat stranding. He was started on intravenous hydration and oxygen supplementation. His abdominal pain resolved and he tolerated a normal solid diet. He had a prolonged hospital course due to increasing oxygen requirements. Repeat imaging revealed possible pancreatic pseudocyst formation. He was diagnosed with SARS-CoV-2 pancreatitis as a diagnosis of exclusion. DISCUSSION: SARS-CoV-2 typically presents with respiratory symptoms. As more data emerges, gastrointestinal symptoms (GI) are being reported which is believed to be caused by feco-oral transmission route. Studies show that SARS-CoV-2, uses Angiotensin converting enzyme -2 (ACE2), a viral receptor found in the intestinal epithelia, to enter host cells downregulating the expression of ACE2 leading to intestinal inflammation. 10% of acute pancreatitis cases are infectious, although the exact incidence of viral pancreatitis is unknown. Studies show viral pancreatitis as a consequence of direct destruction of the pancreatic acinar cells and we hypothesize that SARS-CoV-2 via binding to ACE2, uses a similar mechanism. Also, it is associated with the formation of microthrombi, which may impair microcirculation causing inflammation and ischemia of the pancreas.Earlier, patients were admitted primarily based on respiratory-related symptoms. This case brings to our attention the incidence of GI symptoms and possible complications associated with the virus. It shows the challenges associated with treatment of both, in which fluid overload with subsequent acute respiratory distress syndrome is a concern. This case serves to increase awareness of a possible association of the novel SARS-CoV-2 with pancreatitis.Figure 1.: CT Abdomen and pelvis showing peripancreatic fat stranding.Figure 2.: CT Angiography abdomen and pelvis showing peripancreatic fluid collection.

Caroli Disease: A Presentation of Acute Pancreatitis and Cholangitis

Caroli disease is a rare congenital disorder resulting from the dilation of large intrahepatic bile ducts. Patients affected with Caroli disease are at increased risk of complications resulting from bile stasis and stone formation. We report the case of a 37-year-old woman with a past surgical history of cholecystectomy who presented to the emergency room with a chief complaint of abdominal pain and nausea. The pain was characteristic of acute pancreatitis but she was hemodynamically stable. Total bilirubin was 4.1 mg/dL with a direct fraction of 3.1 mg/dL, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were 850 IU/L and 1025 IU/L, respectively. Serum amylase and lipase were elevated at 581 IU/L and 1328 IU/L, respectively. CT scan of abdomen/pelvis without contrast showed common bile duct (CBD) measuring 1.6 cm with intrahepatic biliary system dilation and mild peripancreatic fat stranding. She was diagnosed with acute pancreatitis. On the second day, she developed a temperature of 99.6°F. Hepatitis immunity panel was negative for acute hepatitis. The patient was started on antibiotics (IV ciprofloxacin and metronidazole) for suspicion of acute cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) was done which showed mild dilated intrahepatic ducts and CBD dilation of 1.6 cm, and a choledochal cyst at CBD. Sphincterotomy was done and good bile drainage was reported. She was later discharged in a stable condition. Caroli disease affects males and females equally and most are diagnosed before the age of 30 years correlated with the onset of symptoms. By far, the most commonly reported symptom is acute cholangitis but pancreatitis occurs rarely. Recurrent bouts of infection lead to portal hypertension, fibrosis of the liver and ultimately end up with an orthotopic liver transplant (OLT). Regular follow-ups are important for disease surveillance and monitoring.

Acute Pancreatitis Complicating Liver Transplantation in a Case of Fulminant Hepatic Failure Due to Yellow Phosphorus Poisoning

Yellow phosphorus (YP) is a general protoplasmic poison causing hepatic, cardiac, renal, and multiorgan failure. We report an unusual case of fulminant liver failure due to ratol (YP) poisoning complicated by acute pancreatitis postoperatively after liver transplantation. A 25-yr-old man presented with alleged consumption of approximately 7gm of Ratol paste. Serum amylase and lipase levels were 880 and 2423, respectively, and CT imaging of pancreas was normal. He developed fulminant liver failure, fulfilling King's college criteria and an living donor liver transplantation was performed. Intraoperatively fat saponification was seen at the root of mesentery. On postoperative day (POD) 13, he developed incisional wound dehiscence and he underwent laparotomy with extensive slough removal from the lateral aspect of wound. On POD 21, wound showed evidence of burst abdomen. CT abdomen revealed inflamed tail of pancreas with peripancreatic fat stranding and an exploratory laparotomy was performed again. Intraoperatively, walled-off necrotic collection was seen in the tail of the pancreas and necrosectomy was carried out. All the aforementioned re-explorations were carried out under steroid immunosuppression. He was restarted on tacrolimus on POD27. Graft function and cholestatic biochemistry improved progressively, and he was discharged and is on regular follow-up. YP is very toxic with rapid absorption and gets accumulated in liver causing acute liver failure. Acute pancreatitis in a patient after liver transplantation for fulminant liver failure owing to Ratol poisoning has not been reported in published English literature. Although clinically relevant pancreatitis is rare in ratol poisoning, despite elevated pancreatic enzymes, it is prudent to meticulously image pancreas before embarking on liver transplantation. In those with pretransplant elevation of pancreatic enzymes, it is desirable to follow up the enzyme values postoperatively.

Arthritis with nodular skin lesions.

A rheumatology consult was taken for a 22-year-old man admitted with acute pancreatitis who developed nodular skin lesions over both shins and joint pains in the ankles, knees, and wrists. The patient had a history of mild dull aching, epigastric pain for 1 year; and presented with fever for 1 month with dyspnoea. In the hospital, blood tests showed raised amylase (1997 units per L) and lipase (889 units per L). MRI of the abdomen (figure 1A) showed diffuse enlargement of the pancreas with mild peripancreatic fat stranding and dilated main and peripheral ducts.

A study on significance of computed tomographic evaluation of acute pancreatitis: A prospective observational study

Background: Acute pancreatitis is a common disease with high rate of morbidity and mortality. Computed tomography is the gold standard technique not only for its global picture of the pathology and for the non-invasive method of evaluating the morphology of pancreas and peripancreatic regions in an acute situation. Aim & Objectives: The purpose of the study was to determine the value of computed tomography evaluation in early diagnosis of severity, differences between pancreatitis & acute pancreatitis caused by mass lesions.Methodology: A prospective study comprise of 60 patients on clinical suspicion/diagnosis of acute pancreatitis, altered biochemical parameters (serum amylase, serum lipase) in favor of acute pancreatitis, Ultrasonography suggestive of acute pancreatitis and known case of chronic pancreatitis with features of acute symptoms referred to Department of Radio-diagnosis, Medical College and Research Hospital for computed tomography scan of abdomen and pelvis using Toshiba Asteion spiral Computed Tomography scan. Plain and post-contrast series of the abdomen and pelvis were taken.Results: In this prospective study of 50 patients, 40 were male and 10 were female patients. Among these edematous pancreatitis was in 20% patients and pancreatic necrosis was in 24% patients. Other features like diffuse/focal pancreatic enlargement in (75%), peri-pancreatic fat stranding in (64%) and peri-pancreatic fluid collection in (40%). Among this alcohol was the most common cause of AP (84%). The accuracy and sensitivity of serum amylase and serum lipase in diagnosing AP were 40% and 64% respectively with CT showing 100% accuracy and sensitivity. Modified CT severity index was classified as mild (2 and 4), moderate (6) and severe (8 and 10) of which majority were mild (66%), moderate (22%) and severe (12%).Conclusion: Computed tomography is a sensitive, non-invasive imaging in early diagnosis and staging of severity of acute pancreatitis which help in prediction of prognosis of the disease. It helps to differentiate between edematous and necrotizing pancreatitis as serum lipase and amylase levels do not help to differentiate the type of AP. Modified CT severity index helps in evaluating the percentage pancreatic necrosis and to predict the possibility of developing local and systemic complications and necessity of tertiary care.