Repeat CT Scan Research Articles

1642 Pelvic Congestion Syndrome: An Unusual Manifestation of Sigmoid Pneumatosis Cystoides Intestinalis

INTRODUCTION: Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by gas-filled cysts in the intestinal subserosa and submucosa. We present a rare case of primary PCI affecting sigmoid colon complicated by pelvic congestion syndrome (PCS). CASE DESCRIPTION/METHODS: A 34-year-old morbidly obese female presented with diffuse lower abdominal pain and intermittent foamy diarrhea without blood or mucus for the past 5 months. CT abdomen showed small bubbles of gas in the peritoneum in the left upper quadrant and large amount of cystic pneumatosis in a loop of sigmoid colon. Lab work was unremarkable. She was given one week course of antibiotics. A repeat CT scan 5 months later showed interval resolution of free intraperitoneal air but pneumatosis bubbles had enlarged in size. A colonoscopy was performed which showed large cystic-appearing air-filled bullae in sigmoid colon causing some luminal narrowing and the scope could not be safely advanced beyond mid-transverse colon. Patient underwent laparoscopic sigmoid colectomy and intraoperatively noted to have dilated and tortuous bilateral gonadal veins. Surgical pathology showed multiple clear fluid-filled cysts throughout the length of the specimen with viable and unremarkable proximal and distal resection margins. Patient recovered well from surgery and was discharged with no further complaints. DISCUSSION: PCI is an unusual condition caused by a myriad of underlying pathophysiological processes that range from benign to life-threatening conditions. Primary PCI is rare (15%), while underlying conditions for secondary PCI can be divided into several groups; traumatic, mechanical, inflammatory, autoimmune, infectious, pulmonary and drug (steroids and chemotherapeutic agents) induced. Conservative management is preferable except in cases of clinical deterioration. This case is unique because even after the resolution of free intraperitoneal air the patient continued to have lower abdominal and pelvic pain with worsening of pneumatosis on repeat CT scan several months later. It is possible that sigmoid anatomic changes due to pneumatosis resulted in chronic intermittent venous obstruction of pelvic veins leading to gonadal veins dilation and tortuosity and hence secondary PCS which resulted in ongoing lower abdominal pain. This case highlights the fact that persistent PCI, with ongoing abdominal symptoms even in the absence of any obvious etiology warrants laparoscopic exploration to rule out any underlying disease process.

METASTATIC PANCREATIC CANCER MASQUERADING AS INTERSTITIAL LUNG DISEASE

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Pancreatic cancer is often metastatic at presentation and occasionally presents with predominantly respiratory symptoms that can lead to further delays in diagnosis. CASE PRESENTATION: A 78 year old female with a history of breast cancer in remission presented with persistent cough for 3 months. She was found to have bilateral basilar ground glass opacities on CT chest [Image 1]. She had bronchoscopy with bronchoalveolar lavage and transbronchial biopsy that showed a neutrophil and macrophage predominant lavage with negative bacterial, fungal and acid fast cultures and benign bronchial cells and chronic inflammation on biopsy. She was treated for a presumed bacterial pneumonia. A myositis and autoimmune panel were normal. A repeat CT chest in 1 month showed worsening bilateral opacities and she was started on prednisone for presumed cryptogenic organizing pneumonia [Image 2]. She unfortunately had worsening dyspnea, worsening hypoxia requiring supplemental oxygen and again worsening bilateral opacities on a repeat CT scan 2 months later [Image 3]. She underwent surgical lung biopsy which was concerning for adenocarcinoma with mucinous and lepidic features. Staining was concerning for malignancy of gastrointestinal origin. A PET-CT scan revealed a pancreatic tail mass and a CA 19-9 was markedly elevated concerning for metastatic pancreatic adenocarcinoma. She unfortunately developed a post-surgical pneumothorax requiring a prolonged hospitalization and further deconditioning. She was not a candidate for aggressive treatment options due to decreased pulmonary reserve and poor performance status. DISCUSSION: In rare circumstances, metastatic cancers, particularly pancreatic adenocarcinomas, can present with acinar and lepidic spread of tumor which can mimic interstitial lung disease, rather than a nodular or lymphangitic presentation [1]. This can confound the diagnosis and lead to a diagnostic delay. Early consideration of surgical lung biopsy may need to be considered in cases where a clear etiology of interstitial lung disease is not evident in order to prevent further delays in diagnosis which may limit treatment options [2]. CONCLUSIONS: We present a case of metastatic pancreatic cancer presenting initially with dyspnea and chest imaging suggestive of interstitial lung disease. Surgical lung biopsy was able to confirm the diagnosis, but unfortunately not until the patient experienced a significant decline in her performance status which limited her treatment options. Early diagnosis is imperative for effective treatment of pancreatic cancer, and acinar and lepidic spread of tumors should remain in the differential for persistent ground glass opacities on radiography. Reference #1: Ozkan E, Balachandran A, Bhosale PR, Tamm EP, Marcal LP, Szklaruk J. Pictorial essay: multimodality imaging of metastases from pancreatic ductal adenocarcinoma. Clin Imaging. 2010; 34(4):277-87 Reference #2: Heraudeau A, Ricordel C, Sale A, et al. Interstitial lung disease and pancreatic cancer: Series of two cases. Rev Mal Respir. 2018 Jan;35(1):78-82 DISCLOSURES: No relevant relationships by Nihal Patel, source=Web Response No relevant relationships by Michael Wert, source=Web Response

2786 Abdominal Pain in a Patient With Anorexia Nervosa

INTRODUCTION: Gastric ischemia is a rare cause of abdominal pain due to the rich blood supply to the stomach. The etiology for gastric ischemia is generally due to systemic hypotension, gastric volvulus, vasculitis or thromboembolism. Acute gastric ischemia can rapidly lead to morbidity and mortality due to the formation of large hemorrhagic and necrotic ulcers unless recognized early. We present a case of gastric ischemia in a patient with a psychiatric history. CASE DESCRIPTION/METHODS: A 60 year old female presented to the ER with acute epigastric pain and nausea. She denied any history of alcohol, aspirin or NSAID use. She had a history of anorexia nervosa and had a recent inpatient psychiatric admission after she was found eating garbage by her family. A few days after her discharge, she reported that she had eaten a large meal and felt that the food was “stuck” in her abdomen. The patient appeared uncomfortable, yet did not seem to be in severe distress. Her exam was only notable for mild abdominal tenderness without rebound or guarding. On computed tomography of the abdomen and pelvis, the patient was found to have a severely distended stomach, gastric wall pneumatosis, perigastric intravenous gas and portal venous gas. She was treated with nasogastric tube decompression, proton pump inhibitor therapy and intravenous antibiotics. A repeat CT scan done 24 hours later showed resolution of ischemic changes and gastric distention. An EGD performed on hospital day 3 noted erosions and large clean based ulcerations in the gastric fundus. Biopsies were negative for Helicobacter pylori infection. DISCUSSION: Due to this patient’s psychiatric history, as well as her benign clinical appearance and abdominal exam, appropriate treatment was initially delayed. Early identification and treatment of acute gastric ischemia, even in patients without typical risk factors for ischemia is vitally important. In patients with anorexia nervosa with binging behaviors, the clinical presentation of gastric dilation and ischemia may not correlate with radiologic findings. Severe gastric distension from binge eating may lead to gastric ischemia and ischemic gastroparesis.

RARE AND RAPID: A CASE OF EXPLOSIVE PLEURITIS

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Parapneumonic effusions (PPE) are pleural effusions associated a bacterial pneumonia or lung abscess. Between 20 to 57% of the 1 million patients hospitalized yearly with pneumonia develop a PPE. We present a rare case of rapidly developing PPE, known as “explosive pleuritis.” CASE PRESENTATION: 56 year old male smoker with mild persistent asthma presented with worsening pleuritic chest pain. Pain was around the right scapula and had been progressively worsening over 5 days. It had no alleviating factor, and worsened with coughing and deep inhalation. He also had intermittent nonproductive coughs as well as a single episode of subjective fever 1 day prior, but no other symptoms. He denied sick contacts and recent travel outside of New York. CT pulmonary embolism protocol was obtained initially, which revealed a mass like structure in the right lower lobe, suspicious for a pneumonia versus an early abscess. He was admitted to the general medical floor and remained hemodynamically stable, required no oxygen supplementation, had no leukocytosis, and was initiated on Ampicillin/Sulbactam therapy. The following day, the patient became more tachypneic needing supplemental oxygen, and developed a leukocytosis of 13.9K/uL. Chest X-ray showed a new right side infiltrate and pleural effusion. Due to his rapidly deteriorating status, he was transferred to the medical ICU. Antibiotics were broadened and a repeat CT scan was obtained. The repeat scan revealed a large loculated right sided pleural effusion. A tube thoracostomy was attempted, however bedside ultrasound exam showed extensive stranding and haziness of the pleural effusion without a safe insertion site. Cardiothoracic surgery was consulted and patient had a video assisted thoracoscopic surgery. Large amount of empyema was evacuated, and the patient had 3 chest tubes inserted. Over the next 4 days, the patient’s respiratory status and leukocytosis had improved, and he had his chest tubes removed without any complications. Patient was discharged on day 8 of admission, and is now completing a 6 week course of antibiotics. Cultures obtained throughout the admission including the pleural peel and rind have unfortunately been negative. DISCUSSION: Explosive pleuritis is a rare entity that develops within 24 hours, involves 90% of the affected hemithorax, and has the tendency to loculate early. Streptococcal infections have been associated with it, owing to the blockage of lymphatics with cellular debris. However, the causative organism often is not isolated. Once identified, prompt initiation of antibiotics and drainage of the effusion is needed. This can be achieved by either tube thoracostomy or by surgical decortication. CONCLUSIONS: Explosive pleuritis should be considered for a rapidly deteriorating patient with pneumonia. It is an emergency that requires prompt investigation and treatment consisting of both medical and surgical treatment. Reference #1: Sharma JK, Marrie TJ. Explosive pleuritis. Can J Infect Dis. 2001;12(2):104-7. Reference #2: Bryant RE, Salmon CJ. Pleural empyema.Clin Infect Dis 1996:22;747-62. Reference #3: Braman SS, Donat WE. Explosive pleuritis.Am J Med 1986;81:723-6. DISCLOSURES: No relevant relationships by Erica Altschul, source=Web Response No relevant relationships by Nader Ishak Gabra, source=Web Response No relevant relationships by Oki Ishikawa, source=Web Response No relevant relationships by Omar Mahmoud, source=Web Response No relevant relationships by Bushra Mina, source=Web Response No relevant relationships by Maly Oron, source=Web Response No relevant relationships by Varun Shah, source=Web Response

2486 Pick the Cause: Streptococcus Intermedius and Mitus/Oralis Hepatic Abscess Due to Occult Gastrointestinal Perforation

INTRODUCTION: Abscess bacteria identification directs both evaluation and management. In our case, identification of Strep intermedius and mitus/oralis led to identification of an unsuspected perforation. CASE DESCRIPTION/METHODS: A 45 y/o female presented to the ED with 5 days of fevers to 103.5 F, headache, cramping RUQ abd pain, diarrhea. CT abd revealed a 6.8 cm hypodense septated collection in the liver. Abnormal labs: WBC 32K TBili 1.3 AP 210 ALT 45. History was negative for IVDA, FH and personal hx of IBD, blood in stool, or travel. IR placed a drainage catheter on HD#1 and sent 60 cc purulent material for culture, gram stain with GPC. Culture several days later revealed sensitive Strep intermedius and Strep mitis/oralis in abscess and one anaerobic blood culture. The patient was treated with vancomycin and zosyn. Echocardiogram HD#3 showed minimal mitral calcification and no vegetations. Despite appropriate antibiotics, the RUQ pain, fevers, and WBC persisted. Repeat CT Abd on HD#7 showed a second hepatic abscess (IR placed second drain) and new pelvic abscess measuring 3.5 × 6 cm. On HD#9 we pursued occult GI causes of the persistent infection. Colonoscopy revealed a 1 cm adenoma (snared/removed) with no colon cancer, perforation, or IBD. EGD revealed a toothpick embedded in the prepyloric stomach; this was removed by snare. The patient did not recall eating food with a toothpick or swallowing one. Patient was discharged to home on HD # 11 with a PICC line to complete Unasyn course. Drainage catheters were removed 29 days after initial presentation; repeat CT scan at 52 days revealed no residual hepatic or pelvic abscess collections. DISCUSSION: Streptococcus intermedius is one of the members of the S. milleri group, which are normal flora in the mouth and gastrointestinal tract. S. milleri may cause liver, pelvis, and subphrenic abscess, cholangitis, peritonitis, and appendicitis. Presence of S. millerigroup bacteremia should direct attention to exclusion of occult abdominal perforation or infection, distant focal suppurative infection, and infective endocarditis. Streptococcus mitus/oralis is a common oral bacteria in the Strep viridans group; this may cause a variety of infections including cerebral, epidural, and liver abscesses and endocarditis. Upon the identification of Strep intermedius as the main abscess pathogen in our patient, prompt search for occult abdominal perforation and removal of the foreign body from the perforation tract resulted in resolution of both symptoms and infection.

2744 A Scary Case of Gastroenteritis

INTRODUCTION: Gas in the gastric venous system or the portal venous system is a critical finding and can be from a life threatening abdominal catastrophe as well as from benign conditions. CASE DESCRIPTION/METHODS: A 52 year old gentleman presented with nausea, vomiting and diarrhea for 2 days. He had multiple episodes of non bloody diarrhea for past two days and had an episode of vigorous non bilious/ non bloody vomiting. No fevers, chills or weight loss was reported. His medical history included diabetes mellitus type 2, hypertension, obstructive sleep apnea, depression and anxiety. On admission, his vitals were stable. The physical examination was completely benign. His laboratory data revealed mild leukocytosis of 13.3. Lactate was normal. There was no anemia or microcytosis. A CT scan of his abdomen was done which revealed gas in the gastric veins and the peri-gastric veins, which was very concerning. Urgent Surgical consultation was placed. The patient was admitted to step down unit and conservative management with hydration, anti emetics and supportive care was initiated. In the next 4 hours, the patient started feeling better and became asymptomatic. The CT of the abdomen was repeated. The entire patient care team was on high alert for a possible abdominal catastrophe/ischemia and need for emergent surgery. The repeat CT scan was done 6 hours later which revealed linear lucencies within the peripheral aspect of the left lobe of the liver, consistent with gas within the portal venous system. Urgent Infectious Disease consultation was called and piperacillin-tazobactam was initiated. At this time, the patient was asymptomatic, his vitals were stable, the lactate remained normal and the leukocytosis had resolved in the repeat laboratory analysis. Close monitoring was continued. The next day, the patient remained in the stable and asymptomatic. A third repeat CT scan of the abdomen revealed complete resolution of all the gas in the gastric and the portal venous system. The diet and activity were advanced gradually and the patient was discharged the same day. DISCUSSION: It is important to recognize that there are many benign causes of gastric venous gas and portal venous gas such as gastroenteritis. We believe that the mechanical trauma of retching and vigorous vomiting may have lead to this finding.

ANCA-NEGATIVE GRANULOMATOSIS WITH POLYANGITIS: HUNT FOR A ZEBRA

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Granulomatosis with polyangiitis (GPA) stays high on the rheumatological differential in cases where there is renal insufficiency, hematuria, cartilaginous abnormalities or necrotizing lesions noted in the upper and lower respiratory tract. Serological testing is often done along with tissue diagnosis. ANCA is generally positive in such scenarios supplementing the diagnosis of GPA. Rarely ANCA can be negative. GPA should therefore be considered in the differential of negative ANCA, since there is high likely hood of misdiagnosis and unnecessary investigation along with a delay in treatment. CASE PRESENTATION: 56-year-old male who occasionally smokes cigars and had been exposed to asbestos from car brakes, complained of bloody urine. Patient had cystoscopy and TURBT performed revealing cystitis cystica. He had CT chest, abdomen and pelvis performed showing several bilateral pulmonary nodules. Couple of speculated nodules previously seen in right lower lobe increased in size. PET scan showed increased uptake in right lower lobe lung nodule. CT-guided lung biopsy was done which showed exuberant acute on chronic inflammation with necrosis. That was negative for fungal organism on gram stain and culture. No malignant cells were found. All serological work up was negative including ANCA. Repeat CT scan in five months showed that right lower lobe pulmonary nodule was increasing in size. Considering hematuria, CT scan and pathology findings there was a high suspicion for granulomatosis with polyangiitis. Patient was taken to VATS of right lower lobe wedge resection to confirm the diagnosis. Pathology report showed necrotizing granulomatous inflammation with geographic necrosis confirming the diagnosis of granulomatosis with polyangiitis. There was no evidence of malignancy. DISCUSSION: In less than 10% cases patients have been reported with granulomatosis with polyangiitis. Unless there is high degree of suspicion kept in cases with clinical scenario suggestive for granulomatosis with polyangiitis even in cases of ANCA negative patients, there is high likelihood of missing the diagnosis. We suggest in cases with strong clinical suspicion, even though ANCA is negative and bronchoscopic biopsy is not revealing further invasive testing is warranted to establish a correct diagnosis. CONCLUSIONS: Negative serologies should not preclude invasive testing for adequate tissue specimen in patients with a strong history suggestive for GPA in order to prevent delay in diagnosis and management. It is well documented that patients with the history of Polyangitis with granulomatosis has involvement of Urinary bladder and are at high risk for cystitis. Cytitis has potential of worsening to cystitis cystica. Reference #1: Falk RJ, Jennette JC. ANCA small-vessel vasculitis. J Am Soc Nephrol. 1997;8(2):314–22. Reference #2: Finkielman JD, Lee AS, Hummel AM, Viss MA, Jacob GL, Homburger HA, et al. ANCA are detectable in nearly all patients with active severe Wegener’s granulomatosis. Am J Med. 2007; 120(7):643.e9–14. Reference #3: Hagen EC, Daha MR, Hermans J, Andrassy K, Csernok E, Gaskin G, et al. Diagnostic value of standardized assays for anti-neutrophil cytoplasmic antibodies in idiopathic systemic vasculitis. EC/BCR Project for ANCA Assay Standardization. Kidney Int. 1998;53(3):743–53. DISCLOSURES: No relevant relationships by Amnah Andrabi, source=Web Response No relevant relationships by Kashif Aslam, source=Web Response No relevant relationships by Bindu Gandrapu, source=Web Response No relevant relationships by Preeyanka Sundar, source=Web Response

2210 Resolution of Hepatocellular Carcinoma in a Patient With Chronic Hepatitis B Treated With Entecavir Therapy

INTRODUCTION: Hepatitis B virus (HBV) is a major cause of hepatocellular carcinoma (HCC) globally. Prolonged HBV DNA suppression with nucleos(t)ide analogues is known to regress hepatic fibrosis and reduce HCC risk. This is an unusual presentation of a patient with hepatitis B-associated HCC whose liver lesion resolved on antiviral therapy alone. CASE DESCRIPTION/METHODS: Patient is a 64-year-old Chinese male with HBeAg negative chronic hepatitis B with persistent normal serum aminotransferases and was antiviral treatment naïve. He had a positive family history of HCC and was first noted to have asymptomatic elevation of alpha-fetoprotein (AFP) to 648.9 ng/ml 6 months prior to his referral to Hepatology. During his initial Liver Center visit, the AFP increased to 1,900 ng/ml with elevated AFP-L3 at 18.4%. His hepatitis B remained inactive with normal ALT and minimal detectable HBV DNA at 1.6 log IU/ml (Table 1). He was started on entecavir 0.5 mg daily in view of his age and suspicious HCC complication. Initial MRI of the abdomen revealed lesions in segment 4 (2 cm) and segment 7 (2.1 cm) of the liver with arterial enhancement, venous washout and pseudocapsule. Targeted liver biopsy of segment 7 lesion and adjacent liver was performed within 2 weeks on entecavir therapy. The targeted liver specimen revealed a necrotic focus with loss of reticulin with strong immunoreactivity for cytokeratin Hep Par1 and Glypican-3; the findings were highly suspicious for HCC. The adjacent liver had only mild inflammation (grade 0-1) and minimal fibrosis (stage 0-1). Six weeks later, AFP decreased to 19 ng/dl but AFP-L3 remained elevated at 17%. On repeat CT scan, the segment 7 lesion decreased to 1.2 cm and no longer met OPTN HCC criteria. Patient remained clinically stable with optimal HBV DNA suppression. By 7-month follow-up, both AFP and AFP-L3 normalized and the liver lesions remained stable in size (Table 1). He continued to have regular monitoring and the segment 7 liver lesion was no longer visualized on abdominal MRI after 2 years. DISCUSSION: Nucleos(t)ide analogue therapy is known to suppress HBV replication but has not been reported to have direct effect on HCC. This HCC case is unique as the liver lesion regressed and resolved on entecavir therapy alone. While the molecular mechanism leading to the HCC resolution is currently unknown, this case highlights the beneficial role of prolonged HBV DNA suppression with antiviral therapy.

2667 Can't You GIST Move Over?

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are a common mesenchymal tumor of the GI tract. Here we present a case of a 60-year-old male with a 33.5 × 27 cm GIST arising from the greater stomach curvature, increased in size from 18.1 × 13.4 cm in five months; an alarming growth rate for a tumor known to grow slowly. CASE DESCRIPTION/METHODS: 60-year-old male with history of GIST and HTN presented to the hospital with abdominal pain and shortness of breath. Physical exam revealed decreased bowel sounds and diffuse tenderness to palpation in the right and left lower quadrants. Patient had previously been diagnosed with a 18.1 × 13.4 cm GIST 5 months prior, and was positive for CKIT (CD117) and DOG1, with 6 mitotic figures/21 HPFs (Figure 1). The patient was lost to follow up and never started on Imatinib. Over a span of five months, the necrotic mass had doubled in size with a repeat CT scan on admission showing a 33.5 × 27 cm GIST (Figures 2 and 3) arising from the greater stomach curvature, invading the left hepatic lobe and compressing the inferior vena cava (IVC). During this admission, he was also found to have bilateral pulmonary embolism, with large clot burden and right heart strain. An IVC filter would have been ideal for prevention of further clot migration, however the compression of the IVC by enlarging GIST prevented intervention. Patient was treated with heparin and started on Imatinib as an outpatient, patient is doing well and following with oncology. DISCUSSION: GISTs can be found in any part of the gastrointestinal tract, with predominance in the stomach. GISTs are often asymptomatic and diagnosed incidentally or they may present with nonspecific symptoms such as early satiety, abdominal pain, anemia, GI bleed or gastric outlet obstruction. Treatment options are dictated by risk of progression which is determined by size (≥3 cm), location, and mitotic count. [1] While the exact rate of tumor growth is unknown, studies have shown a range of 1.2 to 50.7% per annum [2]. On representation to the hospital five months after initial diagnosis, our patients’ mass had increased in size by 54% which surpasses documented growth rates. His mass also created significant compression and prevented integral placement of an IVC filter. While GIST tumors are traditionally thought to be slow growing tumors our case highlights the importance of earlier intervention in high-risk patients; metastatic and compressive complications could have been avoided for this patient had he returned for initial follow-up.

1270 Unexpected Microorganism in an Unexpected Place

INTRODUCTION: Candida Parapsilosis (CP) has been implicated in several intra- and extra- vascular infections and rarely been the cause of intraabdominal infections. We describe a case of CP infection complicating acute severe necrotizing pancreatitis. CASE DESCRIPTION/METHODS: A 68-year-old man presented with acute onset epigastric pain associated with nausea and vomiting. Physical examination revealed epigastric tenderness. Lipase was elevated at 7352 mg/dl and initial abdominal CT scan revealed changes consistent with acute edematous pancreatitis with possible early necrosis. His clinical course was complicated by acute respiratory failure, septic shock, and AKI requiring hemodialysis. He was in and out of the intensive care unit despite medical management including nutrition support and broad spectrum antibiotics. A repeat CT scan 4 weeks later showed acute necrotizing pancreatitis with walled-off necrosis (WON). After an episode of acute decompensation, a percutaneous drain was placed prior to necrosectomy. The aspirated fluid grew Candida Parapsilosis and patient was started initially on Micafungin, and then transitioned to oral fluconazole. Soon after starting antifungals the patient stabilized, clinically improved and was able to be discharged home. He subsequently underwent a video assisted retroperitoneal dissection, which revealed a small amount of necrosis and a pancreatic duct leak into the WON. He underwent ERCP with pancreas duct stent bypassing the leak. Upon most recent visit, patient showed considerable improvement. DISCUSSION: The incidence of CP infections has been greatly increased over the last decade. Primarily, CP is implicated in cases of fungemia accounting for 3–27% of all cases of in large studies and to lesser extent in extravascular infections like osteomyelitis. Intraabdominal infections are unusual and mostly associated with peritonitis complicating surgery and peritoneal dialysis. Despite the organism normally colonizes the GI tract, pancreatic infections by CP are rare, and are usually complicating acute pancreatitis. They could be explained by portal extension and be predisposed by use of broad spectrum antibiotics, surgery, and instrumentation. In conclusion, it is important to consider fungal infections in cases of complicated infected pancreatitis especially those not responding to broad spectrum antibiotics as they share similar clinical features with bacterial causes and prompt diagnosis and treatment are key to a better outcome.

691 Risk Factors for and Frequency of CT Scans in Inflammatory Bowel Disease Patients Seen in the Emergency Department

INTRODUCTION: Patients with inflammatory bowel disease (IBD) frequently have CT scans performed during emergency department (ER) visits and hospitalizations. Previous studies found that the younger a patient is when a CT scan is performed, the higher the risk of malignancy over a lifetime. Younger IBD patients have also been shown to have an increased frequency of ER visits, thus placing them at risk for repeat CT scans. Our aim was to determine the risk factors for and frequency of CT scans performed in all IBD patients seen in our ER. METHODS: A retrospective analysis of IBD patients seen at Houston Methodist Hospital ER from 2014 to 2017 was performed using ICD codes to identify patients with Crohn's disease (CD), ulcerative colitis (UC) or indeterminate colitis from the EMR. There were 559 unique patients with 1489 unique visits confirmed after individual chart review. Data was collected on demographics including age, sex, and ethnicity; medications; and imaging (CT of the abdomen/pelvis). RESULTS: Of the 559 patients with ER visits, 61% were female with an average age of 50 (range 18-95). There were 65% with CD, 34% with UC, and less than 1% had indeterminate IBD. Of these, 23% were on a biologic, 15% on an immunomodulator, and 27% were treated with steroids for IBD. There were 325 patients (58%) with 599 visits during which a CT scan was performed, and of these 88% were ordered in the ER. The average age was 46, and 60% were female. IBD was the primary reason for the visit in 66%. There were 68% with CD, 31% with UC, 24% on a biologic medication, 17% immune modulator, and 35% received steroids. Older age was associated with a decreased risk of CT scan P = <2.2 × 10-16, R -0.002, as well as UC compared to CD, P = 0.009, R -0.06. There was an increased risk of CT scan in patients on a biologic, P = 0.038, R 0.04, immunomodulator, P = 0.039, R 0.029, or when steroids were given for IBD, P = 1.44 × 10-13, R 0.102. There was an increased risk of undergoing a CT scan when the primary reason for the visit was for IBD, P = <2.2 × 10-16, R 0.372. CONCLUSION: Over half of the IBD patients in our study population had CT scans performed, which almost always occurred in the ER. There was an increased risk of a CT in those on a biologic, immunomodulator, or steroids for IBD, suggesting that more severe disease may contribute. Younger patients and those with CD also had an increased risk. Guidelines are needed to limit repeat CT scans in young IBD patients to reduce the risk of increased malignancy over their lifetime.

DISSEMINATED MAC IN A YOUNG IMMUNOCOMPETENT PATIENT

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Disseminated MAC (dMAC) is a disease usually seen in HIV infected patients with a CD4 count less than 50 cells/microL. In immunocompetent hosts, the usual presentation is of an isolated pulmonary infection, that usually presents as upper lobe lesions resembling mycobacterium tuberculosis. It has also been described to present as solitary pulmonary nodule, but virtually all the cases were older females. We describe a case of a young immunocompetent 31 years old female with no known risk factors presenting with dMAC. CASE PRESENTATION: A 31 years old female with type 1 diabetes presented with nausea, vomiting, diarrhea, abdominal pain and a high anion gap suggestive of DKA. DKA resolved with IV fluid resuscitation and insulin drip, but the patient was noted to have high grade fevers that did not resolve with empiric broad spectrum antibiotics. On further questioning, she reported a 13 pound weight loss in the last 2 months. Multiple sets of blood cultures obtained were negative. CT scan imaging of chest abdomen & pelvis noted ground glass opacities in bilateral lower lobes with superimposed multiple pulmonary nodules & infiltration of the mesenteric fat without lymphadenopathy or hepatosplenomegaly. Patient underwent cholecystectomy after a HIDA scan showed acute cholecystitis as a possible source of sepsis syndrome. She was also noted during her admission to have pancytopenia with elevated LFTS which prompted a bone marrow biopsy to be done. Repeat CT scan chest demonstrated a new right upper lobe consolidation, an increase in the size of the pulmonary nodules and new splenomegaly. Patient underwent bronchoscopy with BAL for fungal and bacterial cultures. Patient was diagnosed with dMAC infection after her gallbladder, bone marrow biopsy and her BAL grew Mycobacterium Avium Intracellular. She was started on azithromycin, ethambutol, rifapentine and amikacin with significant improvement. DISCUSSION: The usual presentation of Disseminated MAC is with persistent fevers (>80%), weight loss (>25%) & non- specific symptoms such as fatigue, anorexia. Organs such as bone marrow, lung, lymphoreticular and gastrointestinal tract can be involved. Diagnosis is made by peripheral blood cultures, but care should be taken to order mycobacterial blood cultures to hasten the diagnosis and spare the patient invasive procedures. Susceptibility testing should be done as macrolide resistant isolates have been identified. Macrolide susceptible MAC treatment consists of a macrolide plus ethambutol plus a rifamycin. Amikacin can be added during the initial treatment course if the disease is life threatening. The duration of treatment is at least 6 months. CONCLUSIONS: High clinical suspicion is required to diagnose disseminated MAC with multi-organ involvement in immunocompetent hosts. Mycobaterial blood culture should be ordered and is the least invasive test to diagnose this possible life threatening disease. Reference #1: Teirstein AS, Damsker B, Kirschner PA, et al. Pulmonary infection with Mycobacterium avium-intracellulare: diagnosis, clinical patterns, treatment. Mt Sinai J Med 1990; 57:209. Reference #2: Nightingale SD, Byrd LT, Southern PM, et al. Incidence of Mycobacterium avium-intracellulare complex bacteremia in human immunodeficiency virus-positive patients. J Infect Dis 1992; 165:1082. Reference #3: Yabes JM, Farmer A, Vento T. Disseminated Mycobacterium avium complex in an immunocompetent host. Int J Mycobacteriol 2017;6:202-6 DISCLOSURES: No relevant relationships by Wafic Itani, source=Web Response no disclosure on file for Thomas Smith; No relevant relationships by Ali Wazir, source=Web Response

1449 The “Runaway” Gallstone: Cholecystoduodenal Fistula Presenting as Gallstone Ileus

INTRODUCTION: Gallstone ileus is a rare condition caused by impaction of a gallstone in the ileum after its passage through a biliary-enteric fistula. Diagnosis can often be delayed since symptoms may be intermittent. We present a case of gallstone ileus diagnosed with endoscopic ultrasound and computed tomography. CASE DESCRIPTION/METHODS: A 91-year-old female presented to the Emergency Department with symptoms of left flank pain, nausea, and vomiting. Laboratory studies including liver panel and complete blood count were unremarkable. Initial CT scan of the abdomen showed pericholecystic edema and possible gallstones with pneumobilia. Upper endoscopy revealed an ulcerated area with a fistulous opening containing pigment stone in the first portion of the duodenum. Endoscopic ultrasound findings included thickened gallbladder wall with a fistulous opening in the duodenum consistent with cholecystoduodenal fistula. Over the course of the next couple of days, the patient's symptoms of nausea and vomiting worsened. A repeat CT scan demonstrated signs of small bowel obstruction, pneumobilia, and an impacted stone in the jejunum - findings consistent with Rigler's triad. Patient underwent a laparoscopic-assisted enterotomy with removal of the obstructing intraluminal gallstone. She did well and was discharged home five days later. We postulate that the patient's intermittent obstruction was a result of the stone “tumbling” through the bowel lumen. DISCUSSION: Cholecystoduodenal fistula can be associated with obstruction either in the duodenum (Bouveret's syndrome), or more distally (gallstone ileus). Gallstone ileus can present with vague, intermittent symptoms that evolve over several days. A high index of suspicion is necessary for timely diagnosis. Our case highlights the role of upper endoscopy and endoscopic ultrasound in making an early diagnosis that may allow for expeditious treatment. If initial imaging is not diagnostic, repeat imaging may be helpful in confirming gallstone ileus.

1301 Bleeding Pancreaticoduodenal Fistula: An Unusual Case of Melena

INTRODUCTION: Pancreatic fistulas have been described in the setting of pancreatic resection, trauma, and less commonly in acute or chronic pancreatitis (CP). Spontaneous pancreatic fistulas resulting in gastrointestinal (GI) bleeding are rare. CASE DESCRIPTION/METHODS: An 80 year-old woman presented to the emergency room with shortness of breath and melena. She was afebrile, normotensive, and had a heart rate of 93. Labs showed hemoglobin (Hgb) of 5.2 g/dL. EGD showed a 2 mm clean-based duodenal ulcer. As this did not account for melena, she had a colonoscopy and video capsule endoscopy which did not show a clear source of bleeding. As she continued to have melena with drop in Hgb, she had an abdominal CT scan showing a retroperitoneal fluid collection medial to the 2nd and 3rd portions of the duodenum, hyperattenuating material in the 2nd portion of the duodenum concerning for bleeding, and signs of CP with a pancreatic duct (PD) diameter of 14 mm. A second look EGD showed a duodenal mucosal defect suspicious for a fistulous opening into the PD with evidence of active bleeding (Figures 1 and 2). Repeat CT scan revealed extraluminal contrast extravasation into the retroperitoneum medial to the 2nd part of the duodenum and close in proximity to the superior mesenteric vein (SMV) (Figure 3). Abdominal MRI showed signs of CP and multiple small pseudocysts in the body and tail. Patient's melena resolved and Hgb stabilized prior to discharge. DISCUSSION: Bleeding is a rare complication of CP and occurs in 10-15% of CP patients. Pancreatic structures can be destroyed by enzyme digestion and necrosis. This may create pseudoaneurysms which may create cavities, fistulas, or rupture if they involve arterial or venous structures. The splenic and gastroduodenal artery are most commonly involved. Clinical presentation varies depending on location and severity of bleeding. Diagnosis involves abdominal CT and EGD, however laparotomy may sometimes be needed. Management involves embolization or surgery. Our patient's pancreaticoduodenal fistula was the result of previously undiagnosed CP. Bleeding may have resulted from spontaneous hemorrhage into the cystic cavity or as a result of erosion into the SMV given proximity on imaging. This case highlights the need to maintain a high clinical suspicion for pancreaticoduodenal fistulas in patients with a history of pancreatic disease presenting with GI bleeding.

1564 Hyper Progressive Disease (HPD) in a Colon Cancer Patient on Pembrolizumab

INTRODUCTION: Anti-programmed death one (PD1) and anti-programmed death ligand one (PDL1) has changed the prospective in the management of patients with advanced cancer. Where studies have shown significant response in some cases, a subset of patients might instead suffer from tumor flare. HPD is a term used to refer a drastic flare up of tumor with worsening clinical status in patients treated with PDL1 and PD1. CASE DESCRIPTION/METHODS: A 48-year African American female came with complaints of fatigue, abdominal pain and weight loss for four months. The CT scan of abdomen showed an extensive eccentric mass involving the terminal ileum and lymphadenopathy (LAP) along the portal caval space. She was diagnosed with stage IIIc adenocarcinoma colon with K-RAS wild type. A right hemicolectomy was performed. Patient received various regimen of adjuvant chemotherapy for 15 months. The disease gradually progressed to stage IV, with metastasis to liver, mesentery and retroperitoneal LAP. Meanwhile patient was diagnosed with Lynch syndrome with genetic testing positive for MSH-6 and EGFR/CEP7 2.47. She was started on pembrolizumab. The repeat CT scan of abdomen after five weeks of the first dose of pembrolizumab showed new and enlarging metastatic disease. Previous 51 × 48 mm metastatic lesion now measures 76 × 66 mm along with worsening of retroperitoneal and mesenteric LAP. As this could be pseudo progression, patient received two more doses. The CT scan of the abdomen revealed persistently enlarging liver metastasis along with enlarging mesenteric and retroperitoneal LAP. Further treatment was held. Unfortunately, patient deceased in few weeks after receiving the third dose of pembrolizumab due to HPD. DISCUSSION: Definition, incidence, pathogenesis and predictive factors of HPD are yet to be understood. Studies are available where parameters like tumor growth rate, tumor growth kinetic and time to treatment failure were used to define HPD, but no universally accepted definition exist. In the first study of HPD by Champiat in 2016, HPD was defined as a progression by RECIST criteria at first evaluation with a greater than or equal to two-fold increase in TGR from baseline (before treatment). Studies showed an association of HPD with age >65 years, MDM2/MDM4 amplification and EGFR alteration. Further knowledge about the pathogenesis and predictive factors of HPD may help to better understand the group of individuals that will likely benefit.

2513 Endoscopic Management With an Over-the-Scope Gastric Clip of a Staple-Line Leak Following Sleeve Gastrectomy

INTRODUCTION: Obesity has become a global epidemic with substantial socioeconomic and healthcare-related costs. Due to the limited utility of diet and behavior modification, there is tremendous interest in surgical weight loss strategies. Among those, sleeve gastrectomy (SG) has become the most commonly performed bariatric procedure. This is due to its efficacy and relative safety compared to other surgical options. However, post-SG leaks do occur. For example, staple-line leak (SLL) occurs in up to 3% of patients, most commonly at the proximal border of the staple line, near the esophagogastric junction. Usually, these leaks present in the early postoperative period, but there are increasing reports of SLL occurring months or even years after the initial surgery. Often, bariatric surgical complications are referred to tertiary centers for management. We present a case of a SLL managed at a community hospital. CASE DESCRIPTION/METHODS: A 38 year-old woman, with limited past medical history, presented 6 weeks after SG with a staple-line leak. Her immediate post-op period had been complicated by a peri-splenic abscess, which was managed with IV antibiotics (ABX) and percutaneous drainage (PD). Upper GI series (UGIS) at this time did not reveal a SLL. After clinical and radiographic resolution, the drain was removed. Several days later, the patient presented with nausea, vomiting, and non- bloody watery diarrhea. She was found to be febrile and tachycardic; labs, including a test for Clostridium dificile, were negative. A repeat CT scan confirmed an upper abdominal fluid collection. Subsequent UGIS revealed a SLL in the proximal stomach with a suture line fistula. After several weeks of NPO status, ABX and PD failed to lead to leak closure, the patient underwent endoscopy with successful placement of an Ovesco Over-the-Scope gastric clip (OTSC). Repeat UGIS confirmed fistula closure. After several weeks of additional conservative management, the PD was removed. Several months later, the patient remains stable. DISCUSSION: As the use of SG becomes more widespread, complications such as SLL will need to be addressed. Often, patients with SLL are referred to a tertiary center. We present a case successfully managed in a community hospital with the application of an OTSC. Practitioners who follow SG patients should be familiar with the indications and use of the OTSC.

1411 A Rare Cause of Acute Pancreatitis in a Transgender Female

INTRODUCTION: While hypertriglyceridemia and certain medications are known causes of acute pancreatitis, estrogen resulting in secondary hypertriglyceridemic acute pancreatitis (HTG-AP) is rare. To our knowledge, this is only the third case of a transgender female presenting with acute pancreatitis secondary to estrogen-induced hypertriglyceridemia. CASE DESCRIPTION/METHODS: A 31-year-old transgender female presented to the hospital with epigastric pain, fever, chills and decreased appetite. Laboratory work-up was significant for lipase >7,500 u/L, triglycerides >7,000 mg/dL and calcium of <4 mg/dL. The patient denied alcohol use, diabetes, hypothyroidism or family history of pancreatitis. Initial management included aggressive intravenous fluid resuscitation. CT scan of the abdomen was performed and was notable for a large peripancreatic fluid collection most consistent with walled off necrosis (Figures 1 and 2). Three retroperitoneal drains were placed into the fluid collections with clinical improvement. Upon further questioning, it was discovered that several months prior to admission, the patient had started taking oral estrogen therapy obtained via an online store to transition from male to female, which was ultimately felt to be the most likely cause of her very severe hypertriglyceridemia. Two weeks after discharge, patient had IR drain exchange and repeat CT scan showed almost complete resolution of the fluid collections and her drains were removed. DISCUSSION: Medications are often described as the etiology for why people develop pancreatitis. However, to clearly prove a medication as the inciting factor, reinitiation of that medication needs to occur in order to establish a temporal relationship. Estrogen is a rare cause of drug-induced pancreatitis with approximately 40 cases reported worldwide. It is one of the few medications that has a described mechanism, hypertriglyceridemia, for the development of pancreatitis. Of the 40 cases described only 2 published case reports involve transgender females (7) (Table 1). The number of transgender patients presenting to the healthcare system for care is growing (9.2 per 100 000). Importantly, transgender females require supraphysiologic doses of estrogen therapy to maintain secondary sexual characteristics. Accounting for these factors, it is important for healthcare providers to understand their risk for and ways to prevent acute pancreatitis from occurring in their transgender patient population (8).

3068 Ischemic Colitis With Unresolved Ileus

INTRODUCTION: Ischemic colitis (IC) is the most common form of ischemic injury to the gastrointestinal tract. This can result in inflammation and superficial injury to full thickness necrosis of colon. Most of the non-gangrenous IC resolve spontaneously while gangrenous IC requires operative intervention and is associated with high morbidity and mortality. Almost 90% of the cases of IC are in patients over 60 years of age. Ileus is a common finding in patients with IC and usually self-limiting except in cases where necrosis is present. We present a rare case of unresolved ileus resulting from non-gangrenous ischemic colitis. CASE DESCRIPTION/METHODS: A 90-year-old female with past medical history of Hodgkin's lymphoma in remission for the past five years, presented with nausea, vomiting and non-bloody watery diarrhea for the past four days. She visited the Emergency Department on the first day where she tested positive for E.coli urinary tract infection and was treated with ceftriaxone and nitrofurantoin. Over the last day, she did not have any bowel movements but continued to have right lower quadrant abdominal pain, abdominal distension, and nausea. Her WBC count was 34,000 cells/mm3 and C. difficile testing was negative. CT scan showed distended small bowel loops without transition point and decompressed colon, indicating ileus. She was put on NPO and nasogastric suction and started on broad-spectrum antibiotics. After four days, she continued to have distended abdomen with sluggish bowel sounds. Repeat CT scan of the abdomen showed no changes. She was eventually taken to the OR for exploratory laparotomy. Intraoperative findings showed edematous and thickened right colon with small bowel distension. Subsequent colonoscopy showed significant ischaemic changes in the right colon and the pathology result was consistent with ischaemic colitis with no signs of necrosis. She was started on TPN. Even after our best efforts, her condition continued to deteriorate and she developed sepsis and passed away on the tenth day. DISCUSSION: Ileus in the setting of non-gangrenous ischemic colitis is usually self-limiting. Protracted ileus is observed in cases with necrosis of the colon. Even with no evidence of necrotic disease, our patient's ileus failed to resolve after prolonged medical management. Our patient had multiple indicators of poor prognosis, including old age, isolated right-sided colon involvement, and absence of hematochezia, which could have contributed to her condition.

P2.11-23 Performance of Lung Cancer Risk Prediction Models in I-ELCAP Smokers

To determine the performance of lung cancer risk prediction models in predicting lung cancer in smokers enrolled in the International Early Lung Cancer Program (I-ELCAP). 62,071 asymptomatic ever-smokers enrolled into the international multi-institutions I-ELCAP for low-dose CT screening between 1993-2018. Demographics, smoking history, comorbidities, exposures and family history of lung cancer were collected at time of baseline CT scan. All participants received a baseline screening scan and subsequently annual repeat CT scans, and they were prospectively followed for the diagnosis of lung cancer. Diagnosis and treatment of lung cancer were verified and documented in the ELCAP Management System. To compare the predicted risk of lung cancer, we applied four lung cancer risk models: the Bach Model, the Liverpool Lung Project Incidence (LLPi) Risk model, the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial Model 2012 (PLCOM2012), and the Pittsburgh Predictor Model to the I-ELCAP cohort. Model calibration and discrimination were assessed using expected-to-observed (E/O) ratio and the area under the curve (AUC) statistics. E/O ratio >1 indicates that the model predicts more lung cancer cases than observed. PLCOM2012 model was the most predictive of lung cancer for ever-smokers in I-ELCAP with the AUC 0.61 being the highest, followed by Bach model (AUC 0.58), LLPi model (AUC 0.57) and Pittsburgh Predictor (AUC 0.52). E/O ratios suggested that the PLCOM2012 model, Bach model, LLPi model and Pittsburgh Predictor model tends to overestimate the number of lung cancers. The LLPi model overestimated as many as 4 times more lung cancer cases. Using data from I-ELCAP, the four existing lung cancer risk prediction models have AUCs ranged between 0.52-0.61, PLCOM2012 model was the top performer out of the four models.

2489 A Rare Case of Isolated Symptomatic Hepatic Sarcoidosis

INTRODUCTION: Sarcoidosis is an inflammatory granulomatous disease that has multi- organ involvement with varied course of disease expression and progression. Liver involvement is seen in only a hand full of cases, especially with florid symptoms. Here, we present a rare case of symptomatic isolated hepatic sarcoidosis mimicking malignancy, that was promptly diagnosed. CASE DESCRIPTION/METHODS: A 60- year old African American female, who is otherwise healthy, presented to our tertiary care center with a month-long history of worsening epigastric pain, nausea, vomiting, malaise, weight loss and night sweats. Exam was remarkable for hepatomegaly and labs significant for elevated ALP and GGT, mild transaminitis and elevated CA 19-9 levels. CT scan revealed hypodensities and perfusion defects throughout the liver, hepatosplenomegaly and hilar lymphadenopathy, which had been confirmed by MRI and Triple-phase CT of the liver. With the suspicion for malignancy, liver biopsy was pursued and showed epithelioid-cell granulomas with focal necrosis and multiple asteroid bodies, pathognomonic for sarcoidosis. Subsequently, ACE levels were found to be elevated. Patient was then started on prednisone and immunosuppressants with relief of symptoms. A repeat CT scan 6-months later, showed resolution of liver lesions and improvement in liver chemistries. DISCUSSION: Sarcoidosis is a systemic granulomatous disease of unknown etiology. Per ACCESS study, liver involvement of sarcoidosis was described in only 11.5% of 736 patients, more commonly seen in African American population than Caucasian, with only 10% of them were reported to have transaminitis. Hepatic involvement appears to be clinically silent with most patients presenting with constitutional symptoms, even then liver lesions on CT are described in only 5% of the patients. Steroid therapy and immunomodulators are used to help with symptom control, however their effect on the natural progression of the disease is not established. Our patient presentation with significant symptoms and imaging findings, prompted us to think beyond the obvious. Sarcoidosis is a diagnosis of exclusion; hence it is essential for clinicians to have a high degree of suspicion for hepatic involvement.