Resolution Of Abdominal Pain Research Articles

Acetaminophen-Induced Pancreatitis: A Rare Complication of Acetaminophen Hepatotoxicity

Acetaminophen induced pancreatitis is uncommon and the mechanism of injury is not well understood. To date, only six cases have been reported. A 46 year old Hispanic woman presented with 4 weeks of worsening abdominal pain. The pain was located in the bilateral flanks, described as constant, and associated with chills. For this pain she took 1300 mg of acetaminophen every 4 hours in addition to acetaminophen PM with minimal relief. Eventually the pain migraited to the right upper quadrant. She had a medical history of obesity s/p gastric bypass, biliary colic s/p cholecystectomy, seizures, and hypertension. Initial evaluation revealed normal vital signs; however, several laboratory abnormalities were found: AST/ALT = 3472/1223, lipase of 4664, and serum Acetaminophen level of 69.8. CT of abdomen and pelvis demonstrated pyelonephritis, hepatomegaly, and acute pancreatitis. She was admitted to ICU and treated with NAC therapy for acetaminophen hepatotoxicity, intravenous hydration, and antibiotics for pyelonephritis. Evaluation of common causes of pancreatitis (e.g. ethanol, choledocolithiasis, hypertriglyceridemia) was negative. Medication list was reviewed and no common offending agents were appreciated. Tesitng for infectious etiologies such mumps and salmonella were negative. Her serum calcium was within normal limits. Given her negative workup, it was determined that although rare, the most likely cause seemed to be acetaminophen toxicity. The patient's pancreatitis improved with cessation of acetaminophen and concurrent treatment of drug toxicity, as evidenced by resolution of abdominal pain and down trending lipase levels (4664 on admission, down to 440 two days later). A repeat CT 2 weeks later confirmed nearly resolved pancreatitis. Our proposed mechanism of action is hepatic inflammation/damage leads to inflammation (e.g. seeding) of surrounding organs. Data from a 2015 large cohort study demonstrated patients with acute acetaminophen hepatic toxicity exhibit a 2.4 fold higher risk of acute pancreatitis within the first year of follow up (1). Our case shows treatment of acetaminophen toxicity may mollify associated pancreatitis. Further research is needed concerning the mechanisms of acetaminophen toxicity given the drug's widespread availability and complications.1411_A.tif Figure 1: CT Scan of the Abdomen and Pelvis at time of Admission. In this figure above we can see acute peripancreatic inflammation. The arrow points towards an area of possible necrosis, underscoring the severity of this pancreatitis1411_B.tif Figure 2: AST/ALT/Lipase (IU/L) over a period of time. The figure above shows that treatment of the patient's liver failure coincided concurrent down trending of her lipase levels, and clinical resolution of her pancreatitis

Case of Cystic Fibrosis with Distal Intestinal Obstruction Syndrome Mimicking Acute Appendicitis

Cystic Fibrosis (CF) is a genetic disease affecting multiple organs. Improved life expectancy amongst adult CF patients have given rise to extra-pulmonary and gastrointestinal manifestations. Distal Intestinal Obstruction Syndrome (DIOS) continues to be a rising complication in adult CF patients presenting with acute abdominal pain mimicking abdominal appendicitis. A 22-year-old Turkish Male with history of CF presented with progressively worsening right lower quadrant abdominal pain and constipation for two days. He reported nausea, decreased appetite for three days and his last bowel movement was two days prior to admission. He was diagnosed with CF at the age of four and his disease progressed to an exocrine pancreas insufficiency, which was treated with pancreatic enzymes and other medical therapies. Abdominal exam showed tenderness on right lower quadrant with no rebound tenderness, guarding or peritoneal signs. Laboratory analysis showed leukocytosis with no electrolyte imbalances. CT scan of abdomen showed thickening and inflammation around the terminal ileum and extraluminal free fluid. Since early acute appendicitis cannot be excluded, patient underwent open appendectomy that showed non-inflamed appendix, micro-perforation of the lateral wall of the cecum requiring partial cecectomy. Post operatively he was started on Polyethylene Glycol. Patient had a complete recovery and did not have a recurrence of symptoms on follow up. DIOS is described by the collection of viscid fecal material within the lumen combined with sticky mucoid intestinal content adherent to intestinal wall of the terminal ileum and cecum. Patients characteristically present with right lower quadrant pain, nausea, abdominal distension and failure to pass stools. Though the abdominal X-rays are recommended to aid in diagnosis of DIOS, they are inadequate to differentiate ileus from other causes of abdominal pathologies presenting in CF. Osmotic laxatives are administered to achieve the passage of stool (consisting of clear fluid) along with resolution of abdominal pain and constipation. With increasing migration of patient populations around America, inner-city or community hospitals may not be equipped with CF care centers or programs, which provide expertise in patient management and patient care. Therefore, our case highlights the importance of DIOS to be a differential diagnosis in a patient presenting with history of CF and complaints of abdominal pain and constipation.2513_A Figure 1. Axial view depicting thickening around the terminal ileum (Yellow arrows) along with extraluminal fluid and reactive lymph nodes2513_B Figure 2. Coronal view with thickening of ileum with distended appendix (Yellow arrows)

Efficacy of prebiotics and probiotics in early enteral nutrition for the recovery of gastrointestinal function of pancreas trauma

Objective To study the influence of prebiotics and probiotics combined with early enteral nutrition (EN) on the recovery of gastrointestinal function, improvement of nutritional status and prognosis in postoperative patients with pancreatic trauma. Methods A retrospective analysis of the clinical data of pancreatic injury patients admitted to our hospital from January 2012 to December 2017 was carried out, and those patients were divided into 3 groups: group A (control group), patients treated with operation and routine treatment; group B, patients treated with prebiotics and probiotics in addition to surgery and routine treatment; group C, patients treated as group B in addition to early EN. Comparisons of blood biochemical markers, mortality, time required for resolution of abdominal pain, length of hospital stay, hospitalization expenses and complication rate among three groups. Results The time required for resolution of abdominal pain, length of hospital stay, hospital costs in group C were significantly lower than those in other groups (P < 0.05). The score of gastrointestinal dysfunction at one week after surgery in group C was significantly lower than that in group A and group B (P<0.05). Serum amylase, lipase and CRP levels were significantly lower in group C than those in other groups (P < 0.05). Plasma albumin level significantly higher in group C than that in other groups (P < 0.05). Conclusion Prebiotics and probiotics combined with early EN treatment have certain advantages in patients with pancreatic injury. Key words: Prebiotics; Probiotics; Early enteral nutrition; Pancreatitis trauma; Gastrointestinal function; Influence

T-PA power-pulse spray with rheolytic mechanical thrombectomy using cross-sectional image-guided portal vein access for single setting treatment of subacute superior mesenteric vein thrombosis.

Background:Isolated superior mesenteric vein (SMV) thrombosis is a rare but potentially fatal condition if untreated. Current treatments include transjugular or transhepatic approaches for rheolytic mechanical thrombectomy and subsequent infusions of thrombolytics. Tissue plasminogen activator (t-PA) power-pulse spray can provide benefit in a single setting without thrombolytic infusions. Computed tomography (CT) guidance for portal vein access is underutilized in this setting.Materials and Methods:Case 1 discusses acute SMV thrombosis treated with rheolytic mechanical thrombectomy alone using ultrasound guidance for portal vein access. Case 2 discusses subacute SMV thrombosis treated with the addition of t-PA power-pulse spray to the rheolytic mechanical thrombectomy, using CT guidance for portal vein access.Results:With rheolytic mechanical thrombectomy alone, the patient in Case 1 had significant improvement in abdominal pain. Follow-up CT demonstrated no residual SMV thrombosis and the patient continued to do well in long-term follow-up. With the addition of t-PA power-pulse spray to rheolytic mechanical thrombectomy, the patient in Case 2 with subacute SMV thrombosis dramatically improved postprocedure with resolution of abdominal pain. Follow-up imaging demonstrated patency to the SMV and partial resolution of thrombus. The patient continued to do well at 2-year follow-up.Conclusions:Adding t-PA power-pulse spray to rheolytic mechanical thrombectomy can provide benefit in a single setting versus mechanical thrombectomy alone and prevent the need for subsequent infusions of thrombolytic therapy. CT guidance is a useful alternative of localization for portal vein access via the transhepatic route that is nonoperator-dependent and helpful in the case of obese patients.

Randomized clinical trial to evaluate the effect of fecal microbiota transplant for initial Clostridium difficile infection in intestinal microbiome.

ObjectiveThe aim of this study was to evaluate the impact of fecal donor-unrelated donor mix (FMT-FURM) transplantation as first-line therapy for C. difficile infection (CDI) in intestinal microbiome.MethodsWe designed an open, two-arm pilot study with oral vancomycin (250mg every 6 h for 10–14 days) or FMT-FURM as treatments for the first CDI episode in hospitalized adult patients in Hospital Universitario “Dr. Jose Eleuterio Gonzalez”. Patients were randomized by a closed envelope method in a 1: 1 ratio to either oral vancomycin or FMT-FURM. CDI resolution was considered when there was a reduction on the Bristol scale of at least 2 points, a reduction of at least 50% in the number of bowel movements, absence of fever, and resolution of abdominal pain (at least two criteria).From each patient, a fecal sample was obtained at days 0, 3, and 7 after treatment. Specimens were cultured to isolate C. difficile, and isolates were characterized by PCR. Susceptibility testing of isolates was performed using the agar dilution method. Fecal samples and FMT-FURM were analyzed by 16S rRNA sequencing.ResultsWe included 19 patients; 10 in the vancomycin arm and 9 in the FMT-FURM arm. However, one of the patients in the vancomycin arm and two patients in the FMT-FURM arm were eliminated. Symptoms resolved in 8/9 patients (88.9%) in the vancomycin group, while symptoms resolved in 4/7 patients (57.1%) after the first FMT-FURM dose (P = 0.26) and in 5/7 patients (71.4%) after the second dose (P = 0.55). During the study, no adverse effects attributable to FMT-FURM were observed in patients.Twelve isolates were recovered, most isolates carried tcdB, tcdA, cdtA, and cdtB, with an 18-bp deletion in tcdC. All isolates were resistant to ciprofloxacin and moxifloxacin but susceptible to metronidazole, linezolid, fidaxomicin, and tetracycline. In the FMT-FURM group, the bacterial composition was dominated by Firmicutes, Bacteroidetes, and Proteobacteria at all-time points and the microbiota were remarkably stable over time. The vancomycin group showed a very different pattern of the microbial composition when comparing to the FMT-FURM group over time.ConclusionThe results of this preliminary study showed that FMT-FURM for initial CDI is associated with specific bacterial communities that do not resemble the donors’ sample.

A Cause of Pancreatitis in a Commonly Used Antibiotic: Metronidazole-induced Pancreatitis

Metronidazole is a nitroimidazole antibacterial medication used in the treatment of anaerobic bacteria and protozoa. The main adverse effects include headache, nausea, vaginitis, metallic taste, neuropathy and rarely pancreatitis. Acute Pancreatitis is characterized by abdominal pain and elevated pancreatic enzymes including lipase. Here we present a case of elderly female who had pancreatitis associated with metronidazole therapy. The patient was an 85 year old female with medical history of colon cancer s/p resection, atrial fibrillation, hypertension, diabetes mellitus type 2 and hypothyroidism who presented with abdominal pain, nausea. One month prior to presentation she was treated for a urinary infection with cefpodoxime. She started having diarrhea and tested positive for Clostridium Difficile toxin. She was started on metronidazole. Two weeks later, she developed abdominal pain and nausea. Epigastric tenderness was present on exam with a negative murphy sign. Her lipase level was 17604 U/L. Liver function tests were unremarkable; ALT of 26 U/L, AST of 19 U/L, alkaline phosphatase of 46 U/L and a total bilirubin of 0.2 mg/dL. Serum triglycerides were 122. A right upper quadrant ultrasound was done which showed normal gallbladder size, wall thickness and normal common bile duct of 5.5mm. Metronidazole was stopped with resolution of abdominal pain and elevated lipase. No other obvious etiology of her pancreatitis was found. The Naranjo adverse drug reaction probability scale score was calculated to be a 4, indicating a possibility of adverse reaction from metronidazole. Approximately 2% of pancreatitis cases are drug-induced. Per our literature review there have been only 9 cases of pancreatitis associated with metronidazole. Although the mechanism is unknown, one possibility is redox cycling of metronidazole yielding hydrogen peroxide, superoxide and other free radicals which are toxic to pancreatic beta-cells. If metronidazole-induced pancreatitis is suspected, we recommend discontinuation of the medication and supportive care. In summary, physicians should be aware of the possibility of metronidazole as a possible etiology of pancreatitis, given that several million prescriptions of this medication dispensed every year in the United States.

Liver Cholestasis Secondary to Syphilis in an Immunocompetent Patient: 2017 Presidential Poster Award

Clinicians frequently encounter abnormal liver chemistries in both the hospital and outpatient medical settings. Due to a wide array of potential causes, determining the etiology of hepatic dysfunction can be a diagnostic challenge. Although syphilis is an uncommon cause of clinical hepatitis, it should be considered in the differential diagnosis of these patients. A 37-year-old African American man with a history of type I diabetes and sickle cell trait was referred for jaundice. He presented with right upper quadrant (RUQ) abdominal pain for ten days and elevated liver chemistries with a total bilirubin (TB) of 11.4, alanine aminotransferase (ALT) of 59, aspartate aminotransferase (AST) of 39, and alkaline phosphatase (ALP) of 657. His viral hepatitis panel was negative and he denied the use of alcohol or hepatotoxic drugs. Physical exam revealed scleral icterus and RUQ abdominal tenderness. Abdominal ultrasound showed mild hepatic fatty infiltration without biliary obstruction or stones. Both CT scan of the abdomen and MRCP were negative for biliary or pancreatic ductal dilation. Metabolic liver disease work up was negative. Hemolysis labs including lactate dehydrogenase and haptoglobin were within normal limits and there was absence of sickling on peripheral blood smear. RPR returned positive with a reflex titer of 1:64. Treponema pallidum IgG was checked for confirmation and was reactive. Liver biopsy showed chronic hepatitis with normal hepatic architecture, Kupffer cell hyperplasia, hepatic cholestasis and ductal proliferation suggestive of syphilitic hepatitis. The patient was given penicillin G 2.4 million units IM once for treatment. Two weeks later, liver chemistries improved to TB of 1.7, ALT of 45, AST of 39 and ALP of 298 with resolution of abdominal pain. Liver involvement is a unique and often unrecognized manifestation of early syphilis. Its diagnosis is suggested by elevated liver chemistries, positive syphilis serology and resolution of symptoms and biochemical abnormalities following antimicrobial treatment. Pericholangiolar inflammation may cause a cholestatic picture and disproportional elevation in serum ALP levels, as seen in this patient. Due to the rapid reversibility with penicillin G treatment, it is important to consider syphilis in the differential diagnosis of hepatitis.Figure: Liver biopsy Moderate canalicular cholestasis. H&E stain high power (400x).Figure: Liver biopsy with eosinophil and cholestasis. The white lines indicate cholestasis and bile plugging. The yellow arrow indicates an eosinophil. H&E stain High power (400x).

Remnant gastropathy due to bile reflux after Roux-en-Y gastric bypass: a unique cause of abdominal pain and successful treatment with ursodiol.

Chronic abdominal pain can occur after Roux-en-Y gastric bypass (RYGB), and can remain unexplained despite extensive investigation. Bile can pool in the gastric remnant and create a bile reflux gastropathy. The aim of this study was to assess gastric remnant findings in patients with RYGB and chronic abdominal pain of unclear etiology, and to determine the effectiveness of ursodiol therapy for patients with confirmed remnant gastropathy. All consecutive patients with RYGB and a diagnosis of chronic abdominal pain, and a negative diagnostic workup (including physical examination, routine laboratory work, cross-sectional imaging, and standard upper endoscopy), who underwent device-assisted enteroscopy for evaluation of the gastric remnant, were included. Pathology reports, treatments, and clinical follow-up were recorded. 28 post-RYGB patients (all female) with chronic abdominal pain and negative evaluation were included. Pooling of bile with gastric erythema was noted in 22/28 patients. All 22 patients with endoscopic erythema had pathology consistent with bile reflux chemical gastropathy. Of these patients, 12 were started on a proton pump inhibitor (PPI) alone, and 10 were started on ursodiol. Of the ursodiol group, 8/10 (80%) patients reported substantial improvement or resolution of abdominal pain at clinical follow-up. All three ursodiol patients with repeat endoscopic examination of the gastric remnant had endoscopic and histologic resolution of gastropathy. Of the PPI patients, 1/12 reported improvement in abdominal pain at clinical follow-up (p=0.002), and both patients with repeat endoscopic examination of the gastric remnant had persistent remnant gastropathy. Roux-en-Y gastric bypass patients with unexplained chronic pain, and biopsy-confirmed chemical gastropathy, had a significantly higher rate of abdominal pain resolution with ursodiol treatment compared to PPI. Remnant gastropathy due to bile reflux is a treatable cause of chronic abdominal pain in RYGB patients, and ursodiol should be considered for empiric treatment in RYGB patients with unexplained chronic abdominal pain.

Treat to Target in Inflammatory Bowel Disease: An Updated Review of Literature.

Therapeutic management of patients with inflammatory bowel diseases (IBDs) has, for years, been tailored towards monitoring patient clinical presentation as a way to gauge therapeutic management. With the advent of newer biological agents, treatment and management have begun to focus on more objective rather than subjective parameters. These objective parameters include endoscopic targets and focus on the impact of mucosal healing, radiologic and histologic targets, patient reported outcomes, and use of non-invasive biomarkers. However, a recent consensus statement has identified clinical/patient-reported outcome (PRO) remission and endoscopic remission (defined as a Mayo endoscopic subscore of 0-1) as the target for UC with histological remission being an adjunctive goal. For CD, clinical/PRO remission defined as resolution of abdominal pain and diarrhea/altered bowel habit and endoscopic remission, defined as resolution of ulceration at ileocolonoscopy, and resolution of findings of inflammation on cross-sectional imaging in patients who cannot be adequately assessed with ileocolonoscopy were the primary targets. Biomarker remission (normal C-reactive protein (CRP) and calprotectin) was considered as an adjunctive target. This approach requires continuous monitoring and therapeutic adjustments with an aim to achieve the target. This article attempts to review the most updated literature regarding the treat to target approach and thus provides current recommendations and supported evidence.

An Unexpected Showing at Nineteen Weeks Pregnant

A 31-year-old Nigerian female in the 19th week of her 5th pregnancy with a past medical history of diabetes mellitus presented with one week of intermittent right upper quadrant and epigastric abdominal pain with radiation to her back. She also reported associated nausea, decreased appetite, bloating, and steatorrhea. She had similar pain three years ago during her last pregnancy, but had no known history of pancreatitis or gallstone disease, and denied alcohol abuse. Her physical exam was normal except for a gravid abdomen and tenderness to palpation in the right upper quadrant and epigastric regions. Liver enzymes, lipase and amylase were normal. MRI of the abdomen demonstrated a 20 x 12 x 13 cm thick-walled, lobular cyst arising from the proximal pancreatic body. EGD showed significant external compression of gastric antrum and duodenum. Endoscopic ultrasound guided diagnostic cyst fluid aspiration was performed with cyst fluid demonstrating elevated amylase (value >1300 U/L), low CEA (4.8 ng/mL), and cytology was negative for malignancy, consistent with a pancreatic pseudocyst. We performed endoscopic cystogastrostomy placing a fully covered metal biliary stent. This was followed by cyst re-expansion on MRI with extrinsic compression on the common bile duct and an infected pseudocyst which was managed with intravenous antibiotics and cystoduodenostomy with copious drainage of purulent material and resolution of abdominal pain. At 37 weeks of pregnancy, she presented with contractions and complete breech presentation. A cesarean section was performed and she delivered a viable male infant. A CT scan after delivery showed complete resolution of the pseudocyst. Pancreatic pseudocysts complicating pregnancy are rare with only 10 cases reported in the literature since 1980. Although pseudocysts may regress spontaneously, approximately 30%-40% are complicated by infection, rupture, hemorrhage, or obstruction of the stomach, small bowel, colon, or bile duct. The natural history of pancreatic pseudocysts in pregnant patients seems to be similar to non-gravid patients, however there is concern for increased risk of rupture during vaginal delivery. Symptomatic, enlarging, very large, or complicated pseudocysts require drainage. While the management of pancreatic pseudocysts is not standardized in pregnant patients, the second trimester is generally considered the safest time to intervene.Figure 1Figure 2Figure 3

Primary Hepatic Amyloidosis

A 55 yr old female was referred to us for abnormal liver enzymes and 80lb weight loss with early satiety, abdominal pain and dysphagia. On physical exam, patient was noted to have large hepatomegaly. Liver profile was normal apart from a very elevated alkaline phosphatase at 349 IU/L. Abdominal US showed an enlarged 25cm liver with homogeneous parenchyma, no focal lesions and a normal biliary tree. Further workup with EGD revealed mild gastritis with large amounts of bile in the stomach. Colonoscopy revealed diverticulosis and 5mm cecal polyp which was a tubular adenoma. She was found to have elevated gamma globulins 4 gm/dl and positive ANA 1:1280. ANCA, ASMA, Hepatitis B and Hepatitis C were negative and AFP and CA 19-9 were within normal limits. Patient then underwent liver biopsy which revealed significant pericellular and sinusoidal amyloid deposition and chronic inflammation without fibrosis or steatosis which was confirmed with congo red stain. Findings were significant for AL Amyloidosis. Meanwhile her SPIEP results returned and showed faint atypical staining in the gamma region. UPIEP showed no evidence of monoclonal protein and immunofixation was negative. Bone marrow biopsy showed extensive amyloid deposition and mildly increased plasma cells. Further analysis with FISH using multiple myeloma specific set of probes showed hyperdiploidy however given only mildly elevated light chains on SPIEP and lack of monoclonal protein on UPIEP, diagnosis of multiple myeloma was excluded. Diagnosis of primary hepatic amyloidosis was confirmed. Patient was followed up outpatient by Heme/Onc and started on chemotherapy in anticipation of eventual stem cell transplant. Six months since initiation of treatment, patient's kappa chains decreased from 5.21mg/dL to 2.17mg/dL. She also had significant improvement in symptoms including near resolution of abdominal pain and dysphagia. Incidence of amyloidosis is eight per million persons per year and 25% of these patients present with hepatomegaly. Cardinal features of hepatic amyloidosis are hepatomegaly with increased alkaline phosphatase, minimal change in transaminases, proteinuria, a monoclonal light chain in the serum or urine, and hyposplenism. The purpose of this case report is to demonstrate the importance of early diagnosis of an unusual disease presentation as patients with AL hepatic amyloidosis have a poor one year survival rate, especially those with heart failure and/or hyperbilirubinemia.Figure 1Figure 2

New models of care in IBD in changing times.

New models of care in IBD in changing times.

Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE): Determining Therapeutic Goals for Treat-to-Target.

The Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) program was initiated by the International Organization for the Study of Inflammatory Bowel Diseases (IOIBD). It examined potential treatment targets for inflammatory bowel disease (IBD) to be used for a "treat-to-target" clinical management strategy using an evidence-based expert consensus process. A Steering Committee of 28 IBD specialists developed recommendations based on a systematic literature review and expert opinion. Consensus was gained if ≥75% of participants scored the recommendation as 7-10 on a 10-point rating scale (where 10=agree completely). The group agreed upon 12 recommendations for ulcerative colitis (UC) and Crohn's disease (CD). The agreed target for UC was clinical/patient-reported outcome (PRO) remission (defined as resolution of rectal bleeding and diarrhea/altered bowel habit) and endoscopic remission (defined as a Mayo endoscopic subscore of 0-1). Histological remission was considered as an adjunctive goal. Clinical/PRO remission was also agreed upon as a target for CD and defined as resolution of abdominal pain and diarrhea/altered bowel habit; and endoscopic remission, defined as resolution of ulceration at ileocolonoscopy, or resolution of findings of inflammation on cross-sectional imaging in patients who cannot be adequately assessed with ileocolonoscopy. Biomarker remission (normal C-reactive protein (CRP) and calprotectin) was considered as an adjunctive target. Evidence- and consensus-based recommendations for selecting the goals for treat-to-target strategies in patients with IBD are made available. Prospective studies are needed to determine how these targets will change disease course and patients' quality of life.

Acute Pancreatitis Caused by Hemobilia From a Hepatic Artery Pseudoaneurysm

Introduction: Hemobilia, defined as hemorrhage into the biliary tract, is caused by a pathological communication between hepatic vessels and bile ducts. The most common etiology of hemobilia is trauma, followed by gallstones, inflammatory diseases, vascular lesions, and neoplasms. Hemobilia classically presents as a clinical triad of biliary colic, jaundice, and upper gastrointestinal tract bleed, though the typical symptoms are only found in about 40% of cases. Acute pancreatitis is an unusual presentation of hemobilia. The proposed mechanism is that blood in the biliary system causes obstruction of the pancreatic and common bile duct, leading to pancreatitis and obstructive jaundice. We report a case of hemobilia-induced pancreatitis secondary to a hepatic artery pseudoaneurysm. Case Report: A 36-year-old female with a history of methamphetamine use presented with 1 day of epigastric abdominal pain with nausea and nonbloody, nonbilious emesis. There was no history of trauma or recent procedures. On physical exam, the patient had tenderness to palpation in the epigastric region without peritoneal signs. Exam was notable for mild scleral icterus. She had no stigmata of chronic liver disease or organomegaly. Labs revealed a leukocyte count of 8900/mm3, aspartate aminotransferase 188 U/L, alanine aminotransferase 143 U/L, total bilirubin 2.4 mg/dL, which increased to 7.2 mg/dL the following day, alkaline phosphatase 183 U/L, and lipase 2583 U/L. Abdominal ultrasound showed 2 stones within the gallbladder lumen and normal-sized bile duct. The patient was admitted for management of acute pancreatitis. EUS and ERCP were performed with visualization of large blood clots occluding the ampulla. Biliary sphincterotomy led to removal of large blood clots; no stones were retrieved from the bile duct. The source of bleeding was not identified. Post-procedure, the patient clinically improved with resolution of abdominal pain and normalization of lipase and total bilirubin. Hepatic angiography revealed a right hepatic artery superior branch pseudoaneurysm that was thought to be the cause of hemobilia. Coil embolization was performed, which resulted in successful hemostasis. Discussion: We describe a case of hemobilia from a bleeding hepatic artery pseudoaneurysm with an atypical presentation of acute pancreatitis. The most common cause of hemobilia is trauma, with an increasing incidence of iatrogenic trauma. However, we should maintain a high index of suspicion for hemobilia caused by other etiologies as seen in this case.

Therapeutic Plasmapheresis in Primary Presentation of Diabetes Mellitus With Diabetic Ketoacidosis, Hypertriglyceridemia and Acute Pancreatitis

Severe hypertriglyceridemia (SHTG)-induced acute pancreatitis has been well described. Currently accepted therapeutic options are limited. We report a case of acute pancreatitis associated with hypertriglyceridemia and diabetic ketoacidosis that was safely and effectively managed with plasmapheresis. A 38-year-old female with history of gestational diabetes presented with acute onset of nausea and abdominal pain. She denied alcohol use and was on oral contraceptive pills. On physical exam, she was afebrile, normotensive, and tachycardic with mild abdominal distension and diffuse tenderness. Diagnostic tests revealed a serum glucose of 414 mg/dL, triglycerides &gt; 816 mg/dL, amylase of 106 U/L, lipase of 272 U/L, anion gap of 23, BUN of 13 mg/dL, creatinine of 0.3 mg/dL, sodium of 120 mmol/L, HCO 3 of 14 mmol/L, and positive urine ketones. Computed tomography (CT) findings were consistent with severe acute pancreatitis. The patient was managed conservatively on day 1. Due to persistence of symptoms, plasma exchange using NxStage plasmafilter was performed on day 2 and day 3, which resulted in significant reduction of the triglyceride level and resolution of abdominal pain. Patient was discharged home with gemfibrozil and glyburide as maintenance therapy. The exact mechanism of hypertriglyceridemia-induced pancreatitis is not clear. It has been postulated that hyperviscosity of blood due to lipid particles causes ischemia in the pancreas, releasing inflammatory mediators and leading to pancreatic necrosis and inflammation. The advantage of plasmapheresis over conservative management is the removal of lipid particles in a relatively short period of time and clearance of triglyceridemia-associated pro-inflammatory agents. World J Nephrol Urol. 2014;3(4):162-166 doi: http://dx.doi.org/10.14740/wjnu189w

Primary Lymph Node Gastrinoma Resulting in Zollinger-Ellison Syndrome

Purpose: A 63-year-old man presented with 4 months of non-bloody diarrhea, with 30 bowel movements daily; diarrhea persisted at night while fasting. There was an associated 70-pound unintentional weight loss, along with rare heartburn partially relieved with antacids. Computed tomography of the abdomen revealed a 4.7-cm enhancing mass in the midline adjacent to or arising from the uncinate process of the pancreas. Serum gastrin, obtained off of a proton-pump inhibitor (PPI) was elevated to 1270 pg/mL. Esophagogastroduodenoscopy revealed severe erosive esophagitis and innumerable duodenal bulb and post-bulbar ulcers. Gastric rugae were thickened with large amounts of reaccumulating secretions that had a bedside pH of 3.5. Based on these findings, Zollinger-Ellison syndrome (ZES) was diagnosed. Octreotide scan demonstrated uptake in the lesion seen on CT with no liver lesions. The patient was started on IV PPI with resolution of abdominal pain and diarrhea. Exploratory laparotomy demonstrated, within the gastrinoma triangle, a well-circumscribed 4 x 5-cm mass, which was mobile and not fixed to the pancreas or other adjacent structures. Pancreas and duodenum were palpated extensively with no evidence of occult lesions; the mass was then excised. Pathology with staining determined the tumor to be a primary lymph node (LN) gastrinoma. Post-operatively, diarrhea resolved and there was gradual weight gain. Gastrin level normalized and PPI was eventually discontinued. ZES is caused by the autonomous secretion of gastrin by gastrinomas. Ninety percent of gastrinomas occur in an anatomic area called the gastrinoma triangle, classically in the pancreas or duodenal wall. Surgical resection can result in cure and should be pursued in patients with resectable disease. Not all gastrinomas in LN result from metastatic spread from pancreatic primaries, but rather may be primary LN tumors as shown in our case. This is supported by the absence of gastrinoma in other locations and normalization of gastrin levels postoperatively. Primary LN gastrinomas do not have any distinguishing characteristics compared to other types of gastrinomas. All patients with ZES proceeding to surgery should have detailed exploration to rule out pancreatic or duodenal tumors, as well as routine excision of LNs within the gastrinoma triangle. The existence of primary LN gastrinomas is controversial, although one study suggests they may occur in 10% of ZES cases. They do not occur in MEN 1. They are unique in that they have been cured by lymph node excision alone. This case demonstrates that gastrinomas may develop primarily in LNs rather than the more commonly suspected solid organs.

Early versus delayed laparoscopic cholecystectomy for acute gallstone pancreatitis.

Gallstones and alcohol account for more than 80% of acute pancreatitis. Cholecystectomy is the definitive treatment for gallstones. Laparoscopic cholecystectomy is the preferred route for performing cholecystectomy. The timing of laparoscopic cholecystectomy after an attack of acute biliary pancreatitis is controversial. To compare the benefits and harms of early versus delayed laparoscopic cholecystectomy in people with acute biliary pancreatitis. For mild acute pancreatitis, we considered 'early' laparoscopic cholecystectomy to be laparoscopic cholecystectomy performed within three days of onset of symptoms. We considered all laparoscopic cholecystectomies performed beyond three days of onset of symptoms as 'delayed'. For severe acute pancreatitis, we considered 'early' laparoscopic cholecystectomy as laparoscopic cholecystectomy performed within the index admission. We considered all laparoscopic cholecystectomies performed in a later admission as 'delayed'. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library2012, issue 12), MEDLINE, EMBASE, Science Citation Index Expanded, and trial registers until January 2013. We included randomised controlled trials, irrespective of language or publication status, comparing early versus delayed laparoscopic cholecystectomy for people with acute biliary pancreatitis. Two authors independently assessed trials for inclusion and independently extracted data. We planned to analyse data with both the fixed-effect and the random-effects models using Review Manager 5 (RevMan 2011). We calculated the risk ratio (RR), or mean difference (MD) with 95% confidence intervals (CI) based on an intention-to-treat analysis. We identified one trial comparing early versus delayed laparoscopic cholecystectomy for people with mild acute pancreatitis. Fifty participants with mild acute gallstone pancreatitis were randomised either to early laparoscopic cholecystectomy (within 48 hours of admission irrespective of whether the abdominal symptoms were resolved or the laboratory values had returned to normal) (n = 25), or to delayed laparoscopic cholecystectomy (surgery after resolution of abdominal pain and after the laboratory values had returned to normal) (n = 25). This trial is at high risk of bias. There was no short-term mortality in either group. There was no significant difference between the groups in the proportion of participants who developed serious adverse events (RR 0.33; 95% CI 0.01 to 7.81). Health-related quality of life was not reported in this trial. There were no conversions to open cholecystectomy in either group. The total hospital stay was significantly shorter in the early laparoscopic cholecystectomy group than in the delayed laparoscopic cholecystectomy group (MD -2.30 days; 95% CI -4.40 to -0.20). This trial reported neither the number of work-days lost nor the costs. We did not identify any trials comparing early versus delayed laparoscopic cholecystectomy after severe acute pancreatitis. There is no evidence of increased risk of complications after early laparoscopic cholecystectomy. Early laparoscopic cholecystectomy may shorten the total hospital stay in people with mild acute pancreatitis. If appropriate facilities and expertise are available, early laparoscopic cholecystectomy appears preferable to delayed laparoscopic cholecystectomy in those with mild acute pancreatitis. There is currently no evidence to support or refute early laparoscopic cholecystectomy for people with severe acute pancreatitis. Further randomised controlled trials at low risk of bias are necessary in people with mild acute pancreatitis and severe acute pancreatitis.

Gallstone Pancreatitis

Hwang and colleagues1 offer an interesting look into the management of gallstone pancreatitis through the lens of an integrated health care system, Kaiser Permanente Southern California. The Kaiser system (compared with other insurance plans or hospitals) offers a unique opportunity to study this issue. They have a largely closed system offering synchronized care among various health care providers, and fewer patients move in and out of their umbrella of care. Thus, the article by Hwang et al is an important addition to the current literature suggesting that the recurrence of gallstone pancreatitis is all too common.2 Their data also suggest that endoscopic retrograde cholangiopancreatography (ERCP) during the index admission in patients who do not undergo cholecystectomy may be beneficial in preventing recurrent disease. In their cohort of 1119 patients who did not undergo cholecystectomy, 14.6% developed recurrent gallstone pancreatitis and 11.0% developed other issues related to gallstone disease. In patients who underwent ERCP, there was a 50% reduction in recurrent gallstone pancreatitis. Nonetheless, the risk of recurrence after ERCP remains elevated when compared with patients who underwent cholecystectomy (8.2% vs 5.4%, respectively). Accordingly, we agree with the authors that ERCP for the “definitive” management of gallstone pancreatitis3 should still be reserved for patients with a strong contraindication to surgery. This article also highlightswhatwe view as an even bigger problem: the significant proportion of patients (nearly 40% in thisstudy)whostilldonotundergocholecystectomyduringthe index hospitalization, including 20%who never go on to cholecystectomy. This problem is surely not unique to the Kaiser Permanente system,but rather ispervasive (andmaybeworse) throughout most hospitals. We fear that although some patientsdonotproceed to cholecystectomyowing to clinical factorsorpersonalpreference, in toomanycases theobstaclemay simply be convenience or the packed operating room schedule.Evenintervalcholecystectomyfollowingmildgallstonepancreatitis is associatedwith higher rates of recurrence and thus readmission.4 Inan increasinglycost-consciousandoutcomesdrivenhealth care environment, the importanceof thesemanagement decisions cannot be overlooked. Moreover, recent literature5has suggested thateven the inhospital “cooling-off”period isunnecessary.Patientswithmild gallstone pancreatitis can, in fact, safely undergo laparoscopic cholecystectomywithin24 to48hours regardlessof the resolution of abdominal pain or abnormal laboratory findings.Endoscopic retrogradecholangiopancreatographyshould infrequently enter the algorithm for the management of mild gallstone pancreatitis: in patientswith concomitant cholangitis, theuncommon retained stone, or extensive comorbidities precluding surgery. Evidence-based practice for the managementofmildgallstonepancreatitismust includeearly involvement of the surgeon leading to timely cholecystectomy.

Fecal Microbiota Transplant for Recurrent Clostridium difficile Infection: Mayo Clinic in Arizona Experience

ObjectiveTo report the initial experience of treating recurrent Clostridium difficile infection (CDI) with fecal microbiota transplant (FMT) at Mayo Clinic in Arizona. Patients and MethodsThe study retrospectively reviewed FMTs performed at Mayo Clinic in Arizona between January 1, 2011, and January 31, 2013. All the recipients had multiple recurrent CDIs unresponsive to traditional antibiotic drug therapy. A standardized protocol was developed to identify patients, screen donors, perform FMT, and determine outcomes via telephone surveys. ResultsThirty-one patients (mean ± SD age, 61.26±19.34 years) underwent FMT. Median time from index infection to FMT was 340 days. Ninety-seven percent (29 of 30) of patients reported substantial improvement or resolution of diarrhea (median time to improvement, 3 days), 74% (17 of 23) reported improvement or resolution of abdominal pain (median time to improvement, 3 days), and 55% (16 of 29) had improvement or resolution of fatigue (median time to improvement, 6 days). Three patients underwent repeated FMT owing to persistent symptoms; 2 reported improvement in diarrhea with the second therapy. No serious adverse events directly related to FMT were reported. ConclusionA standardized regimen of FMT for recurrent CDI is safe, is highly effective, and can be provided using a relatively simple protocol.

A Novel Strategy of Vascular Reconstruction After Radical Resection of an Inferior Vena Cava Leiomyosarcoma

Vascular reconstruction after resection of a inferior vena cava (IVC) leiomyosarcoma remains a major challenge. In this study we describe a case of successful vascular reconstruction using a novel approach. A patient underwent the surgical resection of an IVC tumor. The caudal stump of the IVC was then anastomosed to an 18-mm Dacron graft with bilateral 8-mm arms, which were anastomosed to the bilateral renal veins, respectively. Complete resolution of abdominal pain was achieved and the patient did well throughout the 12-month follow-up. No recurrent clinical symptoms were observed. Renal function was well maintained. This novel vascular reconstruction approach may be a feasible, effective surgical strategy for preservation of renal function for IVC leiomyosarcoma.