Severe Epigastric Pain Research Articles

S542 Different Duodenal pH Profiles Relating to Individual Dyspeptic Symptoms Measured by Wireless Motility Capsules in Suspected Gastroparesis: Evidence for Delayed Neutralization in Patients With Greater Epigastric Pain

Introduction: Increased duodenal acid exposure is proposed as a mechanism of symptoms in functional dyspepsia but is rarely measured. Wireless motility capsules (WMC) measure transit in suspected dysmotility but also quantify small bowel (SB) pH. WMC SB pH has not been related to dyspepsia severity. We compared SB pH to severity of epigastric pain and nausea/vomiting (NV) in patients with suspected gastroparesis and devised an estimate of delayed duodenal neutralization as a marker of possible increased duodenal acid exposure. Methods: 91 patients with symptoms suspicious for gastroparesis from a parent study of concurrent WMC and gastric scintigraphy had interpretable WMC SB pH tracings from gastric emptying (GE) to ileocecal junction (ICJ) passage. Nausea/vomiting (NV) scores from GCSI surveys and epigastric pain scores from PAGI-SYM surveys (0=no symptoms, 5=very severe) were related to SB pH. Delayed duodenal neutralization was defined when mean SB pH over the first 30 minutes after GE remained below pH values in the first 15 minutes after GE. Results: GE was detected by WMC pH increases >2 units. Most tracings showed initial rapid duodenal pH decreases followed by increases progressing to ICJ passage (Fig 1A). Others showed delayed pH decreases then slower increases, perhaps reflecting delayed duodenal neutralization (Fig 1B). Duodenal pH profiles were similar in patients with epigastric pain scores above and below median severity (Table). However patients with NV scores above median severity showed higher duodenal pH than with NV scores below median. 18/30 patients (60%) with pain scores above median showed delayed duodenal neutralization (lower pH in the 30 vs. 15 minutes after GE) compared to 20/61 (33%) with pain scores below median (P=0.02). Conversely, 16/36 (44%) with NV scores above median and 22/55 (40%) with NV below median showed delayed neutralization (P=0.83). Conclusion: Duodenal pH profiles in suspected gastroparesis relate to symptom severity and vary depending on the symptom measured. Compared to milder symptoms, severe nausea/vomiting is associated with increased duodenal pH and little delay in duodenal neutralization while increased overall duodenal pH is not seen with severe epigastric pain. Rather, a subset of patients with severe pain exhibits delayed initial duodenal pH decreases followed by slow neutralization. These findings support possible increased duodenal acid exposure relating to dyspeptic pain severity in some patients.Figure 1.: pH tracing on left (A) shows rapid pH decrease after gastric emptying followed by prompt neutralization. pH tracing on right (B) shows delayed pH decrease followed by more gradual neutralization. Table 1. - WMC Duodenal pH Profiles in Relation to Symptom Severity in Suspected Gastroparesis Symptom Symptom Score Severity 0 to 15 Minutes After Gastric Emptying 0 to 30 Minutes After Gastric Emptying 0 to 60 Minutes After Gastric Emptying pH P Value pH P Value pH P Value Epigastric pain Above median (4.2+0.5) 6.3+0.4 0.43 6.3+0.5 0.63 6.4+0.4 0.74 Below median (1.9+1.0) 6.3+0.6 6.3+0.4 6.4+0.4 Nausea/vomiting Above median (2.9+0.9) 6.4+0.4 0.04 6.4+0.4 0.04 6.5+0.4 0.03 Below median (0.7+0.5) 6.2+0.5 6.2+0.5 6.3+0.4

S1721 Doxycycline-Induced Pancreatitis: An Uncommon Complication of a Common Drug

Introduction: Drug induced pancreatitis (DIP) is rare but potential cause of acute pancreatitis and accounts for 0.1-5.3% of all cases. In this case series, we report 2 cases of patients with doxycycline induced pancreatitis. Case Description/Methods: A 60-year-old woman with cervical osteomyelitis on iv ceftriaxone and doxycycline presented with 2-day history of severe nausea, vomiting, and epigastric pain. On exam, she had epigastric and right upper quadrant tenderness. Laboratory evaluation was significant for serum lipase 6,699 u/l , creatinine of 1.94 mg/dl. Liver function tests and lipid panel were within normal limits. Computerized tomography (CT) of the abdomen and pelvis confirmed acute interstitial pancreatitis (Figure). Triglyceride, IgG subclasses and calcium levels were normal. Thorough review of her medications revealed doxycycline induced pancreatitis was suspected. Her symptoms gradually improved and lipase returned to 85 u/l with discontinuation of doxycycline. A 91year-old woman with recent history of left elbow fracture complicated by wound dehiscence on doxycycline therapy, presented for hospital admission with several days of increased confusion, malaise, and generalized, severe abdominal pain. She appeared ill, with dry mucous membranes and diffuse abdominal tenderness. Laboratory test results were notable for blood urea nitrogen (BUN) 56 mg/dl, creatinine 2.35 mg/dl, ALP 223 u/l, total bilirubin 1.1 mg/dl, wbc count 26.7 k/ul, calcium 6.4 mg/dl, lipase 301 u/l, AST, ALT, triglycerides and IgG subclass levels were within normal limits. CT abdomen showed extensive intrapancreatic and peripancreatic edema, the patient was diagnosed with severe pancreatitis. With careful exclusion of other etiologies, she was diagnosed with doxycycline induced pancreatitis. Her symptoms improved with aggressive hydration and discontinuation of doxycycline. Discussion: Onset of symptoms with relation to starting the offending drug is key in identifying the causative agent of DIP. The severity, onset of symptoms, dosage of doxycycline and latency have been reported as variable as in our cases. Symptom onset was at 14 days of doxycycline therapy in the first vs 22 in the second case. Treatment includes cessation of doxycycline and aggressive IV fluid resuscitation. This case series emphasizes the importance of considering doxycycline as a cause of acute pancreatitis especially with its increased use in recent years.Figure 1.: CT abdomen with extensive intrapancreatic and peripancreatic edema (second case presented).

S2469 The Big Stretch: A Report of Three Cases of Gastroparesis as an Uncommon Complication of Hypermobile Ehlers-Danlos Syndrome

Introduction: Ehlers-Danlos syndrome (EDS) is a rare autosomal dominant connective tissue disorder that affects the gastrointestinal system, skin, joints, and vasculature. Hypermobile EDS (hEDS) is a subset of EDS with a prevalence of 1 in 5000 people. Major GI features of hEDS include abdominal pain, nausea, constipation, heartburn, and irritable bowel syndrome-like symptoms. Gastroparesis is a debilitating disorder defined as delayed gastric emptying in the absence of a mechanical obstruction. However, hEDS as a cause of gastroparesis is not well established in the literature. Here we report 3 cases of gastroparesis in patients with hEDS to demonstrate its uncommon and varying presentations. Case Description/Methods: Our first patient is a 20-year-old woman who was diagnosed with hEDS at a young age and then developed severe epigastric postprandial abdominal pain with bloating, intractable nausea, early satiety, and unintentional weight loss. She had multiple ER admissions over the past few years for similar symptoms. Physical examination revealed hyperflexible joints, normal bowel sounds with nontender abdomen. Lab values were within normal limits. Esophagogastroduodenoscopy (EGD) and gastric emptying studies both confirmed Grade III gastroparesis. She was initially started on Metoclopramide and Ondansetron without improvement. Patient ultimately achieved symptom control with Azithromycin, Ondansetron, Promethazine as needed and diet modifications. The second patient is a 24-year-old man who was also diagnosed with hEDS at an early age and presented with recurrent postprandial abdominal pain with bloating and heartburn, but no weight loss. He underwent EGD and was found to have gastritis, hiatal hernia and reflux esophagitis. Subsequent gastric emptying scintigraphy later confirmed Grade II gastroparesis and his symptoms improved with diet modifications as well as Metoclopramide. Lastly, our third patient is a 26-year-old woman also with known history of hEDS who presented with mild intermittent postprandial abdominal pain and abdominal bloating. Prior work-up with EGD and gastric emptying scans confirmed the diagnosis of Grade I gastroparesis. Fortunately, her symptoms clinically resolved with regular cannabis use. Discussion: Gastroparesis should be considered in patients with hEDS complaining of severe postprandial abdominal pain. Due to its uncommon presentation and multi-system organ involvement, EDS should be considered in patients with idiopathic gastric dysmotility and joint hypermobility.

S1871 A Case of Ketamine-Induced Cholangiopathy: A Novel Diagnosis Associated With Chronic Recreational Ketamine Use

Introduction: Ketamine, an analgesic commonly used for procedural sedation, has become a popular agent for recreational use among young adults. The diagnosis of ketamine-induced cholangiopathy is uncommon. We report a case of a young adult with clinical and radiological features consistent with cholangiopathy induced by chronic ketamine use. Case Description/Methods: A 19-year-old female with past medical history of peptic ulcer disease presented to emergency department (ED) with one year history of severe epigastric abdominal pain. On further questioning, patient reported chronic recreational ketamine use. Physical exam revealed mild epigastric and RUQ tenderness. Liver function test demonstrated elevated alkaline phosphatase of 174 U/L, AST of 237 U/L and ALT of 224 U/L. All other hematology and chemistry results were within normal limits. RUQ ultrasound showed minimally dilated common bile duct (CBD). An MRCP was obtained, showing mild-to-moderate dilatation of intra-/extra-hepatic bile ducts and dilated cystic duct (CD) without obvious intraductal calculi (Figure A). Endoscopic ultrasonography (EUS) was performed showing dilatation of CBD, minimal dilatation of common hepatic duct, and minimal dilatation of CD, once again without obvious calculi (Figure B). These imaging findings are compatible with ketamine-induced cholangiopathy. After being admitted for 6 days, the patient demonstrated significant improvement in her abdominal pain, with gradually improving liver test values. She was discharged with the recommendation to abstain from ketamine use and outpatient gastroenterology follow-up. Discussion: Chronic exposure to ketamine has been known to cause urologic injury, referred to as ketamine-induced ulcerative cystitis. In comparison to the urologic complications of chronic ketamine use, its effects on the biliary system have been less commonly reported. Existing reports have mostly come from regions of Asia where recreational ketamine use is more prevalent. The nonspecific gastrointestinal symptoms that are typically reported by patients with ketamine-induced cholangiopathy may make the diagnosis more challenging to recognize. Due to increasing recreational ketamine use among young adults in recent years, cases of ketamine-induced cholangiopathy are likely to rise. Therefore, a better understanding of the clinical and radiological features of this condition are needed to allow for prompt recognition of ketamine-induced cholangiopathy.Figure 1.: A. MRCP image showing mild-to-moderate dilatation of the intrahepatic and extrahepatic bile ducts and dilatation of the cystic duct. There are no visible stones or evidence of other etiology for the dilatation. B. EUS image displaying CBD dilatation measuring up to 10.6 mm in the head region, with smooth tapering to the ampulla where it measured 2.7 mm.

S1720 Diabetic Ketoacidosis as a Rare Complication of Alcoholic Pancreatitis in a Previously Euglycemic Patient

Introduction: Acute alcoholic pancreatitis is an acute inflammation of the pancreas secondary to alcohol intake due to autodigestion from an increase in pancreatic enzyme release. Most commonly due to gallstones, alcohol intake, and hypertriglyceridemia, pancreatitis commonly presents with severe epigastric abdominal pain, nausea and vomiting and is managed with aggressive intravenous (IV) fluid resuscitation. Some complications include acute respiratory distress syndrome and compartment syndrome. A very rare complication of acute pancreatitis is diabetic ketoacidosis (DKA), especially in patients without a history of diabetes mellitus. Case Description/Methods: A 25-year-old female with a medical history significant for alcohol abuse presented with nausea, vomiting, and abdominal pain for 2 days. The patient reported drinking one pint of liquor per day. She was tachycardic with a heart rate of 115 and other vitals were normal. Significant laboratory studies showed a lipase of 1715, aspartate transaminase of 292, alanine transaminase of 155, glucose of 540, venous pH of 7.277, bicarbonate of 9, anion gap of 21, and beta-hydroxybutyrate of 5.1. A computed tomography scan of her abdomen and pelvis without IV contrast showed edematous and inflammatory changes in the tail of the pancreas and severe hepatic steatosis (Figure). The patient was managed with aggressive IV fluids and IV insulin infusion. Her abdominal pain and anion gap resolved on day 2 of admission and she was able to tolerate a diet. Glycated hemoglobin (HbA1c) returned a value of 4.7 and C-peptide was low at < 0.10; the subsequent pancreatic antibody panel was negative. The patient was seen in the clinic 6 months later and HbA1c at that time was 4.8. Discussion: This case illustrates DKA as a rare complication of acute pancreatitis. It provides an example of why a high level of suspicion for DKA should be present in patients presenting with alcoholic pancreatitis even in the absence of any diabetic history. Though there is no definitive mechanism of action for this presentation, it is likely from a combination of pancreatic beta-cell destruction and counter-regulatory hormone effects. Pancreatic beta-cell destruction causes impaired insulin production, leading to acute hyperglycemia. Furthermore, as acute pancreatitis can lead to severe intravascular depletion, increased secretion of counter-regulatory hormones such as cortisol and glucagon, in combination with impaired insulin secretion, can precipitate DKA in such a scenario.Figure 1.: CT abdomen without contrast demonstrating edematous and inflammatory changes in the tail of the pancreas.

S1731 Fibrosing Pancreatitis Initially Diagnosed as Ductal Adenocarcinoma by Endoscopic Ultrasound of a Pancreatic Mass in a Pediatric Patient

Introduction: Pancreatic cancer is very rare in the pediatric population. Incidence data is scarce, and few case reports have been published. Pancreatic ductal adenocarcinoma (PDA) is the most common subtype in adults, but is rare in children. We report a case of a benign pancreatic head mass in a pediatric patient initially diagnosed as PDA on endoscopic ultrasound (EUS) guided biopsy. Case Description/Methods: A 13-year-old male with past medical history of treated Helicobacter pylori infection 6 months prior was admitted for severe acute intermittent epigastric pain. Labs showed elevated transaminases and gamma-glutamyl transferase. Abdominal ultrasound demonstrated an indeterminate solid mass-like lesion of 3 cm at the pancreatic head, and the common bile duct (CBD) was dilated to 0.9 cm. Magnetic resonance cholangiopancreatography showed a 2.2 cm indeterminate lesion along the pancreatic head region with dilated CBD of 1.4 cm, tapering at the level of the lesion. On hospital day 3, the patient underwent esophagogastroduodenoscopy and EUS. A parenchymal mass of 2.2 cm was visualized in the head of pancreas, and fine needle biopsy was performed. Cytology diagnosis was well differentiated ductal adenocarcinoma. Serum carcinoembryonic antigen, carbohydrate antigen 19-9, and alpha-fetoprotein were all normal. The patient underwent elective Whipple procedure. Surprisingly, no malignancy was identified on the surgical specimen. Instead the findings supported a diagnosis of localized fibrosing pancreatitis with high background of immunoglobulin G4 with interlobular pattern. Patient was discharged home on post-operation day 13. EUS cytology was reviewed at a tertiary cancer center and later reported as acute on chronic inflammation without malignancy (Figure). Discussion: Despite increased use of EUS for diagnosis of pancreatic masses, 5-10% of patients who undergo Whipple procedure for presumed malignancy will have benign pathology: most commonly chronic fibrosing pancreatitis, chronic pancreatitis, or focal active pancreatitis. The false positive rate for diagnosing malignancy using EUS-fine needle aspiration (FNA) of solid pancreatic lesions is less than 1%. However, it may be higher in pediatrics as the prevalence of PDA is much lower in adults. For suspected cases of PDA in pediatric patients, additional review of EUS cytology at an experienced and dedicated cancer institution is advisable before further intervention to prevent the medical and psychosocial ramifications of a false positive cancer diagnosis.Figure 1.: (Left) A parenchymal mass (2.2 x 1.8 cm) in the head of the pancreas by endoscopic ultrasound (EUS) adjacent to the portal confluence, with the common bile duct dilated to 12.8 mm (marked by yellow cross signs). Initial cytopathology from EUS-FNA of pancreatic head mass A. Diff-Quik staining at low magnification, 4x. B. Smear is cellular and well preserved with sheets, clusters and single malignant cells, 10x. C. Cells have crowded nuclei, 20x. D. Malignant cells exhibit loss of polarity, irregular nuclear contours, finely granular chromatin and some with prominent nucleoli, 40x . Based on cytomorphological features, the mass is a well differentiated ductal adenocarcinoma of pancreatic head. Note: The review of this cytopathology by a tertiary cancer institution was inconsistent with malignancy. The glandular cells had mild cytologic atypia, and the acinar cells remained lobular in configuration. Although there was some higher nuclear to cytoplasmic ratio, no absolute nuclear enlargement was noticed.

S1822 Recurrent Pancreatitis Secondary to Common Channel Volvulus Through Petersen’s Space Defect in a Patient With Roux-en-Y Bypass

Introduction: Petersen’s space hernia is an internal hernia that can occur after Roux-en-Y gastrojejunostomy. The intestinal loops herniate through a defect between the retroperitoneum, the transverse mesocolon and the small bowel limbs. We present a case of recurrent pancreatitis in a patient with Roux-En-Y bypass found to have common channel hernia through a Petersen’s space defect. Case Description/Methods: We present the case of a 34-year-old female with a history of Roux-en-Y surgery in 2018 and subsequent recurrent pancreatitis who presented to the emergency department with a chief complaint of severe epigastric and left lower quadrant abdominal pain associated with hematemesis. Patient reported 3 episodes of pancreatitis within 1 year previously. CT abdomen and pelvis showed mildly dilated common bile duct and intrahepatic biliary dilatation with no evidence of pancreatitis. Significant lab work included elevated lipase at 184 U/L. Patient was admitted to the medical service. Gallbladder ultrasound revealed no evidence of cholelithiasis, a prominent CBD of 9 mm and redemonstrated mild intrahepatic biliary dilatation. MRCP revealed a mesenteric swirl in the mid abdomen which was suspicious for an internal hernia in the setting of antecolic Roux-en-Y gastric bypass. It also showed focally dilated intrahepatic with underlying segmental atrophy. General surgery consultation was sought, with eventual plans for diagnostic laparoscopy after ruling out marginal ulcer via EGD. An EGD was performed which did not show evidence of marginal ulcer. Patient then underwent diagnostic laparoscopy which revealed a 360-degree volvulus of the common channel through a Petersen’s space defect; this was carefully reduced, and the Petersen’s space defect was closed. Patient also underwent laparoscopic cholecystectomy. Patient did not have any further episodes of pancreatitis after surgery. Discussion: This case demonstrates recurrent pancreatitis in a patient with a history of Roux-En-Y bypass found to have a common channel volvulus through a Petersen’s space defect. It is our understanding that the volvulus likely caused compression of the pancreaticobiliary system, thus causing recurrent pancreatitis. Reduction of the volvulus and closing of the Petersen’s defect resulted in complete resolution of recurrent pancreatitis in the patient.

S1941 Acute Pancreatitis Following a Lower Extremity Angioplasty

Introduction: Acute pancreatitis affects a significant population globally. Usual etiologies are gallstones, alcohol, hypertriglyceridemia, medications; less frequent are trauma, hypercalcemia, infections, toxins, ischemia, anatomic anomalies, vasculitis, and idiopathic. Pancreatitis post coronary intervention is an uncommon cause with only 19 published cases in the last two decades. Being cognizant of this etiology is important given the increasing number of patients undergoing angiography. Case Description/Methods: An 81-year-old female with hypertension, diabetes, peripheral arterial disease, prior cholecystectomy underwent left lower extremity angioplasty at an outside center. Within a few hours, she started having severe epigastric pain radiating to her back, nausea, vomiting and loose bloody stool. She presented to the emergency department 24 hours after symptom onset. Epigastric tenderness was present on exam. Labs revealed leukocytosis (24,450/µL),elevated lipase (1410 U/L), elevated creatinine (1.3 mg/dL), lactate (3.1 mmol/L), calcium 9.4 mg/dL and triglycerides 161 mg/dL. Incidentally, found to be positive for COVID-19. Normal common bile duct diameter seen on sonogram. CT angiogram of the abdomen/pelvis showed acute pancreatitis, duodenal and central small bowel enteritis (Figure). She was not on any medications known to cause pancreatitis and denied alcohol use. Patient improved with analgesics and intravenous fluids. She had no recurrence of bloody stools and hemoglobin remained stable. On day 4, she was able to tolerate a regular diet, and leukocyte count and creatinine normalized. Patient did not have any COVID respiratory symptoms, and was discharged. Discussion: Given the temporal association to angioplasty and no other identifiable cause, acute pancreatitis was presumed to be due to the contrast used during angioplasty. Other possibilities included cholesterol embolism but no peripheral signs of cholesterol embolism were seen. Patient was an asymptomatic COVID-19 case. Although, there are case series of pancreatitis due to COVID, those were found in very sick symptomatic patients. On review of literature, cholesterol embolism was identified as a definite cause only on autopsy or laparotomy (Table). Other possible mechanisms are: high viscosity of the contrast media leading to ischemia and necrosis, contrast causing NF-κB activation followed by epithelial damage, and vasospasm. Pancreatitis after coronary angiography is rare, nonetheless, an important differential especially if there is a temporal relationship.Figure 1.: CT scan (abdomen) of our patient demonstrating acute pancreatitis. Table 1. - Current literature reports on acute pancreatitis after coronary angiography/angioplasty S. NO. YEAR AUTHOR PROCEDURE ETIOLOGY TIME BETWEEN PROCEDURE AND SYMPTOM ONSET CONTRAST USED VOLUME OF CONTRAST(mL) 1 1994 Orvar et al1 Angiography Cholesterol emboli detected on autopsy 14 hours Not Mentioned 80-160 2 1994 Orvar et al1 Angiography Cholesterol emboli detected on autopsy Immediately Not Mentioned 80-160 3 1994 Orvar et al1 Angiography Contrast-Induced Not Mentioned Not Mentioned 80-160 4 1994 Orvar et al1 Angiography Contrast-Induced Not Mentioned Not Mentioned 80-160 5 1994 Orvar et al1 Angiography Contrast-Induced Not Mentioned Not Mentioned 80-160 6 1994 Orvar et al1 Angiography Contrast-Induced Not Mentioned Not Mentioned 80-160 7 1994 Orvar et al1 Angiography Contrast-Induced Not Mentioned Not Mentioned 80-160 8 1994 Orvar et al1 Angiography Contrast-Induced Not Mentioned Not Mentioned 80-160 9 1994 Orvar et al1 Angiography Contrast-Induced Not Mentioned Not Mentioned 80-160 10 1994 Orvar et al1 Angiography Contrast-Induced Not Mentioned Not Mentioned 80-160 11 1994 Orvar et al1 Angiography Cholesterol emboli detected on autopsy Not Mentioned Not Mentioned 80-160 12 1994 Orvar et al1 Angiography Cholesterol emboli detected on autopsy Not Mentioned Not Mentioned 80-160 13 2013 Gorges et al2 Angiography Contrast-Induced 1 hour Iopamidol 120 14 2014 Abstract 343, Journal of Hospital Medicine3 Angioplasty Contrast-Induced Not Mentioned Not Mentioned Not Mentioned 15 2017 Hajimaghsoudi et al4 Angiography Contrast-Induced 48 hours Visipaque(Iodixanol) 100 16 2020 Rafiq et al5 Angioplasty Contrast-Induced Immediately Ioversal 150 17 2020 Mui et al6 Angioplasty Contrast-Induced Immediately Omnipaque(Iohexol) 120 A total of 19 cases were identified. However, only seventeen cases have been shown in the table. Due to inability to get permission for reuse, the remaining 2 cases have not been shown. 1 - Orvar K, Johlin FC. Atheromatous embolization resulting in acute pancreatitis after cardiac catheterization and angiographic studies. Arch Intern Med 1994;154:1755–61 2 - Gorges R, Ghalayini W, Zughaib M. A case of contrast-induced pancreatitis following cardiac catheterization. J Invasive Cardiol 2013;25:E203–4. 3 - An Unusual Source of Abdominal Pain.Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev.. Abstract 343 Journal of Hospital Medicine, Volume 9, Suppl 2. https://shmabstracts.org/abstract/an-unusual-source-of-abdominal-pain/ 4 - Hajimaghsoudi M, Zeinali F, Mansouri M, et al. Acute necrotizing pancreatitis following coronary artery angiography: a case report. ARYA Atheroscler 2017;13:156–8. 5 - S1558 A Rare Case of Pancreatitis Secondary to Coronary Angiogram Dye. Rafiq, Rehan; Rafiq, Ahmad.The American Journal of Gastroenterology: October 2020 - Volume 115 - Issue - p S791doi: 10.14309/01.ajg.0000708280.94586.25 6 - Mui JJ, Shamavonian R, Thien KCP. Acute pancreatitis following coronary angiography: case report and review of contrast-induced pancreatitis. Int Surg J 2020;7:870-2

S1747 Iatrogenic Cushing’s From Celiac Plexus Blocks for Chronic Pancreatitis

Introduction: Celiac plexus blocks (CPB) and celiac plexus neurolysis (CPN) have been implemented to decrease opiate dependency and treat chronic pancreatitis and/or pain resulting from pancreatic malignancy. There are various approaches to facilitate CBP/CPN including percutaneous, surgical and endoscopic, guided as CT, fluoroscopy, US or EUS techniques. EUS is the latest development in CPB/CPN and the least commonly utilized method, however recent studies have shown high efficacy and minimal complications or risks. Despite various complications associated with different techniques, no case report or current literature has documented the development of Iatrogenic Cushing’s disease from use of steroids during CPB via any approach. Herein we report the first case of Iatrogenic Cushing’s disease from CPB in the treatment of chronic pancreatitis. Case Description/Methods: A 27 YO F presented to the ED with severe epigastric pain associated with nausea. She was diagnosed with chronic pancreatitis a year and a half prior. At that time, she underwent an EUS showing severe chronic pancreatitis with biopsies positive for benign pancreatic tissue, fibrotic stromal tissue and scattered eosinophilic infiltrates. Due to recurring pain a subsequent nerve block was repeated. She was prescribed hydromorphone 4 mg q3h as needed, methadone 30 mg BID and Pancrealipase, however a celiac plexus block was repeated due to refractory pain. Upon follow up, she endorsed a 10 lb weight gain, fatigue, acne, facial hair and fullness, dark abdominal striae and insomnia. She was suspected to have iatrogenic cushingoid features due to multiple celiac nerve blocks. A morning cortisol level was 0.3 ug/dL but a salivary cortisol level with within normal limits (< 0.010 ug/dL). She was referred to Endocrinology, who recommended withholding steroids for 3 to 6 months. Repeat testing with ACTH and DEXA suppression confirmed adrenal insufficiency. Five months later, the patient’s pain returned, and her methadone was increased. Repeat EGD/EUS showed pancreatic parenchymal abnormalities consisting of hyperechoic strands, hyperechoic foci and lobularity throughout the entire pancreas. Due to refractory pain, she was referred for a pancreatic transplant program. Discussion: EUS-guided CPB is an effective, minimally invasive modality in treating pain from abdominal malignancy and/or pancreatitis, however future studies are warranted to evaluate the agents used for chemical destruction, to avoid complications such as Iatrogenic Cushing’s disease.

S1681 Pancreatitis Secondary to Paxlovid-Induced Tacrolimus Toxicity

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

Acute pancreatitis in pregnancy following COVID-19 vaccine: a case report

BackgroundSince the approval of the Pfizer–BioNTech (BNT162b2) mRNA vaccine for COVID-19 infection, a few adverse effects have been reported. Acute pancreatitis has been reported in a few patients. However, there is currently no research showing a direct relationship between the vaccine and acute pancreatitis. Here, we report a case of acute pancreatitis following Pfizer vaccination in a young healthy pregnant woman without any known risk factors. To our knowledge, this is the first case report of possible vaccine-induced pancreatitis in a pregnant woman.Case presentationThe patient, a 24-year-old South-Asian female, at 31 weeks of gestation, presented with severe epigastric pain radiating to the back and worsening on lying supine, associated with nausea and vomiting. She was diagnosed with acute pancreatitis with a serum lipase level of 4376 U/L and an ultrasound showing features of pancreatitis. The patient received her first dose of the Pfizer vaccine 1 week prior to these symptoms. Detailed evaluation did not show any etiological cause of pancreatitis. The patient had a spontaneous vaginal delivery and the baby was shifted to the neonatal intensive care unit in a stable condition. A computed tomography scan postpartum (day 2) demonstrated acute interstitial edematous pancreatitis. The patient was managed conservatively in the intensive care unit and discharged home in a stable condition.ConclusionThis report highlights the importance of a detailed history and evaluation, and the close monitoring of any patient presenting with abdominal pain after vaccination. Acute pancreatitis can be fatal if not picked up early.

A Young Man With Epigastric Abdominal Pain

A Young Man With Epigastric Abdominal Pain

Epidural Analgesia for Pain Management in Acute Pancreatitis during Pregnancy and Its Effect on Maternal and Fetal Outcome.

Background Acute pancreatitis (AP) during pregnancy is a rare presentation with an estimated incidence of 1 case per 1000 to 10,000 pregnancies. Severe epigastric and abdominal pain is the earliest and the most common symptom of AP, and adequate pain relief is an integral part of patient management. The aim of our study was to investigate the different pain relief modalities that are used in pregnant women with AP and the efficacy of each method used, in terms of better pain relief and maternal-fetal outcomes. Methods This was a retrospective observational study over a period of 6 years conducted at a tertiary care hospital. Pregnant women with clinical and biochemical diagnoses of acute pancreatitis were included in the study. Patient's history and clinical and biochemical data were collected from the medical records of the hospital. Results A total of 12 patients were included in the study, 5 out of 12 patients had gall stones associated with AP, 2 patients had hypertriglyceridemia, and 1 each had preeclampsia and eclampsia. Epidural analgesia at the level of L1-L2 spinal level showed a reduction of VAS scores from 8 or 9 to 1 or 2, indicating excellent pain as compared to t intravenous (i/v) infusion of fentanyl or i/v boluses of injection tramadol, in whom VAS was never reduced below 3. With satisfactory results, labour analgesia and anesthesia for caesarean section was provided via the same catheter in 2 and 3 patients, respectively. Maternal and fetal outcomes were comparable in all the patients. Conclusion AP in pregnancy, when diagnosed early and managed accordingly, leads to better maternal and fetal outcomes. Epidural analgesia was better than intravenous analgesia in terms of pain management and better recovery of acute pancreatitis patients. In these patients, labour analgesia and anesthesia for caesarean section can be provided through the same catheter, making it a potential novel modality in the treatment of acute pancreatitis in pregnancy.

Hypergastrinemia in Children : A Case Report

Gastrin is an important hormone in the gastrointestinal system that promotes gastric acid secretion. Gastrin hormone is produced by the G-cells in the antrum of the stomach. Besides stimulating gastric acid secretion, gastrin also induces the proliferation of the gut epithelial cells, tissue remodelling, and angiogenesis. Gastrin levels higher than 100-150 pg/ml are known as hypergastrinemia. Hypergastrinemia may cause the hypersecretion of stomach acid, which, if not treated properly, may leads to refractory peptic ulcer, severe gastroesophageal reflux disease (GERD), diarrhea, or death due to complications of refractory peptic ulcer. This case presented a 12 years old boy with a chief complaint of severe epigastric pain in the past month, accompanied by nausea, especially during supine position. The patient had a previous history of esophagitis. He showed no significant changes upon empirical PPI treatment. However, slight improvements were observed after the administration of Helicobacter pylori treatment. The gastrin level in this patient was 198 pg/mL. Upon discharge, the patient was still given PPI treatment. During the follow-up visitation, patient complaints had improved significantly, and the patient was planned to undergo routine evaluations of gastrin.

Pneumoperitoneum: A rare life threatening complication post ERCP!

Respected Editor, Endoscopic Retrograde Cholangiopancreatography (ERCP) is an invasive medical procedure commonly used to identify and treat biliary system and pancreatic disorders. It is the combination of both endoscopic and radiologic imaging techniques that, although widely used, and usually a safe procedure, it can rarely lead to life threatening complications including but not limited to pancreatitis, cholangitis, hemorrhage and perforation leading to pneumoperitoneum. The occurrence of free air in the peritoneal cavity post-ERCP is a rare event (&lt; 1%), which is usually the result of duodenal or ductal perforation related to therapeutic ERCP with sphincterotomy.[1] Our discussion is based on the incidence of pneumoperitoneum occurring in patients post ERCP. According to a case report, a 29- year- old female was diagnosed with postpartum jaundice and biliary stones. Consequently, she was investigated using ERCP and treated with biliary stenting and bile flow restoration. Post ERCP, the patient developed severe epigastric pain radiating to the right shoulder and x-ray revealed air under the diaphragm, i.e. pneumoperitoneum.[2] In another report, a 72 year old woman who underwent ERCP to treat biliary stricture and provide stenting was found to have pneumobilia and pneumoperitoneum due to rupture of intrahepatic bile ducts during ERCP.[3] Another case has been reported with the same issue in which an 84 year old known case of pancreatic carcinoma with hepatic and lung metastasis underwent multiple ERCPs due to obstructive jaundice, performed an urgent CT scan, the very next day, which showed the presence of free air in the peritoneal cavity.[4] Therefore, in light of the cases mentioned above-, physicians should be mindful of this rare, life- threatening complication of ERCP and take great care and warn the patient before performing the procedure. A useful strategy to combat this complication, a nasogastric tube for bowel decompression immediately after ERCP can greatly reduce the chances of developing a pneumoperitoneum.

EP-570 Rare case of pre-pyloric perforation of stomach secondary to foreign body ingestion

Abstract Background Gastrointestinal perforation remains a common cause of acute abdomen in clinical practice. However, pre-pyloric perforation secondary to ingested foreign body (FB) in the adult population is rare. Nearly 80–90% of ingested foreign bodies will pass through the GI system spontaneously with only 1% requiring surgery. We report a rare incidence of pre-pyloric perforation in a patient unaware of ingestion of any foreign body. Case presentation A 59 year old female with no medical history, presented to the ED department with severe epigastric pain, vomiting and fever. She had a peritonitic abdomen and corroborative inflammatory markers. An urgent computed tomography scan demonstrated a 7×5cm collection near the transverse colon and a linear streak of hyperdense material near the collection. Patient had no recollection of ingestion of FB. Diagnostic laparoscopy followed by laparotomy, revealed inflammation and necrotic adipose tissue between the transverse colon and stomach walling of a purulent cavity. A 2cm shard of glass was retrieved. Examination of the posterior wall of the stomach eventually located the site of perforation. Generous washout, debridement and suture repair with omental plug was performed. She made an uneventful recovery. Conclusion Sharp objects do not pass via the pylorus easily and can cause perforation in the proximal part of gastrointestinal tract. Any features of complication mandates exploration and examination of the posterior surface of the stomach is quintessential

Case report: Epigastric abdominal pain from beverage ingestion of freshly squeezed juice of the Hardy Orange Flying Dragon plant (Poncirus trifoliata)

We report the case of a 25-year-old male who presented to the Emergency Department (ED) with severe epigastric abdominal pain immediately after ingesting a freshly squeezed beverage form of Flying Dragon Hardy Orange plant (Poncirus trifoliata). Poisoncontrol was contacted and recommended symptomatic treatment only. The patient’s painresolved while in the emergency department. Seed and rind preparations have been used as an herbal remedy in East Asia. A number of research articles point to ongoing investigations into the antiinflammatory and possible antiviral properties of Poncirus species. Freshly squeezed Poncirus trifoliata can cause significant abdominal pain.

Periorbital emphysema and pneumomediastinum following blunt orbital fracture: A case report and review of the literature

Objective: Orbital emphysema, defined as the presence of air in orbital and periorbital tissues, is a relatively uncommon clinical condition which occurs mostly following facial trauma. It can not only resolve spontaneously without any treatment, but it can also cause life threatening complications such as pneumomediastinum (PM). PM is an uncommon complication of facial fractures and is defined as the presence of air in the mediastinal space. Developing PM following blunt trauma is commonly considered as a red flag for underlying injuries, such as trachea and esophagus rupture. Therefore, other complementary diagnostic procedures, including bronchoscopy and esophagostomy, are often necessary for patients developing this condition. Case Presentation: A 31-year-old man with a history of facial and neck trauma was presented to the emergency room of our tertiary referral hospital with a complaint of right orbital swelling. On physical examination, vital signs were stable. There was a mild swelling of right upper eyelid, but no proptosis. An hour after admission, following sneezing and blowing his nose, the patient had further swelling of his right face with extension of swelling through the right side of his neck to the nipple. He also complained of dyspnea and acute severe progressive epigastric pain. Conclusion: Orbital emphysema following orbital wall fracture is typically benign and selflimited, but physicians should be aware of serious complications such as PM. Therefore, monitoring the patient is crucial and should be considered in such conditions.

Acute pancreatitis following laparoscopic sleeve gastrectomy :a case report and literature review.

recent reports showed an association between barbaric surgery and the development of acute pancreatitis.in this report we present a case of acute pancreatitis following a laparoscopic sleeve gastrectomy in a 24-year-old Indian female patient,who presented to the emergency department at Hamad General Hospital,Qatar with severe epigastric pain and persistent vomiting 13 days after laparoscopic sleeve gastrectomy.She was diagnosed with acute pancreatitis based on high level of lipasegreater than 3 times the upper limit of normal and a computed tomography of the abdomen consistant with acute pancreatitis.she treated conservatively with significant improvement in her symptoms and consequently was discharged.

Clinical presentation and surgical management of perforated peptic ulcer in a tertiary hospital in Mogadishu, Somalia: a 5-year retrospective study

BackgroundPerforated peptic ulcer is a common surgical emergency condition worldwide, which is associated with significant morbidity and mortality if early diagnosis and immediate surgical management were not carried out. Perforation occurs in roughly 5% of PUD patients during their lifetime; this study aimed to explore the wide range of clinical presentations, associated risk factors, complications, and surgical management of perforated peptic ulcer patients.MethodsA 5-year retrospective observational study on the clinical presentation and surgical management of perforated peptic ulcer is carried out in a tertiary hospital in Mogadishu, Somalia, Department of General Surgery, from January 2017 to December 2021. We included all patients undergoing operations with an intraoperative confirmed diagnosis of perforated peptic ulcer at the general surgery department. For operated patients, follow-up evaluation was performed in the outpatient department.ResultsFifty-one patients underwent an emergency operation for perforated peptic ulcer during the study period. The sociodemographic distribution of patients was 45 (88.2%) males and 6 (11.8%) females, giving a male-to-female ratio of 7.5:1. The mean age of patients was 35.5 ± 16.8 years, and the peak frequency was in the third decade. The commonest presenting symptoms were sudden onset of severe epigastric pain in 42 (82.4%) patients. Patients who presented perforated peptic ulcer within 24 h of initiation of symptoms were free from complications. Age-group and delayed presentation > 48 h after onset of symptoms were linked to postoperative complications and were statistically significant (P 0.032 and P 0.005), respectively. Four patients died (mortality rate of 7.8%). Two patients were reoperated because of the failed primary repair, and 4 patients had > 5 cm intra-abdominal abscess image-guided percutaneous drainage, and the rest were given antibiotic therapy according to peritoneal fluid culture and sensitivity results. The most common microorganism isolated was E. coli 22% and Klebsiella 11%. Other rare microorganisms (pseudomonas, Staphylococcus aureus, and Candida spp.) were identified. In half (51%) of the patients with peritoneal fluid culture, no microorganism growth was seen.ConclusionThe distribution of perforated peptic ulcer is common in the young age-group in the third decades of life. Delayed presentation of the disease is linked because most patients arrived from remote areas where proper facilities of health care and health education are not available and the patient might come to the hospital in an advanced stage of the disease. We suggest conducting further researches, health awareness related to complications over-the-counter drugs self-medication, and bad habit including smoking, and to improve health-seeking behaviors of society.