Upper Quadrant Pain Research Articles

Cholecystalgia: An Atypical Presentation of Congestive Heart Failure in a New Diagnosis of Alcohol-Induced Cardiomyopathy

Right upper quadrant (RUQ) pain is a frequent presenting symptom in the emergency department, and gallstone-induced acute cholecystitis is one of the main causes; in addition, RUQ pain can be a consequence of several other conditions. Although rare, it may also indicate cholecystalgia from gallbladder edema, which is usually related to other conditions, such as congestive heart failure (CHF), alcoholic and nonalcoholic liver cirrhosis, acute viral or drug-induced hepatitis, renal failure, and hypoproteinemia. We present a case of cholecystalgia resulting from gallbladder edema in a patient with a newly diagnosed alcohol-induced cardiomyopathy without the common CHF signs and symptoms.

Frequency Of Splenomegaly In Patients With Abdominal Ultrasound

Aims and objectives: To find out the frequency of splenomegaly in patients with abdominal ultrasound Methods: This prospective cross-sectional study was conducted at the Radiology Department of City Care Hospital in Gujranwala. A total of 65 participants with pain in the left upper quadrant were included in the study. Patients ranged in age from 21 to 75 years old, with 37 men and 28 females. Statistical analysis was then performed using SPSS. In individuals with left upper quadrant pain, the frequency of splenomegaly is calculated. Results: Out of 65 patients who presented with splenomegaly, positive cases for splenomegaly reported were 26 and negative cases were 39
 Conclusion: For detecting splenomegaly, sonography is a good modality with numerous advantages. It is nonionizing radiation free, relatively inexpensive, widely available, and simple to use, with a high diagnostic effectiveness. Patients who have complained of abdominal pain have been concluded.

Self-limited thrombotic thrombocytopenic purpura.

Our team is presenting a patient who is a 57-year -old woman with a past medical history of cerebral vascular accident. The patient presented to the emergency department with symptoms of fever, right upper quadrant pain, and emesis. Initial diagnostic studies revealed thrombocytopenia with acute kidney injury, fever, and leukocytosis. After initiation of treatment for sepsis, the patient developed a hemolytic anemia, which resolved with administration of methylprednisolone. Labs subsequently revealed ADAMTS-13 activity of 4% with positive inhibitor, which confirmed the diagnosis of thrombotic thrombocytopenic purpura (TTP) after the patient's discharge. On retrospective analysis, the case represents a unique and rapid clinical recovery from TTP without administration of therapeutic plasma exchange, rituximab, or caplacizumab.

Unusual Rapid Growth of Primary Splenic Diffuse Large B-Cell Lymphoma with Extensive Necrosis.

The primary splenic lymphoma is extremely uncommon with an incidence rate of <1% of all the lymphomas under the strict criteria for diagnosis expounded by Das Gupta et al. Clinical presentations of nonspecific symptoms are weight loss, weakness, fever, and left upper quadrant pain or discomfort due to enlarged spleen. Abdominal ultrasound and CT are the most widely used imaging modality for the assessment of lymphoma. The imaged features of splenic lymphoma are nonspecific; typical lymphoma presents as a diffusely enlarged spleen. The abdominal CT scan in our case showed a large cystic splenic mass measuring 14 cm without enhancement after contrast medium. Lymphoma is often described as an aggressive tumor because its rapid doubling time can quickly increase the size of a tumor. In our case, the tumor grew to more than 100 times its original size in 4 months. So, we present this unusual rapid growth of primary splenic lymphoma.

Impact of Early Versus Late Approach on the Management of Acute Cholangitis in an Ecuadorian Level-4 Health Center

Introduction: Acute cholangitis is a bile duct inflammation and infection resulting from complete or partial obstruction due to different etiologies, including gallstones, malignant occlusion, etc. Clinical presentation includes intermittent fever with chills, right upper quadrant pain, and jaundice. With advances in minimally invasive techniques such as endoscopic techniques, the prognosis has improved in the last 30 years with a current mortality of 2.7 to 10%. Objective: compare the impact of the early versus late approach in the management of acute cholangitis according to the TG in patients admitted to the General Surgery Department of Luis Vernaza Hospital during 2018 to 2020. Methodology: Observational, retrospective, comparative and analytical study. Data was obtained from electronic medical records, organized using Microsoft Excel ®, and analyzed using SPSS 25.0 ®. Chi-square or Fisher's test were applied to compare the clinical characteristics by type of approach or severity scale. Statistical significance was established for p- value &lt;0.05. Results: Ninety-eight patients were included, female: 54.08%. Grade II (moderate) cholangitis was the most frequent (64.29%). The main approach for biliary drainage was endoscopic (ERCP) (57.14%). A late approach (&gt; 48 hours since hospital admission) was seen in 69.4%. Mortality by type of approach presented significant differences (p = 0.029): 0% with early approach vs. 14.71% with the late approach. Discussion: Patients with acute cholangitis were mainly approached late for biliary decompression; a worrying fact since it demonstrates non- compliance of fundamental TG recommendations were early or urgent bile duct decompression is described as a mainstay in acute cholangitis. Conclusions: Hospital stay was directly proportional to the type of approach (early or late). Mortality was higher in patients who underwent a late approach, and directly proportional to the severity. An early approach should always be preferred.

Acute acalculous cholecystitis in a patient with dengue fever: A case report

and importance: Although dengue fever classically presents with fever, headache, retro-orbital pain, myalgia, arthralgia, and vomiting, it can have unusual manifestations like acalculous cholecystitis. The study highlights the importance of atypical presentations of dengue fever in suspecting dengue earlier, especially during outbreaks. Herein, we report a case of a 29 years old female who presented with fever for 5 days which was associated with headache, body ache, vomiting, and abdominal pain in the right hypochondriac region. Lab results came positive for dengue NS1 antigen, and ultrasonography showed features suggestive of acalculous cholecystitis. She was managed conservatively after which her symptoms resolved gradually. Acute acalculous cholecystitis in dengue could be due to increased vascular permeability leading to edematous thickening of the gall bladder wall. It should be suspected if a patient presents with fever, right upper quadrant pain, abnormal liver function tests, and thickened gall bladder wall without stones on abdominal ultrasonography. Acute acalculous cholecystitis is an atypical presentation of dengue fever. Awareness of atypical presentations of dengue helps in identifying dengue earlier and preventing complications.

Survival After Ruptured Spontaneous Hepatic Subcapsular Hematoma Following Heparin Initiation for Submassive Pulmonary Embolism

Hepatic subcapsular hematomas (HSHs) are rare outside the context of trauma, endoscopic retrograde cholangiopancreatography, and pregnancy. Ruptured HSHs present with abdominal pain and hypotension, with high mortality. We present the patient case of a 69-year-old man readmitted with deep venous thrombosis and pulmonary embolus after uncomplicated laparoscopic prostatectomy. Soon after receiving heparin, he experienced acute abdominal distention and right upper quadrant pain. A large ruptured subcapsular hematoma with focal active bleeding was identified and eventually controlled surgically. We highlight that HSHs can complicate anticoagulant therapy. Awareness and prompt intervention can be lifesaving.

S101 Colosplenic Fistula in Inflammatory Bowel Disease: A Scoping Review

Background: A colosplenic fistula is an extremely rare complication of Crohn’s disease (CD) first described in a 1985 case report that remains relatively poorly understood due to its infrequent incidence. With only a few colosplenic fistulas reported worldwide, the diagnosis and management of patients with colosplenic fistula is vague. Hence, we described a review of patients with colosplenic fistula due to inflammatory bowel disease (IBD) to summarize colosplenic fistula etiology, clinical features, diagnosis, management, and prognosis to help clinicians gain a better understanding of this unusual complication and provide an aid if it were to be encountered. Methods: We conducted a systematic search of articles published from 1946 to June 2022 in Ovid MEDLINE, Ovid EMBASE, Scopus, Web of Science, and Wiley Cochrane Library to identify patients with colosplenic fistulas. Studies with etiology of IBD were included. Results: The search strategy retrieved 141 references and a total of 4 studies reporting 4 patients with colosplenic fistula in the setting of IBD were analyzed. Most patients (75%) were male, with a median age of 33 years. All 4 (100%) patients had prior diagnosis of CD, with a median time of 12.5 years since diagnosis. Two patients had extraintestinal manifestations of IBD (uveitis, erythema nodosum, ankylosing spondylitis). Three patients were on long-term sulfasalazine and 2 (50%) were on corticosteroids. Etiology: Our review revealed that patients with CD formed a fistula tract from their colon to the adjacent spleen due to chronic, transmural inflammation and ulceration. Active inflammation was observed in the adjacent colon on pathology or endoscopy. Clinical features: Most patients presented with complaints of recurring fever, leukocytosis, and left upper quadrant pain or discomfort. Diagnosis: The most widely-used and effective diagnostic imaging was the computed tomography (CT) scan. CT with intravenous (IV) contrast helped identify splenic lesions and colonic thickening, while enteral contrast was useful to identify fistula tract. Chest X-rays, plain abdominal films, and colonoscopy were not essential in diagnosing a colosplenic fistula. Use of magnetic resonance imaging (MRI) was not reported in any case. Management: Most patients were promptly treated with IV fluid and broad-spectrum antibiotics. Only one patient was started on IV steroids. Most patients underwent surgical intervention of colosplenic fistulas with splenectomy and segmental resection of the affected col1on. One case offered temporary diverting loop ileostomy with plans for future splenectomy and colectomy. Prognosis: Symptoms resolved with surgical intervention. No postoperative complications or mortalities were reported. Conclusion(s): Our review revealed that patients with Crohn’s disease can form a fistula tract from their diseased colon to the adjacent spleen due to transmural inflammation. Diagnosis can be achieved with a CT scan with enteral and/or intravenous contrast. Most colosplenic fistulas can be successfully treated with laparotomy, splenectomy, and resection of the affected colon with low rate of postoperative complications. Our pooled analysis of available colosplenic fistula cases may serve as an aid for diagnosis and management of this rare entity.

A Rare Cause of Abdominal Pain After Transjugular Intrahepatic Portosystemic Shunt

Question: A 77-year-old woman presented with progressive dyspnea for 4 months. The patient was diagnosed with primary biliary cirrhosis more than 1 years ago and was ever since on ursodeoxycholic acid medication. Recurrent ascites occurred at least 6 months before diagnosis and was responsive to diuretics. Beyond these, she did not experience any onset of gastrointestinal bleeding or hepatic encephalopathy. Laboratory examination indicated the decreased hemoglobin (10.7 g/dL, normal value [nv]: 11.5–15 g/dL), leukocyte (2.85 × 103/μL, nv: [3.5–9.5] × 103/μL), and platelet counts (53 × 103/μL, nv: [100–300] × 103 /μL), increased alkaline phosphatase (195 IU/L, nv: 50–135 IU/L) and glutamyl transpeptidase (149 IU/L, nv: <45 IU/L), and normal aminotransferase and total bilirubin levels. Chest computerized tomography showed a large amount of right-sided pleural effusion. Pleural fluid tests revealed an uncomplicated hepatic hydrothorax with serum-pleural fluid albumin gradient >1.1 g/dL and polymorphonuclear cell count <500 cells/μL. However, the patient did not show significant improvement of symptoms with dietary sodium restriction and adequate-dose diuretics. Considering the existence of hepatic hydrothorax refractory, transjugular intrahepatic portosystemic shunt (TIPS) was performed thereafter. The portal pressure gradient decreased from 18 mm Hg–7 mm Hg after stent implantation. The interventional procedure was uneventful and no complication occurred during the processes. Postoperatively, the patient experienced slight dull pain in the right upper abdomen, and the symptom intensified gradually despite giving analgesic medication in the following 36 hours. Abdominal examination showed tenderness in the right upper quadrant and percussion pain in the liver area. Liver function tests revealed obviously elevated alanine aminotransferase (1147 IU/L, nv: <50 IU/L) and aspartate aminotransferase (1582 IU/L, nv: <40 IU/L), mildly elevated total bilirubin (1.73 mg/dL, nv: 0.29–1.64 mg/dL). Blood routine showed the change of hemoglobin (11.4 g/dL) and leukocyte (6.67 × 103 /μL). Abdominal computerized tomography showed multiple strips of low-density shadows along the blood vessels and scattered low-density nodules in the liver parenchyma (Figure A, white arrowheads). What is the most likely diagnosis? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Abdominal contrast-enhanced computerized tomography (CECT) showed diffuse linear hypodensity around portal vein branches and multiple low-density nodules in the liver, but no obvious enhancement was observed (Figures B and C, white arrowheads). These imaging findings were absent from hepatic vein and intrahepatic inferior vena cava (Figure D). According to the history of hepatic invasive procedure, laboratory findings, and CECT presentation, intrahepatic lymphangiectasia was suspected. After a short course of nonsteroidal anti-inflammatory drug therapy, her symptoms completely resolved and transaminases gradually returned to normal levels. Follow-up CECT scans at 30 days showed complete resolution of the periportal low-density areas (Figures E and F). Intrahepatic lymphangiectasia (IHL), manifested as dilated hepatic lymphatics and related lymphedema, is caused by either increased lymph flow or lymphatic obstruction.1Pupulim L.F. Vilgrain V. Ronot M. et al.Hepatic lymphatics: anatomy and related diseases.Abdom Imaging. 2015; 40: 1997-2011Crossref PubMed Scopus (26) Google Scholar Liver transplantation, blunt abdominal trauma, hepatic malignant neoplasms, and congestive hepatomegaly due to cardiac decompensation are the most common underlying etiology of IHL.2Koslin D.B. Stanley R.J. Berland L.L. et al.Hepatic perivascular lymphedema: CT appearance.AJR Am J Roentgenol. 1988; 150: 111-113Crossref PubMed Google Scholar “Periportal halo,” characterized by hypodense appearance on computed tomography and hyperintense appearance on T2-weighted magnetic resonance images, has important clinical significance in the diagnosis of IHL.3Karcaaltincaba M. Haliloglu M. Akpinar E. et al.Multidetector CT and MRI findings in periportal space pathologies.Eur J Radiol. 2007; 61: 3-10Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Presence of hypodense appearance on both sides of the portal venous system can allow differentiation from biliary dilatation.3Karcaaltincaba M. Haliloglu M. Akpinar E. et al.Multidetector CT and MRI findings in periportal space pathologies.Eur J Radiol. 2007; 61: 3-10Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar In fact, IHL could be an overlooked complication of TIPS that has never been previously reported. Iatrogenic injury during a TIPS procedure may interrupt lymphatic vessels and initiate coagulation at the injury site, and thrombus/microthrombus provisionally compresses and blocks the hepatic lymphatic system. Once the thrombus/microthrombus dissolves, the occluded lymphatics are recanalized and IHL could be spontaneously resolved. In conclusion, IHL is a procedure-related complication of TIPS that should not be neglected. Periportal halo by CECT provides valuable evidence for both diagnosis and differential diagnosis. Further studies with a larger sample size are necessary to investigate the morbidity and natural course of IHL after TIPS.

Angiomatoid Fibrous Histiocytoma with EWSR1 Rearrangement in an Unusual Location

Abstract Introduction/Objective Angiomatoid fibrous histiocytoma (AFH) is a rare mesenchymal neoplasm most often arising in the superficial extremities of children and young adults. AFH can mimic clinical, histologic, and radiologic presentation of several different tumors, therefore diagnosis can be quite challenging. Methods/Case Report We report the case of a 32-year-old woman with no significant medical history who presented with three days of right upper quadrant pain. Radiologic studies showed a 2.3 centimeter right lower lobe soft tissue nodule abutting the right lower lobe bronchus. Results (if a Case Study enter NA) Subsequent lobectomy with mediastinal lymph node dissection was performed. Histopathologic examination of the right middle and lower lobes revealed a fibrohistiocytic appearing neoplasm with bland nuclear features and brisk associated lymphoplasmacytic and histiocytic infiltrate. Given the suspicion for AFH, fluorescent in situ hybridization for EWSR1 and FUS were performed at an outside facility with detection of EWSR1 gene rearrangement supporting the diagnosis of AFH. Conclusion AFH is a rare soft tissue neoplasm that is often indolent but intermediate in potential given the rare possibility of metastasis. While most common in superficial extremities, increasing unusual anatomic sites are being reported. Histologically, the tumor can show a spectrum of morphologic patterns including nodules to sheets of often monomorphic bland, spindle or ovoid cells in an inflammatory background and with associated fibrous pseudocapsule. Three characteristic chromosomal translocations have been identified: EWSR1-CREB1, EWSR1-ATF1 and FUS- ATF1. Treatment is wide surgical excision or radiotherapy if unresectable. The differential diagnosis can be broad with a spectrum from reactive, benign lesions to malignant neoplasms, including a variety of sarcomas.

Endoscopic Ultrasound-Guided Fine Needle Aspiration of Solid Pseudopapillary Neoplasm of the Pancreas in a Male Patient: A Rare Report

Abstract Introduction/Objective Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare pancreatic tumor with low malignant potential composed of poorly cohesive epithelial cells forming solid and pseudopapillary structures. It develops almost exclusively (90%) in young females (mean age: 28 years, range: 7-79 years), while it rarely develops in men (mean age: 35 years, range: 25-72 years). Methods/Case Report Herein we report an unusual presentation of SPN in a 59-year-old male who presented with severe nausea, vomiting, right upper quadrant pain, and weight loss. Computed tomography imaging revealed a large pancreatic head/uncinate process mass. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) biopsies showed abundant monomorphic cuboidal tumor cells arranged in loosely cohesive groups and singly dispersed cells. A few tumor cells are arranged in multiple layers around vascular structures expanded by metachromatic hyaline material. The tumor cells have thin cytoplasm, indistinct cell borders, round to oval nuclei, finely dispersed chromatin, and indistinct nucleoli. No mitosis, tumor necrosis, or other high-grade features are identified. Immunohistochemical stains are performed on cell block material and the tumor cells are positive for beta-catenin (nuclear), cyclin D1, vimentin, CD10, synaptophysin, and CD56, and negative for DOG-1, tryptase, and AE1/AE3. Ki-67 proliferative index is less than 2% in tumor cells. The cytomorphologic features and immunoreactivity are diagnostic of solid pseudopapillary neoplasm. We diagnosed SPN preoperatively by EUS-FNA using cytopathologic and immunochemical characteristics, which are very helpful to differentiate SPN from acinar cell carcinoma, neuroendocrine tumor, pancreatoblastoma, or other pancreatic tumors. Results (if a Case Study enter NA) NA Conclusion EUS-FNA can be used as a gold standard method to characterize and diagnose SPN preoperatively and help to guide clinical management.

PSAT038 A Case of Spontaneous Atraumatic Unilateral Adrenal Hemorrhage

Abstract Background Adrenal hemorrhage is a rare disorder with an incidence of 0.1 to 1% for which a cause is identified in most cases. It is usually classified as traumatic or atraumatic, unilateral or bilateral and can result in serious consequences such as adrenal crisis and death if not diagnosed and treated properly. We describe a patient with an atraumatic unilateral adrenal hemorrhage without a known coagulopathy Case presentation: A 51-year-old man with history of COPD and Reynaud's phenomenon presented to the hospital for severe right upper quadrant pain. CT of the abdomen demonstrated a right adrenal hemorrhage of 5.2×4.0×2.6 cm in size, for which Endocrinology was consulted. The patient denied recent trauma or anticoagulation use. Physical examination exhibited generalized abdominal tenderness, without hypotension, or symptoms of acute adrenal insufficiency. Biochemical evaluation showed an AM Cortisol level of 14.3 ug/dL (4.2 - 22.4 ug/dL) and ACTH 67.1 pg/mL (7.2 - 63.3 pg/mL). MRI abdomen showed a decrease in size of the hemorrhage measuring 3.1×1.7×5.2 cm. He was referred to Hematology/Oncology to evaluate for coagulopathy which was unrevealing. About one month from hospital discharge, the patient reported voice hoarseness and was diagnosed with moderately differentiated keratinizing squamous cell carcinoma of larynx. Ten months later PET-CT scan showed hypermetabolic laryngeal mass with bilateral cervical lymphadenopathy without evidence of adrenal gland metastasis with resolution of adrenal hemorrhage, indicative that the hemorrhagic episode is unrelated to this newly diagnosed malignancy. Discussion Adrenal hemorrhage is a rare disorder that overall is associated with a 10-20% mortality rate, it is usually classified as traumatic and no traumatic. Most times it is caused by secondary disorders such as trauma, surgery, anticoagulants, infections, but in rare instances is idiopathic. Clinical manifestations of adrenal hemorrhages vary depending on extension of the hemorrhage and early diagnosis is crucial for better outcomes. As per current guidelines, assessment for adrenal insufficiency including hemodynamics, biochemical evaluation and imaging is paramount. To date, clear etiology of primary adrenal hemorrhage is lacking. This case demonstrated an unusual presentation of idiopathic unilateral adrenal hemorrhage without evidence of adrenal insufficiency. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Cystic artery pseudoaneurysm: an uncommon complication of a common disease

Cystic artery pseudoaneurysm, though rare, is a notable cause of upper GI bleed. Here, we report an unusual presentation of upper gastrointestinal haemorrhage due to a cystic artery pseudoaneurysm secondary to acute cholecystitis in a 54-year-old male. Initial imaging revealed cholelithiasis with evidence of acute cholecystitis. Further investigations with Doppler ultrasound and CT suggested evidence of a cystic artery pseudoaneurysm with hyperdense contents in the gall bladder suggesting blood products. Taking into consideration the risk of hemorrhage during the procedure, the patient was taken up for open cholecystectomy. This case emphasizes the need for a high level of awareness of pseudo-aneurysmal disease and inclusion of cystic artery pseudoaneurysm as one of the differential diagnosis for a patient presenting with recurrent upper quadrant pain, jaundice and melena or hemobilia.

Experience on the surgical management of biliary stones in Sokoto, North West Nigeria

Background: Cholelithiasis are relatively rare in Nigeria and Africa at large. However, recently the incidence has been reported to be on the rise. We present a ten-year review of our experience in managing gallstones to highlight the recent trends in our practice.Methods: This is a 10-year retrospective study on patients who were managed for gall bladder disease in the Usmanu Danfodiyo university teaching hospital Sokoto from August 2011 to July 2021. The biographic data, clinical features, radiologic, operative findings, histologic findings and outcome of treatment were analyzed with IBM SPSS 25.Results: There were 82 patients over the period of the study comprising of 18 (22%) males and 64 females (78%). Their ages range was 17 to 60 years with a mean of 37.59 years ±11.02. All patients had right upper quadrant pain as the main complaint with 24 patients (29.3%) having associated epigastric pain and 14 patients (17.1%) presented with jaundice. Preoperative ultrasound (USS) diagnosis was in keeping with intraoperative diagnosis in 97.6%. All patients had cholecystectomy out of which 62 patients (75.6%) had open cholecystectomy while 20 patients (24.4%) had laparoscopic cholecystectomy. There was no hospital mortality, the average hospital stay was 8.2 days following open cholecystectomy however this was shorter, 4.5 days for laparoscopic procedure.Conclusions: The prevalence of gallstones is still comparatively low when compared to the western world. Ultrasonography is very sensitive imaging modality. Laparoscopic cholecystectomy is safe and superior to open surgery in our environment.

Attempting to Bridge the Gap: Comparison of Clinical Characteristics, Ultrasound, and Final Surgical Pathology of Emergency Department vs Outpatient Clinic Patients Undergoing Cholecystectomy

INTRODUCTION: After emergency department (ED) discharge for symptomatic cholelithiasis, many patients fail the outpatient clinic (OC) algorithm. Our previous study showed that clinical diagnosis is better at predicting cholecystitis than ultrasound (US) in ED patients. This study compares clinical presentation (CP), US, and final surgical pathology (FSP) in the ED and OC patients undergoing cholecystectomy. METHODS: This retrospective chart review compared ED and OC patients at a single institution with right upper quadrant pain (RUQ) and cholelithiasis who underwent cholecystectomy. CP including duration of pain and Murphy’s sign, laboratory values, US, and FSP were compared. RESULTS: A total of 607 patients underwent cholecystectomy: 299 OC and 308 ED. ED patients were younger, more likely to have RUQ pain >4 hours (90% vs 27.5%), positive Murphy’s sign, leukocytosis, and positive US (30% vs 5% (p < 0.0001)). Although, FSP revealed chronic cholecystitis in a majority of patients including 56% and 72% of ED and OC, respectively, ED patients were more likely to have acute cholecystitis (39.3% vs 4.7%) and less likely to have isolated cholelithiasis (4.6% vs 23% [p < 0.0001]). Among patients with an acute component, RUQ pain >4 hours was more frequently positive than US in both ED (p < 0.0001) and OC (p < 0.02; Table 1). Table 1. - Demographic and Clinical Characteristics Variable Inpatient308 (50.7) Outpatient299 (49.3) p Value Age, mean (+SD) 40.3 (14.5) 47.5(28.0) 0.0001 Pathology, n (%): acute and chronic cholecystitis 76 (24.7) 5 (1.7) <0.0001 Acute cholecystitis 45 (14.6) 10 (3.4) Chronic cholecystitis 173 (56.2) 216 (72.2) Cholelithiasis 14 (4.6) 68 (22.7) Pain history: pain duration ≥ 4 h 276 (90.2) 82 (27.7) <0.0001 Provider + Murphy’s sign 100 (33.3) 18 (6.1) <0.0001 Laboratory tests, n (%): white blood cells >11,000 148 (48.1) 22 (8.2) <0.0001 US findings positive 93 (30.2) 12 (5.0) <0.0001 CONCLUSION: CP and duration of pain is a better predictor than US for cholecystitis in both OC and ED populations. Although chronic cholecystitis on FSP is prevalent in both populations, ED presentation likely represents an acute exacerbation of chronic disease, despite negative US findings, and urgent inpatient cholecystectomy is recommended.

S1932 Acute Pancreatitis After Liver Biopsy: Clots or Stones?

Introduction: Percutaneous liver biopsy is a frequently utilized tool in the diagnosis of many liver diseases including metastatic liver lesions. Bleeding complications occur in 1% of cases and hemobilia is rare. Hemobilia causing acute pancreatitis after percutaneous liver biopsy is extremely rare with approximately 20 reported cases in literature. Symptoms include right upper quadrant pain, nausea, jaundice, hematemesis, hematochezia or melena. We present an interesting case of a woman who developed acute pancreatitis secondary to hemobilia after liver biopsy. Case Description/Methods: A 60-year-old female with recurrent high-grade serious peritoneal cancer and recent metastases to liver was admitted for acute pancreatitis. Patient presented with nausea and right upper quadrant pain that started after percutaneous liver biopsy one day prior. Labs notable for Hgb 10.4, lipase > 3000, amylase 3349, total bilirubin 3.6, direct 3.3, AST 631, ALT 482, alkaline phosphatase 240. CT A/P showed diffuse swelling of pancreas with fluid and mesenteric fat stranding suspicious for acute pancreatitis. Given liver enzyme elevation with mixed hepatocellular and cholestasis pattern, abdominal MRI was obtained to evaluate any biliary obstruction. MRI showed mildly prominent CBD at 0.8 cm with debris in distal CBD, cystic duct, and gallbladder indicative of hemorrhagic products. No hematoma noted in the liver parenchyma. Patient underwent ERCP with sphincterotomy and clots were cleared from the duct with balloon sweep (Figure). Discussion: Hemobilia, described as upper GI bleeding within the biliary tree has a reported incidence of less than 0.059% after percutaneous liver biopsy. It can occur within a few hours or several days later, with an average interval of five days. Although rare, hemobilia can lead to acute pancreatitis in a mechanism similar to gallstone pancreatitis. Excessive bleeding and increased clot formation cause obstruction in the biliary tree and impedes drainage from the ampulla which in turn triggers pancreatitis. Diagnosis can be made by ultrasound, angiography, ERCP, or MRCP. Treatment depends on the extent of bleeding and includes conservative management to advanced interventions-hepatic angiography with arterial embolization, ERCP with sphincterotomy or stent placement. Thus, our case highlights importance of recognizing hemobilia as an etiology for acute pancreatitis after percutaneous liver biopsy.Figure 1.: Removal of blood clots from bile duct by balloon sweep via ERCP

S2838 Giant Choledocholithiasis Treated by Direct Cholangioscopy With Gastroscope and Electrohydraulic Lithotripsy

Introduction: The extraction of very large bile duct stones can pose significant challenges. In the following report, we describe the use of direct cholangioscopy with a gastroscope to facilitate electrohydraulic lithotripsy (EHL) and remove a giant common bile duct (CBD) stone. Case Description/Methods: A 71-year-old female presented to the emergency department with 3 months of intermittent right upper quadrant pain. She denied having nausea, vomiting, or loss of appetite, and physical examination was unremarkable. A CT of the abdomen and pelvis was performed, which revealed a large 9 x 4 x 4 cm hyperdense mass underneath the liver, adjacent to the gallbladder. An endoscopic ultrasound showed a very large radiopaque filing defect in a very dilated bile duct, and a cholangiogram during endoscopic retrograde cholangiopancreatography confirmed a very large stone occupying the entire CBD. To remove the stone, a biliary sphincterotomy was performed, and the bile duct orifice was dilated with a 12-15 mm balloon. Next, the duodenoscope was replaced with a standard adult gastroscope. The gastroscope was guided through the major papilla into the bile duct, and EHL was used for stone fragmentation. Large stone fragments were removed under direct visualization using a wire basket through the gastroscope. Two sessions of EHL via direct cholangioscopy with the gastroscope were required to achieve complete bile duct clearance. (Figure) Discussion: Choledocholithiasis is the presence of a gallstone in the CBD, occurring in up to 20% of patients with cholelithiasis. While smaller stones (< 1.5 cm) can often be removed intact via endoscopic sphincterotomy and sphincteroplasty, larger stones can be more difficult to remove and may require lithotripsy (mechanical, EHL or laser). In rare instances and depending on local expertise, surgery is also considered. Nevertheless, cholangioscopy using SpyGlass and EHL is the most common technique for bile duct stone fragmentation. In this case, due to the large size of the CBD and giant size of the stone, we decided to use direct cholangioscopy via a standard adult gastroscope and EHL. Scope stability and visibility within such a large bile duct was significantly superior to SpyGlass, and irrigation and suction through the gastroscope allowed for high quality EHL and removal of large debris. This technique can only be applied to bile ducts that are dilated more than 15 mm in diameter and requires advancing the gastroscope into the distal bile duct using a free-handed technique.Figure 1.: Computed tomography of the abdomen and pelvis revealing a large 9 x 4 x 4 cm bile duct stone.

S2829 ERCP via EUS Guided Duodenojejunostomy for a Biliary Stricture After Roux-en-Y Hepaticojejunostomy

Introduction: Patients with a Roux-en-Y hepaticojejunostomy (RYHJ) present a unique challenge when endoscopic retrograde cholangiography (ERC) is required. Standard approaches range from a surgical approach involving laparoscopic assistance to device assisted enteroscopy, with transoral approaches generally being variably successful, due to anatomy, length of intestinal limbs after surgery, and limitations in available accessories for use in device assisted enteroscopy. Here, we report the endoscopic use of a LAMS to create a duodenojejunostomy (DJ), thereby enabling ERC in a patient with RYHJ. Case Description/Methods: A 46-year-old woman status post cholecystectomy complicated by common bile duct injury necessitating RHYJ and prior anastamotic strictures, presented with recurrent self-limited cholangitis. She presented to clinic with intermittent episodes right upper quadrant pain, and fever which were treated conservatively with antibiotics. MRCP demonstrated stricture of the hepatic duct near the anastomosis [1]. Device assisted endoscopy was performed, but the anastomosis was unable to be reached. After discussing endoscopic, IR, and surigcal options we proceeded with EUS guided interventions given the anticipated need for recurrent interventions for a biliary stricture. EUS demonstrated mild intrahepatic dilation with limited access points for hepaticogastrostomy. The bile duct and hepaticojejunostomy were visualized from the bulb with small bowel adjacent to the anastomosis [2]. The jejunum was accessed using a 19 G FNA needle, and bile was aspirated to confirm intraluminal location. The jejunum was filled with 200 mL of sterile water and contrast [3]. A 15 mm x 10 mm AXIOS was then deployed in good position, creating a DJ, which was confirmed fluoroscopically and endoscopically [4]. Contrast was then injected through the stent to exclude a leak. 4 weeks later, ERCP was performed via the DJ [5]. Cholangioscopy was performed which showed some edematous bile duct mucosa without findings concerning for malignancy [6]. Biopsies and brushings were performed and three plastic stents were placed. The patient tolerated the procedure well, the tissue was benign and the patient has had resolution of her cholangitis symptoms. Discussion: In conclusion, we report a novel use of LAMS enabling ERC in patient’s status post RHYJ which allows easy access for repeat interventions and avoids the difficulties and limitations of device assisted enteroscopy ERCP.Figure 1.: Image 1. MRCP showing hepatic duct stricture near the anastomosis Image 2. EUS with bile duct adjacent to fluid filled jejunum Image 3. EUS with FNA needle accessing hepaticojejunostomy Image 4. EUS with LAMS deployed from duodenum to jejunum Image 5. Matured duodenojejunostomy Image 6. Cholangioscopy demonstrating edematous mucosa.

S1907 A Rare Case of Type 1 Choledochal Cyst With Type C Anomalous Pancreaticobiliary Maljunction in a 52-Year-Old Patient

Introduction: Choledochal cysts are rare anomalies of the bile duct that generally present in childhood but can rarely be delayed until adulthood in 20% of cases. They are often diagnosed incidentally or present with acute pancreatitis or cholangitis. We report a case of a type 1 choledochal cyst (T1CC) and type C anomalous pancreaticobiliary maljunction (PBM), successfully managed by a multidisciplinary approach. Case Description/Methods: A 52-year-old woman presented with right upper quadrant pain, jaundice and vomiting. Labs revealed elevated lipase, bilirubin, AST, ALT and alkaline phosphatase. A CT of the abdomen showed no gallstones but a marked dilation of extrahepatic bile duct with a transition point in the distal intrapancreatic portion (Figure a). An endoscopic retrograde cholangiopancreaticogram (ERCP) showed fusiform dilation of the CBD consistent with T1CC (Figure b). Spyglass cholangioscopy revealed focal stenosis in the distal CBD joining above the ventral pancreatic duct opening within the long common channel, suggestive of type C anomalous PBM (Figure c). A plastic biliary stent was placed into the CBD. EUS guided fine needle biopsy of the stricture showed no evidence of malignancy. Her clinical course was complicated by multiple admissions due to stent occlusion. After multidisciplinary discussion, the patient underwent choledochal cyst resection with hepaticojejunostomy, cholecystectomy and biliary reconstruction. Intraoperative gallbladder specimen revealed poorly differentiated adenocarcinoma with plan for chemotherapy. Discussion: Choledochal cysts are a rare congenital anomaly characterized by enlargement of the CBD. There are five types of choledochal cysts (Table). Etiology remains unclear and while some believe these cysts are congenital in nature, others propose they arise from anomalous PBM. PBM is defined as congenital malformation in which the pancreatic and bile duct join outside the duodenal wall forming a long common channel. This leads to reflux of biliary secretions leading to chronic inflammation, increasing the risk of developing cholangiocarcinoma and gallbladder cancer, as seen in our patient. Placement of biliary stents can temporarily alleviate symptoms, but surgical excision is the definitive treatment. Our case highlights the importance of including type 1 choledochal cyst in the differential diagnosis even in adult patients with a significantly dilated CBD. A thorough endoscopic and radiological work up should be done to prevent progression to malignancy.Figure 1.: A. CT of the abdomen showing marked dilatation of extrahepatic bile duct with a transition point in the distal intrapancreatic portion. B. Cholangiogram showing Type 1 Choledochal Cyst and Type C Anomalous Pancreaticobiliary Maljunction. C. Spyglass cholangioscopy showing JagwireTM within the CBD (yellow arrow) revealing focal stenotic CBD joining the common channel just above the ventral pancreatic duct (blue arrow). Table 1. - Types of Choledochal Cysts Type Description Type I Fusiform dilation of the CBD Type II Bile duct diverticulum Type III Saccular dilation of the intraduodenal portion of the CBD Type IVa Multiple cysts at intra and extrahepatic ducts Type IVb Multiple cysts at extrahepatic ducts only Type V Fusiform or saccular cystic dilation of the intrahepatic bile duct

S348 Creating Your Own Paths: EUS-Guided Transjejunal Gallbladder Drainage and ERCP, Cholecystoscopy, and Electrohydraulic Lithotripsy for Choledocholithiasis and Cholelithiasis in a Patient With Roux-en-Y Gastric Bypass

Introduction: Treating choledocholithiasis and cholelithiasis in patients with altered gastrointestinal anatomy is a challenge given the difficulty in accessing the biliary tract using conventional endoscopic techniques. Endoscopic ultrasound (EUS) directed transgastric ERCP (EDGE) represents a novel solution to this challenge. It allows access to the excluded stomach allowing safe performance of ERCP and interventional EUS procedures including gallbladder drainage. Case Description/Methods: A 61-year-old man with a history of morbid obesity, Roux-en-Y gastric bypass, and bowel perforation complicated by extensive resection and short gut syndrome, as well as rheumatoid arthritis and chronic kidney disease, presented to clinic for intermittent right upper quadrant pain, nausea, and vomiting. Imaging revealed large cholelithiasis, choledocholithiasis, and biliary dilatation with gallbladder distention. Given his high surgical risk and symptomatic biliary disease, EDGE and EUS-guided management of the large gallstone was planned. The first step was to create a jejunogastrostomy (JG) which was performed using EUS-guided 15mmx10mm lumen-apposing metal stent (LAMS) deployment through the Roux limb into the excluded stomach. ERCP was performed 4 weeks later finding choledocholithiasis, and complete removal of two stones was accomplished. This was followed by EUS-guided gallbladder drainage via JG and successful creation of a cholecystoduodenostomy (CDS) using the 15mmx10mm AXIOS stent system. Direct cholecystoscopy, electrohydraulic lithotripsy and removal of a large gallstone were then performed. Both LAMS from JG and CDS were removed at the end of the procedure. Follow-up upper GI series at 6 weeks showed complete closure of the jejunogastrostomy fistula. Discussion: The EDGE approach provides access to the excluded remnant stomach enabling ERCP and interventional EUS procedures such as gall bladder drainage. In this case, we demonstrate the utility of this procedure in enabling access to the gallbladder and permitting direct cholecystoscopy, electrohydraulic lithotripsy, and removal of a large symptomatic gallstone, thus avoiding long-term percutaneous drains and recurrent symptoms, in addition to the risk of cholecystitis or Mirizzi syndrome from a large gallstone. Watch the video at https://tinyurl.com/ACGAbstractS348