The Diagnostic Yield of Endoscopic Ultrasound in Asymptomatic Patients with Unexplained Dilated Common Bile Duct, or Double Duct Sign with Normal Transaminase a Retrospective Study from a Single Urban-based University Endoscopy Center.

Background: Common bile duct dilatation alone or double duct sign (both CBD and dilated pancreatic duct dilatation) and abnormal liver enzymes are highly predictive of biliary disease. This can be identified on ultrasound (US), CT scan, and/or magnetic resonance cholangiopancreatography (MRCP). Unexplained dilatation on imaging might warrant endoscopic ultrasound (EUS) to identify any occult causes. Supporting literature about the importance of using EUS in these conditions is evolving with no clear evidence-based approach to evaluate asymptomatic dilated ducts.We aim to investigate the diagnostic yield of EUS in unexplained CBD dilatation or double duct sign with normal liver enzymes. Method: A retrospective data analysis was conducted from January 2015 to October 2021 on asymptomatic patients with a dilatated CBD of 7 mm or more and 9 mm if the patient had a cholecystectomy history or double duct sign with normal liver enzymes. Result: 32 EUS procedures were indicated for unexplained dilated CBD or double duct sign on imaging with normal liver enzymes. 23 had CBD dilatation alone (72 %), and 9 had a double duct sign (28 %). 20 of the included patients were females (63 %), and 12 were males (37 %), with a mean age of 63.8 ± 17 and 68.2 ± 14 years old, respectively (p = 0.424). The diagnosis after EUS in CBD dilatation alone showed a yield of 56 % as follow; no pathology in 10 (44 %), sludge in 9 patients (39 %), CBD stone in 3 (13 %), malignant stricture in 1 (4 %) (Fig. 1). On the other hand, EUS in those with double duct signs showed a diagnostic yield of 55 %; no pathology in 4 (45 %), pancreatic head adenocarcinoma in 3 patients (33 %), Biliary stone in one patient, and malignant CBD stricture in one patient (11 % each) (Fig. 2). Conclusion: Unexplained CBD dilatation or Double duct sign on imagining in patients with normal liver enzymes should warrant further investigation with EUS to avoid missing serious pathological conditions such as stones, sludge, stricture, or a mass.

Salmonella aortitis successfully treated with antibiotics without surgery.

Aortitis is an inflammation of the aorta that is linked to large vessel vasculitis and other rheumatologic cases. Less often, an infectious etiology of aortitis is diagnosed. Aortitis is associated with high mortality and morbidity and requires a high index of suspicion. Here we present a rare case of aortitis secondary to Salmonella Septicemia treated with six weeks of antibiotics in the hospital without and remained asymptomatic and inflammatory markers normalized at 2 weeks follow up (ESR, CRP, and WBCs).

Re-Educating Residents About Non-Invasive Colorectal Cancer Screening: An Approach to Improving Colon Cancer Screening Compliance.

BACKGROUND: Colorectal cancer is the third leading cause of cancer death; therefore early detection by screening is beneficial. Residents at a clinic in NJ, USA were not offering other forms of colon cancer screening when patients refused colonoscopy, which lead to the creation of the quality improvement project. METHODS: Residents practicing at the clinic were given an anonymous survey determining which method of colon cancer screening they used and which alternative method they offered when patients refused the original method. The residents were educated about all methods of colon cancer screening and the residents were resurveyed. RESULTS: A total of 64% of residents offered less invasive testing when colonoscopy was refused. Six months after education, 95% of residents offered less invasive testing when colonoscopy was refused. CONCLUSIONS: Early detection and removal of polyps by colonoscopy reduce the risk of cancer development. Colonoscopy is the gold standard for colon cancer screening; however other less invasive modalities are approved. This quality improvement project lead to offering the fecal immunochemical test or fecal occult blood test once patients refused colonoscopy at the clinic, increasing the number of patients receiving colorectal cancer screening, and thus providing better medical care.

Chronic Pancreatitis Leading to Pancreatogenic Diabetes Presenting in Diabetic Ketoacidosis: A Rare Entity.

Diabetes mellitus type 3c (DM3c) is an uncommon cause of diabetes due to pancreatic pathology. Its prevalence reaches about 5-10% among all diabetics in the Western world, largely due to chronic pancreatitis. DM3c occurs due to the destruction of the endocrine islet cells. Glucagon and insulin levels are both decreased due to the destruction of alpha and beta cells, respectively. This makes the development of diabetic ketoacidosis (DKA) a rare process in patients with DM3c because of the destruction of glucagon, which facilitates ketone production. We report a case of DM3c presenting with DKA. The patient presented with a history of chronic pancreatitis and was on pancreatic enzyme replacement therapy. Prior records revealed that HbA1c levels were normal. Prior computed tomography evidence revealed diffuse pancreatic calcifications. The patient was admitted for DKA, presenting with hyperglycemia, blood glucose of 703 mg/dL, bicarbonate of 16 mmol/L, ketones in the urine and acetone in the blood. The patient's anion gap corrected for albumin was 27. The patient was admitted to the medical intensive care unit where he was treated with intravenous (IV) insulin and IV hydration. Once the anion gap closed, the patient was transitioned to long-acting insulin. HbA1c level on admission was elevated, autoimmune causes of diabetes were sent and were negative, ruling out late onset type 1 diabetes. This shows that although it is a rare phenomenon, diabetics with DM3c can present in DKA.