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.

"Bariatric Beriberi": A Rare Case of Wernicke Encephalopathy Two Weeks After Laparoscopic Sleeve Gastrectomy.

Wernicke encephalopathy (WE) is an acute neurological syndrome caused by thiamine (vitamin B1) deficiency. This disorder manifests as a triad of gait ataxia, confusion, and vision abnormalities. The absence of a full triad does not rule out WE. Because of its vague presentation, WE is commonly missed in patients with no history of alcohol abuse. Other risk factors for WE include bariatric surgery, hemodialysis, hyperemesis gravidarum, and malabsorption syndromes. WE is a clinical diagnosis that can be confirmed with an MRI of the brain as hyperintensities in the mammillary bodies, periaqueductal area, thalami, and hippocampus. If suspected in a patient, WE must be immediately treated with intravenous thiamine to prevent evolution into Korsakoff syndrome, coma, or death. Currently, there is no consensus in the medical community as to how much thiamine must be given and for how long. Therefore, there is a need for more research in the diagnosis and management of WE after bariatric surgery. Herein, we report a rare case of a 23-year-old female with a history of morbid obesity who developed WE two weeks after a laparoscopic sleeve gastrectomy.

Chemotherapy Port Induced SVC Thrombosis in a Patient with Non-metastatic Breast Cancer.

Cancer patients are at a higher risk of complications such as venous thromboembolism (VTE). This risk increases in patients who receive chemotherapy. Despite the increased risk, common locations for VTE are similar to those in patients without cancer. Chemotherapy-port-related thrombosis represents a rare complication due to the location and frequent use of access (with Heparin flushes) as part of the standard care. Attention should be made to this rare complication, which may progress to superior vena cava (SVC) syndrome. SVC syndrome typically presents in females around the age of 57 years old. Management of this syndrome can be difficult and generally requires the initiation of systemic anticoagulation therapy. Here, we present a rare case of a 45-year-old female who presented to the Emergency Department with right arm swelling, found to be secondary to her chemo port thrombosis, causing SVC syndrome.

Pulmonary Carcinosarcoma: A Rare Disease With Challenging Diagnosis and Treatment.

Pulmonary carcinosarcoma (PCS) is a rare type of non-small cell cancer. Overall, middle-aged and older smokers are the most affected age and sex groups. The diagnosis of PCS is difficult due to the absence of characteristic imaging findings. Additionally, preoperative biopsies do not usually reflect the heterologous nature of this tumor. Given the rarity of such tumors and the challenging diagnosis, the prognostic factors have not been established, and the overall prognosis remains poor. The valid therapeutic options are still limited. Here, we report a rare case of metastatic PCS that was accidentally discovered by imaging and properly diagnosed after surgical resection. The clinicopathological features, diagnostic tools, genetic theories, prognosis, and therapeutic options of this rare cancer are also discussed.

Hemosuccus Pancreaticus: Challenging Diagnosis and Treatment.

Hemosuccus pancreaticus (HP) is defined as bleeding from the ampulla of Vater through the pancreatic duct. It is a rare complication associated with acute or chronic pancreatitis. The source of bleeding can be from the pancreas itself or surrounding vessels, with the splenic artery most commonly involved. Diagnosing HP is challenging and computed tomography angiography remains the gold standard for diagnosis. We present the case of a 62-year-old male with recurrent pancreatitis complicated with HP. Imaging and endoscopy were consistent with bleeding from the section portion of the duodenum, which resolved without intervention. LEARNING POINTS: Hemosuccus pancreaticus is a rare complication associated with acute or chronic pancreatitis.CT angiography is the gold standard for diagnosing hemosuccus pancreaticus.Arterial embolization is the first-line treatment of hemosuccus pancreaticus.

A Case Report of Autoimmune Encephalitis: Could Post-COVID-19 Autoimmunity Become a Lethal Health Issue?

While it is primarily thought of as a respiratory illness, COVID-19 is now recognized as a multi-organ disease that can present with a wide range of clinical manifestations. Particularly in patients with severe respiratory illness, neurological manifestations ranging from headaches, and loss of smell to strokes have been associated with the virus. In the setting of resolving respiratory illness, it is important to consider autoimmune encephalitis (AE) in the instance of new-onset neurological manifestations. The typical patient presentation includes altered mental status, fever, seizures, and/or focal neurological deficits. These neurological manifestations make it crucial to consider either underlying COVID-19 infection or post COVID-19 autoimmunity so as not to delay the administration of the appropriate treatment. Herein, we present the case of an 88-year-old female with new-onset right leg weakness, and dysarthria, that progressively developed to altered mental status months after having respiratory symptoms of COVID-19. According to the criteria of AE diagnosis, the patient's clinical course and work-up findings proved the diagnosis.

A Favorable Outcome of Grade 3 Follicular Lymphoma Treated With Surgery and Obinutuzumab Combined With Chemotherapy: A Case Report and Literature Review.

Follicular lymphoma is the most common type of low-grade non-Hodgkin lymphoma and the second most common type of lymphoma. Primary extranodal follicular lymphoma is rare compared with nodular follicular lymphoma involving the gastrointestinal (GI) tract. There has been uncertainty regarding follicular lymphomas due to the heterogeneous presentation and severity in which they present. However, studies showed that patients diagnosed with primary gastrointestinal follicular lymphoma do not typically differ in their presentation from those diagnosed with nodular follicular lymphoma involving the GI tract. Furthermore, recent literature identifies that patients diagnosed with grade 3 follicular lymphoma tend to have similar genetic and molecular entities to those diagnosed with diffuse large B-cell lymphoma (DLBCL). Based on these results, current studies have shown that patients with grade 3 follicular lymphoma who are treated with anthracycline-based regimens have similar outcomes to those with diffuse large B-cell lymphoma. However, additional studies are warranted to demonstrate the benefit of managing grade 3 follicular lymphoma with more aggressive anthracycline/rituximab-based regimens. Here, we present a case of a 44-year-old male diagnosed with grade 3 follicular lymphoma involving the gastrointestinal tract, who demonstrated an excellent treatment response following therapy similar to the treatment of bulky diffuse large B-cell lymphoma despite a tumor burden size below 7.5 cm.

Unintentional Dual Benefit: Improvement in Secondary Polycythemia in a Patient Receiving Chemotherapy for Metastatic Clear Cell Renal Cell Carcinoma.

Complete blood counts are frequently collected from cancer patients, but laboratory findings may be misleading. Secondary polycythemia can occur in renal cell carcinoma (RCC) due to erythropoietin (EPO) stimulation. Therefore, complete blood counts should be closely monitored to prevent complications such as thrombosis. We discuss the case of a 47-year-old man with metastatic RCC who presented with secondary polycythemia that improved with chemotherapy. His secondary erythrocytosis was anticipated, but his haemoglobin levels were lower than expected after therapy. This article discusses the treatment and diagnosis of secondary polycythemia in patients with RCC. LEARNING POINTS: Haemoglobin and haematocrit levels should be closely monitored in renal cell carcinoma (RCC) patients as they may develop secondary polycythemia as a result of their malignancy.Secondary polycythemia can be managed with chemotherapy and immunotherapy in RCC, with anti-cancer agents preventing the need for phlebotomy.Chemotherapy may benefit RCC patients by decreasing tumour burden, preventing progression, and by lowering haemoglobin levels, thus improving secondary polycythemia.

A Rare Case of Benign Histiocytic Neoplasm of Cutaneous Rosai-Dorfman Disease: A Case Report and Literature Review.

Rosai-Dorfman disease (RDD) is a rare disorder characterized by the proliferation of histiocytes in lymph nodes. It can occur anywhere in the body but commonly involves the cervical area of the neck. Its clinical presentation varies and patients with skin manifestations may develop papules, nodules, plaques, or pustules. Histologically, it typically presents with emperipolesis, where intact lymphocytes are found within histiocytes. The definitive treatment of RDD is not well established given the rarity of the disease and indeed skin lesions can regress spontaneously. Therapeutic treatment options include cryotherapy, radiation, or topical agents such as steroids or retinoids. Here we describe the case of a 24-year-old Hispanic female who presented with skin manifestations which proved to be histologically positive for Rosai-Dorfman disease. The patient clinically improved following the administration of intralesional steroids. LEARNING POINTS: RDD is a rare self-limiting benign lymphoproliferative disorder, which can be associated with autoimmune disease, hematological malignancies, and post-infectious conditions.Skin lesions can be self-limiting in many cases of RDD.Therapeutic treatment options include cryotherapy, local radiation, and topical steroids and retinoids.

Aortic dissection presenting as stroke with focal neurologic deficits: A case report.

Aortic dissection is a relatively uncommon and potentially misdiagnosed disease. Early and accurate diagnosis and appropriate treatment are imperative for patient survival. In this case, we present a 55-year-old male who presented to the Emergency Department with severe abdominal pain and acute neurological deficits who was triaged for stroke protocol. After unexpected findings on physical examination, other diagnostic hypotheses were evaluated, culminating in the diagnosis of aortic dissection. The purpose of this article is to exemplify a patient who presents with noteworthy neurologic clinical features who ultimately was diagnosed with Type B aortic dissection, to help benefit the rapid diagnosis and subsequent treatment for future patients with similar presentations.

Pyogenic Liver Abscess Secondary to Appendicitis.

A pyogenic liver abscess secondary to appendicitis infection is a rare manifestation that has not been well illustrated in the United States due to its infrequency and the variability of each clinical presentation. Here, we discuss a 55-year-old male who presented with abdominal pain, fever, chills, and weight loss and was found to have a pyogenic liver abscess suspected secondary to radiographic-proven acute appendicitis. The purpose of this article is to describe a patient who presented with noteworthy clinical features and a rare cause of hepatic abscess, to aid in the treatment and diagnosis of future patients.

Endovascular Embolization of Pulmonary Sequestration Presenting With Hemoptysis: A Promising Alternative to Surgery.

Pulmonary sequestration is abnormal lung parenchyma separated from the normal tracheobronchial system and supplied by an aberrant systemic artery. It is usually asymptomatic; however, it can present with hemoptysis and recurrent pulmonary infections. Although surgery is the classical treatment, arterial embolization is recently established as an alternative treatment to avoid surgical complications. We present a case of left lower lobe intralobar pulmonary sequestration presented with hemoptysis and was successfully treated with coil embolization.

Massive Mixed Adenoneuroendocrine Carcinoma: A Case Report.

Mixed adenoneuroendocrine carcinoma (MANEC) of the gastrointestinal (GI) tract is a rare subtype of mixed tumors, and it is scarcely described in the literature. MANEC tumors are composed of adenocarcinoma and neuroendocrine carcinoma components, each of which comprises at least 30% of the lesion. Diagnosing MANEC requires specific histological and immunohistochemistry (IHC) analysis. Typically, MANEC tumors carry a poor prognosis due to their very aggressive nature. We report the case of a 70-year-old female patient with no past medical history who presented with a three-week history of abdominal pain and one episode of hematemesis one week prior to presentation. Initial CT of the abdomen showed a large, 8 x 6 x 6-cm mass arising from the stomach and extending to the lesser sac as well as the central crus of the diaphragm with bilateral retroperitoneal lymphadenopathy. Upper endoscopy revealed an excavated, ulcerated, and partially necrotic mass on the lesser curvature of the proximal gastric body. Tissue biopsy of the lesion showed infiltrating mixed poorly differentiated adenocarcinoma and neuroendocrine carcinoma. On IHC, the adenocarcinoma component stained positively for CDX2 and pancytokeratin, and the neuroendocrine component stained positively for synaptophysin and chromogranin. Further workup included CT of the chest, which demonstrated extensive bilateral pulmonary emboli and new liver lesions with moderate ascites not seen on the initial abdominal CT. The latter was repeated and showed remarkable enlargement of the gastric mass (up to 12 cm) with extensive retroperitoneal adenopathy and mesenteric implants. Given the rapid clinical deterioration and progression of tumor burden, comfort measures were offered and the patient passed away soon after. MANEC tumors are highly aggressive subtypes of "collision" tumors, which are not well described in the medical literature due to their rarity. The etiology is poorly understood with various theories proposing different pathophysiological mechanisms. Standard therapy is not well developed at present; however, a few reports have demonstrated successful outcomes with surgery or combined chemotherapy (cisplatin with irinotecan or etoposide) if diagnosed at an early stage.

More Than Just an Ulcer: A Case of HIV-Associated Iliac Aneurysms Presenting With a Leg Ulcer.

The incidence of symptomatic vasculitis in human immunodeficiency virus (HIV)-infected patients is approximately 1%, and it commonly presents as arterial occlusive disease or aneurysmal disease. Early diagnosis of vascular complications in those patients is essential; however, it is extremely challenging. Iliac aneurysms are usually silent, and because of their deep location, detection of these aneurysms is typically difficult. Therefore, they always continue to be asymptomatic until rupture unless they are discovered incidentally on a radiological investigation for an irrelative condition. We present the case of a 61-year-old HIV-positive man with bilateral iliac aneurysms and total coronary artery occlusion presenting with a leg ulcer.

Multiple Arterial Thrombosis in a COVID Patient With No Known Comorbidities With Mild Elevation of D-Dimer.

Since the coronavirus (COVID-19) pandemic started, new challenges have emerged regarding the management of coronavirus-infected patients. One of the most known devastating complications associated with COVID-19 is hypercoagulability. This can lead to severe disability or even death, especially in critically ill patients with known chronic comorbidities such as hypertension (HTN) and diabetes. D-dimer and clinical condition are among the most important tools currently used by clinicians to guide therapy and anticoagulation prophylaxis. Here we present a case of a COVID-19-infected patient with no known comorbidities and mild elevation in initial D-dimer level who had a rapid deterioration ultimately leading to death within weeks of admission.

Ileosigmoid Anastomotic Perforation Three Weeks After Placement of Lumen-Apposing Metal Stent (LAMS).

Benign anastomotic intestinal strictures are difficult to manage as there may be limited response to dilation. Fully covered self-expanding metal stents have been utilized in small case series; however, stent suturing is required due to the high risk of stent migration. Lumen-apposing metal stents (LAMS) are fully covered and have a novel dumbbell shape that prevents stent migration. Initial reports identify low migration rates and good clinical success rates. This is the first report of perforation following treatment of an ileosigmoid stricture in a 52-year-old female, three weeks after LAMS placement.