Geriatric mortality risk factors in emergency department for non-traumatic abdominal pain.

OBJECTIVES: The study aimed to determine the factors affecting the mortality of geriatric patients presenting to the emergency department with non-traumatic abdominal pain, as well as the associations of these factors with mortality. BACKGROUND: With the increasing number of elderly patients, early recognition of patients with risk-bearing diagnoses is crucial. METHODS: This prospective cross-sectional study included 466 patients over 65 years of age who were admitted to THE emergency department of a tertiary hospital and consented to participate. Data was collected on patient demographics, vital signs, chronic diseases, laboratory investigations, diagnoses, disposition, and 30-day mortality. RESULTS: The results showed that the mean patient age was 74.42 years, with 47.4 % being male and 52.6 % female. 15.6 % of the patients had nonspecific causes. The risk of mortality within one month was 5.797 times higher in patients with neurological diseases and 5.183 times higher in those with a history of surgery. A one-unit decrease in hemoglobin increased the mortality risk by 0.656 times. CONCLUSION: This study highlights the importance of careful evaluation of elderly patients with neurological diseases, previous surgical history, and anemia in the emergency department with non-traumatic abdominal pain (Tab. 5, Ref. 18).

Characteristics of and risk factors for biliary pathogen infection in patients with acute pancreatitis.

BACKGROUND: Infection in patients with acute pancreatitis, especially severe acute pancreatitis patients, is a common and important phenomenon, and the distributions and drug resistance profiles of bacteria causing biliary infection and related risk factors are dynamic. We conducted this study to explore the characteristics of and risk factors for bacterial infection in the biliary tract to understand antimicrobial susceptibility, promote the rational use of antibiotics, control multidrug-resistant bacterial infections and provide guidance for the treatment of acute pancreatitis caused by drug-resistant bacteria. METHODS: The distribution of 132 strains of biliary pathogenic bacteria in patients with acute pancreatitis from January 2016 to December 2020 were analyzed. We assessed drug resistance in the dominant Gram-negative bacteria and studied the drug resistance profiles of multidrug-resistant bacteria by classifying Enterobacteriaceae and nonfermentative bacteria. We then retrospectively analyzed the clinical data and risk factors associated with 72 strains of Gram-negative bacilli, which were divided into multidrug-resistant bacteria (50 cases) and non-multidrug-resistant bacteria (22 cases). RESULTS: The main bacteria were Escherichia coli, Acinetobacter baumannii, Klebsiella pneumoniae and Pseudomonas aeruginosa. Extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli had a 66.67% detection rate. Acinetobacter baumannii had more than 50.00% drug resistance to carbapenems, ESBL-producing Klebsiella pneumoniae had 100.00% drug resistance, and Pseudomonas aeruginosa had 66.67% resistance to carbapenems. Multivariate logistic regression analysis suggested that the administration of third- or fourth-generation cephalosporins was an independent risk factor for Gram-negative multidrug-resistant biliary bacterial infection in acute pancreatitis patients. CONCLUSION: Drug resistance among biliary pathogens in acute pancreatitis patients remains high; therefore, rational antimicrobial drug use and control measures should be carried out considering associated risk factors to improve diagnosis and treatment quality in acute pancreatitis patients.

Opiate Prescriptions at Discharge Are Not Associated with Early Readmissions in Acute Pancreatitis.

BACKGROUND: Early readmissions in acute pancreatitis (AP) are common. The impact of opiate prescriptions on readmissions is unknown. AIMS: To determine whether the prescription of opiates at hospital discharge and the dose prescribed are associated with early readmissions in AP. METHODS: Direct admissions from the Emergency Department (ED) for AP from September 1, 2013, to August 31, 2016 were identified. Opiate prescription was defined as a new prescription at discharge in an opiate-naïve patient. Early readmission was ED visit or hospitalization within 30 days for an AP-related reason. Multivariable logistic regression was performed, adjusted for age, Charlson Comorbidity Index, pancreatic necrosis, baseline opiate use, non-opiate analgesics, and pain score at discharge. RESULTS: A total of 318 AP patients were identified; the overall early readmission rate was 18%. One hundred and twenty-one (38%) were prescribed opiates at discharge, and 22% had an early readmission. One hundred and ninety-seven (62%) were not prescribed opiates, and 16% had an early readmission. Median opiate dose was 48 mg (24-h morphine equivalents). On multivariable analysis, neither the prescription of opiates (OR 1.2, 95% CI 0.6-2.4, p = 0.55) nor the dose of opiates (OR 0.99, 95% CI 0.99-1.00, p = 0.39) was associated with early readmission. In subset analysis of patients discharged with an opiate prescription, those on opiates at baseline were significantly more likely to have an early readmission (OR 4.19, 95% CI 1.04-16.94, p = 0.04). CONCLUSIONS: In AP patients, neither prescription of opiates at discharge nor prescribed dose was associated with early readmission. Patients on opiates at baseline discharged with an opiate prescription were more likely to have an early readmission.

Infectious Complications in Severe Acute Pancreatitis: Pathogens, Drug Resistance, and Status of Nosocomial Infection in a University-Affiliated Teaching Hospital.

BACKGROUND: Secondary infection is an important factor affecting mortality and quality of life in patients with severe acute pancreatitis. The characteristics of secondary infection, which are well known to clinicians, need to be re-examined in detail, and their understanding among clinicians needs to be updated accordingly. AIM: This study aims to investigate the characteristics and drug resistance of pathogens causing severe acute pancreatitis (SAP) secondary infection, to objectively present infection situation, and to provide reference for improved clinical management. METHODS: A retrospective analysis was performed on 55 consecutive patients with SAP who developed secondary infection with an accurate evidence of bacterial/fungal culture from 2016 to 2018. The statistics included the spectrum and distribution of pathogens, the drug resistance of main pathogens, and associations between multiple infectious parameters and mortality. RESULTS: A total of 181 strains of pathogens were isolated from (peri)pancreas; bloodstream; and respiratory, urinary, and biliary systems in 55 patients. The strains included 98 g-negative bacteria, 58 g-positive bacteria, and 25 fungi. Bloodstream infection (36.5%) was the most frequent infectious complication, followed by (peri)pancreatic infection (32.0%). Acinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, and Stenotrophomonas maltophilia were predominant among gram-negative bacteria. Gram-positive bacterial infections were mainly caused by Enterococcus faecium and Staphylococcus spp. Fungal infections were predominantly caused by Candida spp. The drug resistance of pathogens causing SAP secondary infection was generally higher than the surveillance level. Patients in the death group were older (55 ± 13 years vs. 46 ± 14 years; p = 0.039) and had longer intensive care unit (ICU) stay (14 vs. 8; p = 0.026) than those in the survival group. A. baumannii infection (68.4% vs. 33%; p = 0.013), number of pathogens ≥ 4 (10 vs. 6; p = 0.005), pancreatic infection (14 vs. 15, p = 0.024), and urinary infection (8 vs. 5; p = 0.019) were significantly associated with mortality. CONCLUSION: Gram-negative bacteria are the main pathogens causing SAP secondary infection, in which nosocomial infections play a major role. The drug resistance profile of gram-negative bacteria is seriously threatening, and the commonly used antibiotics in SAP are gradually losing their effectiveness. Much attention should be paid to the rational use of antibiotics, and strategies should be established for infection prevention in SAP.

What are the Specifics of Biliary Surgery in Cirrhotic Patients?

This work's objective was to review the literature on biliary surgery in order to best define the surgical indications and the specifics of their management. A review of the literature from 1995 to August 2015 was conducted in Pubmed and Google Scholar.

Nationwide observational study of mortality from complicated intra-abdominal infections and the role of bacterial cultures.

BACKGROUND: The benefit of taking intra-abdominal cultures during source control procedures in patients with complicated intra-abdominal infection (CIAI) is unknown. The aim of this study was to evaluate whether intra-abdominal cultures reduce the mortality rate of CIAI. METHODS: The Japanese Diagnosis Procedure Combination database was used to identify adult patients with CIAI who had undergone source control procedures on the first day of admission to hospital between April 2014 and March 2016. In-hospital mortality was compared between patients who did and those who did not have intra-abdominal cultures taken. A generalized linear mixed-effect logistic regression model and a random intercept per hospital were used to adjust for baseline confounders and institutional differences. Subgroup analyses were also performed according to disease cause, site of onset and severity of CIAI. RESULTS: Intra-abdominal cultures were taken from 16 303 of 41 495 included patients. Multivariable logistic regression analysis showed that patients with intra-abdominal cultures had a significantly lower mortality than those without (odds ratio 0·85, 95 per cent c.i. 0·77 to 0·95). Subgroup analyses revealed statistically significant differences in mortality between patients with and without cultures among those with lower intestinal perforation, biliary tract infection/perforation, healthcare-associated CIAI and high-risk community-acquired CIAI. CONCLUSIONS: Intra-abdominal cultures obtained during source control procedures may reduce in-hospital mortality, especially in patients with lower intestinal perforation, biliary tract infection/perforation, or healthcare-associated or high-risk community-acquired CIAI.

GC-MS based metabolomics strategy to distinguish three types of acute pancreatitis.

Acute pancreatitis (AP) is a progressive systemic inflammatory response with high morbidity and high mortality, which is mainly caused by alcohol, bulimia, gallstones and hyperlipidemia. The early diagnosis of different types of AP and further explore potential pathophysiological mechanism of each type of AP is beneficial for optimized treatment strategies and better patient's care. In this study, a metabolomics approach based on gas chromatography-mass spectrometry (GC-MS), and random forests algorithm was established to distinguish biliary acute pancreatitis (BAP), Hyperlipidemia acute pancreatitis (HLAP), and alcoholic acute pancreatitis (AAP), from healthy controls. The classification accuracies for BAP, HLAP, and AAP patients compared with healthy control, were 0.886, 0.906 and 0.857, respectively, by using 5-fold cross-validation method. And some special metabolites for each type of AP were discovered, such as l-Lactic acid, (R)-3-Hydroxybutyric acid, Phosphoric acid, Glycine, Erythronic acid, l-Phenylalanine, d-Galactose, l-Tyrosine, Arachidonic acid, Glycerol 1-hexadecanoate. Furthermore, associations between these metabolites with the metabolism of amino acids, fatty acids were identified. Our studies have illuminated the biomarkers and physiological mechanism of disease in a clinical setting, which suggested that metabolomics is a valuable tool for identifying the molecular mechanisms that are involved in the etiology of BAP, AAP, HLAP and thus novel therapeutic targets.

Hepatic hilar mass in an adolescent: a rare case of hepatobiliary tuberculosis.

BACKGROUND: Hepatobiliary tuberculosis is a rare manifestation of Mycobacterium tuberculosis infection, especially in younger patients. The non-specific symptoms and signs as well as the lack of definite imaging characteristics often impedes diagnosis. Definite diagnosis of tuberculosiscan be obtained through histopathological examination; conventional anti-tuberculosis drugs and surgery are the most commonly recommended treatments. CASE PRESENTATION: A previously healthy 15-year-old rural adolescent male presented with a 2-month history of weight loss and fatigue. We strongly suspected a Klatskin tumor; therefore, exploratory laparotomy was performed. However, the microscopical findings revealed a granuloma consisting of epithelioid cells, caseous necrosis, and lymphocytic infiltration, indicating caseating granulomatous inflammation and yielding a final diagnosis of hepatic hilar tuberculosis. CONCLUSION: Hepatic hilar tuberculosis is an extremely rare case; few physicians may have actually treated a case. This report therefore aims to improve the overall understanding of lymphatic tuberculosis of the hepatic hilum.

Rituximab Maintenance Therapy Reduces Rate of Relapse of Pancreaticobiliary Immunoglobulin G4-related Disease.

BACKGROUND & AIMS: IgG4-related disease (IgG4-RD), a multi-organ fibroinflammatory syndrome, typically responds to steroids. However, some cases are steroid resistant, and pancreaticobiliary IgG4-RD commonly relapses after steroid withdrawal. Rituximab induces remission of IgG4-RD, but the need for and safety of maintenance rituximab treatment are unknown. We compared outcomes of patients with pancreaticobiliary IgG4-RD treated with or without maintenance rituximab therapy. METHODS: We performed a retrospective study of patients with pancreaticobiliary IgG4-RD treated with rituximab at the Mayo Clinic in Rochester, Minnesota, from January 2005 through December 2015. The cohort was divided into patients who received only rituximab induction therapy (group 1, n = 14) and patients who received rituximab induction followed by maintenance therapy (group 2, n = 29). We collected data on recurrence of IgG4-RD symptoms and findings, as well as information on evaluations, treatment, and adverse events. RESULTS: Median follow-up times were similar between group 1 (34 mo) and group 2 (27 mo) (P = .99). Thirty-seven patients (86%) were in steroid-free remission 6 months after rituximab initiation. A higher proportion of patients in group 1 had disease relapse (3-year event rate, 45%) than in group 2 (3-year event rate, 11%) (P = .034). Younger age, higher IgG4 responder index score after induction therapy, and increased serum levels of alkaline phosphatase at baseline or after rituximab induction were associated with relapse. Infections developed in 6 of 43 patients, all in group 2 (P = .067 vs group 1); all but 1 occurred during maintenance therapy. CONCLUSIONS: In a retrospective study of patients with pancreaticobiliary IgG4-RD, we found rituximab maintenance therapy prolongs remission. Relapses are uncommon among patients receiving maintenance therapy, but maintenance therapy may increase risk of infection. Patients with factors that predict relapse could be candidates for rituximab maintenance therapy.

Endoscopic biliary drainage management for children with serious cholangitis caused by congenital biliary dilatation.

Congenital biliary dilatation (CBD) is usually associated with complications such as recurrent cholangitis, manifested as abdominal pain, vomiting, and jaundice. If cholangitis cannot be controlled by conservative treatment, a good therapeutic effect can be obtained through percutaneous biliary drainage or open T-tube drainage. We aimed to evaluate our experiences in biliary drainage through endoscopic retrograde cholangiopancreatography in children with cholangitis caused by CBD. From January 2014 to December 2017, 167 children with CBD were treated in our hospital. 17 patients (10.18%) with serious cholangitis caused by CBD underwent ERCP. There were 4 males and 13 females with an age range of 10-120 months (average 56.4 months). Placement of a biliary stent was attempted for biliary drainage through endoscopic retrograde cholangiopancreatography. Of the 17 patients studied, 13 children had jaundice and 15 had elevated aminotransferases. ERCP showed CBD in all patients and a common biliopancreatic duct in 12 of 17 patients (70.6%). Five patients underwent nasobiliary drainage and 12 patients underwent biliary drainage through double pigtail tubes. All patients achieved successful biliary drainage. Postoperative pancreatitis occurred in one patient. Biochemical indicators decreased significantly in 12 patients (70.6%) on the second postoperative day. The average length of hospital stay after surgery was 4.5 (range 3-7) days. No major complications related to ERCP were observed and all children had a good prognosis so far. Endoscopic biliary drainage is a safe, simple, and reliable technique. It can be used to resolve CBD-associated cholangitis, evaluate the biliary tract and pancreatobiliary duct junction, and guide pediatric surgeons to choose the right time and the correct procedure for CBD.

Systematic unenhanced CT for acute abdominal symptoms in the elderly patients improves both emergency department diagnosis and prompt clinical management.

OBJECTIVES: To assess the added-value of systematic unenhanced abdominal computed tomography (CT) on emergency department (ED) diagnosis and management accuracy compared to current practice, in elderly patients with non-traumatic acute abdominal symptoms. METHODS: Institutional review board approval and informed consent were obtained. This prospective study included 401 consecutive patients 75 years of age or older, admitted to the ED with acute abdominal symptoms, and investigated by early systematic unenhanced abdominal CT scan. ED diagnosis and intended management before CT, after unenhanced CT, and after contrast CT if requested, were recorded. Diagnosis and management accuracies were evaluated and compared before CT (clinical strategy) and for two conditional strategies (current practice and systematic unenhanced CT). An expert clinical panel assigned a final diagnosis and management after a 3-month follow-up. RESULTS: Systematic unenhanced CT significantly improved the accurate diagnosis (76.8% to 85%, p=1.1x10-6) and management (88.5% to 95.8%, p=2.6x10-6) rates compared to current practice. It allowed diagnosing 30.3% of acute unsuspected pathologies, 3.4% of which were unexpected surgical procedure requirement. CONCLUSIONS: Systematic unenhanced abdominal CT improves ED diagnosis accuracy and appropriate management in elderly patients presenting with acute abdominal symptoms compared to current practice. KEY POINTS: • Systematic unenhanced CT improves significantly diagnosis accuracy compared to current practice. • Systematic unenhanced CT optimizes appropriate hospitalization by increasing the number of discharged patients. • Systematic unenhanced CT allows detection of about one-third of acute unsuspected abdominal conditions. • It should allow boosting emergency department management decision-making confidence in old patients.

Biliary strictures complicating liver transplantation in pediatric patients: Experience in a South American transplant center.

OBJECTIVE: To describe the experience of percutaneous transhepatic cholangiography (PTC) with biliary dilatation and drainage after pediatric liver transplantation and to determine the long-term outcome of this procedure. METHODS: Retrospective study from 2001 to 2013. Follow-up after treatment was also undertaken. A survival analysis was performed in patients in whom the procedure and eventual removal of the catheter were successful. RESULTS: In all, 196 children received liver transplants; 40 of them (20 boys and 20 girls; median age of 4 years) were treated using PTC due to biliary complications. Sixty-one PTC procedures were performed in 40 liver transplant recipients. Technically successful PTC was achieved in 87.5% of the patients. The probability of a patient not developing unfavorable outcomes 1, 5, and 10 years after treatment was 88.9%, 83.0%, and 74.1%.

Non-specific abdominal pain remains as the most common reason for acute abdomen: 26-year retrospective audit in one emergency unit.

OBJECTIVE: Distribution of diagnoses causing acute abdominal pain (AAP) may change because of population aging, increased obesity, advanced diagnostic imaging and changes in nutritional habits. Our aim was to evaluate the diagnoses causing AAP during a 26-year period. MATERIALS AND METHODS: This was a retrospective cross-sectional cohort study in one emergency department (ED) covering population about 250,000. All patients admitted to the ED in 1986, 2003 and 2012 were evaluated from hospital electronic database. Demographic data, utilization of diagnostic tests, surgical treatment and discharge diagnosis were analyzed. Statistical data of population aging, obesity and alcohol consumption during 1980-2012 were obtained from national registers. RESULTS: The AAP patients represented 10-20% of our total ED census. The most common causes of AAP were nonspecific abdominal pain (NSAP, 31-37%), acute appendicitis (11-23%), biliary disease (9-11%), bowel obstruction (5-7%), acute pancreatitis (4-8%) and acute diverticulitis (1-7%). The percentage of NSAP remained highest throughout the study period. Decrease in the number of acute appendicitis (from 23 to 11%; p < .0001), increase in acute diverticulitis (from 1 to 5%; p ≤ .0001) and acute pancreatitis (from 4 to 7%; p = .0273) was observed over time. The utilization of diagnostic imaging increased significantly (CT from 2 to 37% and US from 4 to 38%, p < .0001). Hospital mortality was very low (1-2%). CONCLUSIONS: NSAP is still the main differential diagnostic problem in the ED. Except acute appendicitis, distribution of specific diagnoses causing AAP remained rather stable through 26-year audit.

Secondary sclerosing cholangitis in localized hepatobiliary tuberculosis simulating cholangiocarcinoma: a rare case report.

BACKGROUND: Hepatobiliary tuberculosis includes miliary, tuberculous hepatitis or localized forms. The localised form is extremely uncommon and can mimic malignancy. Still rarer is its presentation as sclerosing cholangitis. CASE PRESENTATION: A 50 year male presented with acute onset jaundice, significant weight loss and elevated liver enzymes with clinico-radiological suspicion of cholangiocarcinoma. A left hepatectomy was done and dilated bile ducts filled with caseous necrotic material were seen intra-operatively. Histopathology suggested localized hepatobiliary tuberculosis with features of secondary sclerosing cholangitis. CONCLUSION: Localised hepatobiliary tuberculosis can cause diagnostic difficulties and its possibility should be considered especially in endemic areas.

Right Upper Quadrant Pain: Ultrasound First!

Acute right upper quadrant (RUQ) pain is a common presenting symptom in emergency departments and outpatient medical practices, and is most commonly attributable to biliary and hepatic pathology. Ultrasound should be used as a first-line imaging modality for the diagnosis of gallstones and cholecystitis, as it allows the differentiation of medical and surgical causes of upper abdominal pathology, and in many circumstances is sufficient to guide patient management. Knowledge of strengths and limitations of ultrasound in the evaluation of RUQ is paramount in correct diagnosis. A spectrum of RUQ pathology for which a RUQ ultrasound examination should reasonably be considered as the initial imaging modality of choice will be reviewed.

New concept of traction force applied to biliary self-expandable metallic stents.

BACKGROUND AND STUDY AIMS: Various mechanical properties of self-expandable metallic stents (SEMSs) have been reported. They can be classified into the device behavior during and after deployment. While there have been several reports on the latter, information on the former is insufficient. During deployment, the position is maintained by retracting the delivery catheter. We propose that this pulling force be called the traction force and that the magnitude of traction force is termed the traction momentum. The aim of this study was to measure these parameters in order to clarify the properties of SEMSs in terms of their deployment. MATERIAL AND METHODS: The traction force, traction momentum, and shortening rate of 10 different SEMSs were measured. Traction force was measured using in-house equipment, and the shortening rate was determined by measuring the stents. RESULTS: The shortening rate was closely related to the stent structure. The traction force varied between 1.5 N and 9.4 N, and the traction momentum was significantly elevated in covered and braided stents. A high traction force did not imply a high traction momentum. CONCLUSIONS: A low or constant traction force and a minimal shortening rate significantly facilitated SEMS deployment to optimal positions. Traction force could be an important element for new ideal SEMS design.

A comparative outcome analysis of incisional hernia repair in patients who underwent liver transplantation vs. those that underwent hepatopancreaticobiliary surgery using the EHS guidelines as a means of comparison.

AIM: We retrospectively analyzed incisional hernia (IH) outcomes of liver transplant (LT) vs. hepatopancreaticobiliary (HPB) cases sharing the same incision. METHODS: IH repair patients with a history of LT were compared with those with HPB surgical history sharing the same type of incision and using the European Hernia Society classification and nomenclature for reporting outcome. RESULTS: Eighty-two patients (27 HPB and 55 LT) between February 2001 and February 2014 were analyzed. Baseline demographics showed that the LT group had more diabetes and steroid use, but were less physical active. Outcomes showed no differences in wound complication, SSI rate, and recurrence rate (recurrence rate of 11.1% and 16.4% for HPB and LT, respectively). Multivariate analysis showed longer operating time to be a risk factor for both wound complication and SSI. M-tor inhibitor use was an additional risk factor for SSI. Interval to recurrence was significant longer in the LT group (35 vs. 61 months). Cox analysis showed steroid use, immunosuppression and not using a synthetic mesh as risk factors for recurrence. CONCLUSION: Incisional hernia repair with synthetic mesh after liver transplantation does not result in more wound complications, SSI, and recurrences, when compared to patients without immunosuppression.

Timing of Cholecystectomy in Children With Biliary Pancreatitis.

BACKGROUND: Biliary pancreatitis (BP) is common in adults and children. Current standard of care is to perform a cholecystectomy (CCE) to decrease the recurrence risk of pancreatitis. Controversy exists as to the timing of surgery, early versus delayed surgical intervention. Adult literature suggests a greater benefit of early CCE. Comparatively, there is limited pediatric literature as to the optimal timing of a CCE in children. We report a retrospective case series of children with BP who underwent early versus late CCE. METHODS: A retrospective chart review was performed of children with BP for a period of 45 months. Reviewed information included patient demographics, timing of CCE, and the occurrence of adverse events preceding or following surgical intervention. Early CCE was defined as surgery during the index admission; late CCE was defined as surgery during a subsequent admission. RESULTS: Nineteen children and adolescents (17 girls) were identified to have had BP with a subsequent CCE. Cholecystectomy was performed early in 9 patients with no adverse events. Ten patients had delayed surgery with 4 occurrences of adverse clinical events (recurrence of pancreatitis or biliary colic abdominal pain) while awaiting their CCE. CONCLUSIONS: Adverse biliary-related events occur at a higher rate in children with mild BP who undergo a delayed CCE when compared to early CCE performance. Early CCE is safe to perform in children with mild BP.

CT and MRI of Rare Extraintestinal Manifestations of Inflammatory Bowel Disease in Children and Adolescents.

Inflammatory bowel disease (IBD) is associated with a spectrum of extraintestinal manifestations (EIMs) affecting many organ systems. EIMs can occur in more than 40% of patients with IBD and are associated with significant morbidity. They occur at any time point in the course of disease, often during an active phase of bowel inflammation, but sometimes preceding bowel disease. Prompt recognition of EIMs enables timely and more effective therapy. Physicians who image patients with IBD should be aware of the myriad extraintestinal conditions that may be detected on imaging studies, both within and outside of the abdomen, as they may predate the diagnosis of IBD. Cross-sectional imaging of unusual conditions associated with IBD will be presented, including pathology in the hepatobiliary, pancreatic, genitourinary, musculoskeletal, mucocutaneous, vascular, neurologic, and pulmonary systems.