Unusual causes of gastrointestinal bleeding in the intensive care unit through the radiology lens.

The great majority of patients admitted to the intensive care unit (ICU) for critical gastrointestinal bleeding (GIB) will have a predictable etiology. Once the site is localized to the upper versus the lower gastrointestinal tract, the number of typically encountered etiological possibilities is quite limited. On rare occasions, the cause of GIB requiring ICU care is not one of the standard considerations, potentially leading to diagnostic and therapeutic delays. Within a short time period, three patients were admitted to our institution's medical ICU each with a different unexpected cause of GIB. All three cases generated a variety of instructive images, which are used in the present series to illustrate these conditions and the role of radiology in their evaluation and management.

Sharp recanalization of CBD occlusion in patient with second orthotropic liver transplant with cocoon syndrome.

Biliary complications after orthotopic liver transplant (OLT) remain one of the primary causes of morbidity and mortality in liver transplant recipients with an approximate incidence between 5% and 32%. Given the limited supply of hepatic grafts, one of the most feared outcomes as a result of biliary complications is acute and or chronic graft failure. Biliary complications include leaks, biliary stasis, and stone formation, sphincter of Oddi dysfunction, recurrence of biliary disease (primary sclerosing cholangitis and primary biliary cirrhosis), and biliary strictures/obstruction. Overwhelmingly, the most common complication in hepatic transplantation is biliary stricture formation accounting for more than 50%. Currently, the mainstay of therapy as it pertains to biliary strictures/obstruction includes endoscopic retrograde cholangiography-guided therapy, percutaneous transhepatic cholangiography-guided therapy, or surgical revision/retransplantation. We present a case of biliary obstruction in a patient with a second liver transplant complicated by Cocoon Syndrome managed via sharp recanalization of CBD occlusion and placement of an endoscopic biliary Viabil stent.

Nonoperative management of periappendiceal abscess in children: A comparison of antibiotics alone versus antibiotics plus percutaneous drainage.

PURPOSE: To determine the optimal nonoperative management of periappendiceal abscess in a pediatric population, we compared the therapeutic efficacy and cost-effectiveness of antibiotics alone versus antibiotics plus percutaneous drainage (PD). METHODS: We conducted a 10-year retrospective chart review of pediatric patients less than 18 years of age who had acute perforated appendicitis complicated by periappendiceal abscess. Group 1 consisted of patients (N = 35) who received nonoperative management with antibiotics only. Group 2 consisted of patients (N = 11) who underwent PD and also received antibiotics. Group 1 was subdivided into groups 1A and 1B. Group 1A consisted of patients (N = 25) who responded to antibiotics treatment. Group 1B consisted of patients (N = 10) who were initially treated with antibiotics but subsequently required PD. Patients' demographics, initial clinical presentation, abscess size and location, length of hospital stay, outcome, and complications were compared among these groups. RESULTS: Median hospital stay of group 1A and group 2 was identical at 6 days. Group 1B had a significantly longer median hospital stay of 13 days. There were no deaths and no significant long-term complications in any group. One patient in group 1A returned to the emergency room (ER) for abdominal pain and was readmitted for observation. Four patients in group 1B returned to the ER shortly after discharge and required readmission. One of these 4 patients developed acute pancreatitis in addition to enlarging abscess and underwent surgical drainage. There were no documented failures or complications of treatment in group 2 prior to interval appendectomy with the exception of 1 patient lost to follow-up. The presence of small bowel obstruction at the time of admission was an independent predictor of increased length of stay. CONCLUSIONS: Antibiotic therapy alone can be effective in a majority of patients and is recommended as initial management. To prevent potential complications and increased cost, PD should not be delayed if clinical symptoms persist or the abscess remains unchanged. Reimaging 6 days after initiation of antibiotic therapy with ultrasound or MRI is recommended to identify patients who would progress on antibiotics alone or who need to receive drainage without delay. LEVEL OF EVIDENCE: Level III.

Conservative management of uterine rupture in gestational trophoblastic neoplasia.

•Uterine artery embolization as management of uterine rupture due to invasive GTN.•Fertility preservation for select cases of uterine rupture due to invasive GTN.•Conservative surgery and chemotherapy for invasive GTN with uterine rupture.

The correlation between sarcopaenia and post-transjugular intrahepatic portosystemic shunt hepatic encephalopathy: a single-institution review.

INTRODUCTION: Sarcopaenia, or muscle wasting, can be used to objectively quantify malnutrition in cirrhotic patients. MATERIAL AND METHODS: In this retrospective study, a list of all patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) procedure at Westchester Medical Centre from September 2009 to July 2018 was obtained, and individual chart reviews were performed. RESULTS: In total, 90 charts were reviewed. Fifty-six patients satisfied our inclusion criteria. Using PMA cut-off values determined in prior studies, we found that 50 of the 56 patients in our study were sarcopaenic. The majority of the patients were male (n = 45). The most common aetiology of cirrhosis was alcoholic cirrhosis (n = 27), followed by viral hepatitis (n = 10), and the most common indication for TIPS was refractory ascites (n = 34). The mean age in the sarcopaenic group was 60.1 years compared to 57.4 years in the non-sarcopaenic group. Mean MELD-Na scores and albumin levels were comparable in both groups. Only one patient was deceased at 6 months post-TIPS. Of the 56 patients included, 18 developed clinically significant hepatic encephalopathy within 6 months of their TIPS procedure. All 18 patients belonged to the sarcopaenic group; 6 patients were not sarcopaenic, and none of them were noted to develop HE within 6 months of their TIPS (p = 0.074). CONCLUSIONS: Based on our results, we concluded that sarcopaenia correlates with the development of hepatic encephalopathy within 6 months of a TIPS procedure; however, the results did not reach statistical significance.