Impact of frailty on endoscopic retrograde cholangiopancreatography outcomes in nonagenarians: A United States national experience.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an essential therapeutic tool for biliary and pancreatic diseases. Frail and elderly patients, especially those aged ≥ 90 years are generally considered a higher-risk population for ERCP-related complications. AIM: To investigate outcomes of ERCP in the Non-agenarian population (≥ 90 years) concerning Frailty. METHODS: This is a cohort study using the 2018-2020 National Readmission Database. Patients aged ≥ 90 were identified who underwent ERCP, using the international classification of diseases-10 code with clinical modification. Johns Hopkins's adjusted clinical groups frailty indicator was used to classify patients as frail and non-frail. The primary outcome was mortality, and the secondary outcomes were morbidity and the 30 d readmission rate related to ERCP. We used univariate and multivariate regression models for analysis. RESULTS: A total of 9448 patients were admitted for any indications of ERCP. Frail and non-frail patients were 3445 (36.46%) and 6003 (63.53%) respectively. Indications for ERCP were Choledocholithiasis (74.84%), Biliary pancreatitis (9.19%), Pancreatico-biliary cancer (7.6%), Biliary stricture (4.84%), and Cholangitis (1.51%). Mortality rates were higher in frail group [adjusted odds ratio (aOR) = 1.68, P = 0.02]. The Intra-procedural complications were insignificant between the two groups which included bleeding (aOR = 0.72, P = 0.67), accidental punctures/lacerations (aOR = 0.77, P = 0.5), and mechanical ventilation rates (aOR = 1.19, P = 0.6). Post-ERCP complication rate was similar for bleeding (aOR = 0.72, P = 0.41) and post-ERCP pancreatitis (aOR = 1.4, P = 0.44). Frail patients had a longer length of stay (6.7 d vs 5.5 d) and higher mean total charges of hospitalization ($78807 vs $71392) compared to controls (P < 0.001). The 30 d all-cause readmission rates between frail and non-frail patients were similar (P = 0.96). CONCLUSION: There was a significantly higher mortality risk and healthcare burden amongst nonagenarian frail patients undergoing ERCP compared to non-frail. Larger studies are warranted to investigate and mitigate modifiable risk factors.

Type V gastric ulcer: An unusual etiology of gastrosplenic fistula associated with upper gastrointestinal bleeding.

Type V gastric ulcer is an unusual etiology of gastrosplenic fistula (GSF). Prompt diagnosis and early embolization of splenic vessels prior to esophagogastroduodenoscopy and surgical resection is crucial.

Gastric Glomus Tumors: The Roles of Endoscopic Ultrasound and Shared Decision-Making.

Gastric glomus tumors (GGTs) are mesenchymal neoplasms with indolent behavior that originate from the subepithelial layers of the stomach and represent up to 1% of all gastric tumors. GGT is detected incidentally during esophagogastroduodenoscopy (EGD) in a proportion of patients. Endoscopic ultrasound (EUS) evaluation of GGT is essential to establish the diagnosis and to differentiate it from gastrointestinal stromal tumors or gastric neuroendocrine tumors. An 80-year-old man who presented for abdominal discomfort was incidentally found to have a gastric antral nodule on EGD. Endoscopic biopsy demonstrated moderately erythematous gastric antral mucosa and a 1.5 cm subepithelial lesion along the greater curvature. An EUS revealed a subepithelial 1.6 cm × 1.3 cm isoechoic, homogenous lesion with small calcifications. Immunohistochemical staining of the fine needle biopsy specimen of the nodule was positive for neoplastic cells, smooth muscle actin, vimentin, patchy muscle-specific actin, and synaptophysin. There were no atypical cytologic features. These findings were consistent with GGT. The patient was not deemed to be a candidate for surgical resection due to advanced age and resolution of his symptoms. A shared decision was made to pursue regular surveillance. EUS is essential for evaluation of GGT. Currently, there are no guideline recommendations for surveillance of GGT detected on routine EGD in asymptomatic individuals. A definitive surgical treatment with partial gastrectomy was favored in previously published literature. For asymptomatic patients with GGT or those with resolution of symptoms, careful surveillance with serial abdominal imaging and EUS may be a reasonable option, especially in older patients with poor surgical candidacy.

Co-Presentation of Lupus Nephritis with Autoimmune Hepatitis.

BACKGROUND Systemic lupus erythematosus (SLE) is a multiorgan immunologic disease which commonly results in systemic manifestations by involving joints, kidneys, skin, heart, hematologic cell lines, pulmonary and central nervous systems. The hepatic involvement of lupus is relatively less common, which creates diagnostic challenges, as the clinical presentations of lupus hepatitis and autoimmune hepatitis (AIH) are similar. CASE REPORT A 51-year-old woman presented for multiple joint pain that began 2 years ago. Her work-up, including kidney biopsy, was consistent with a diagnosis of class V lupus nephritis. Subsequently, within a few months, she was admitted with acute elevation of liver enzymes and high immunoglobulin IgG level, and a liver biopsy demonstrated impressive interface hepatitis with many plasma cells and lymphocytes, suggestive of chronic hepatitis with high histological activity. This case illustrates the co-presentation of lupus nephritis and AIH, which is a rare association. The patient was managed with a tapering dose of prednisone, hydroxychloroquine initially, and later with mycophenolate mofetil, with complete resolution of liver enzyme abnormalities by 4-month follow-up. CONCLUSIONS Lupus hepatitis is hepatic involvement of SLE, which should be distinguished from AIH. Accurate diagnosis is important, as management and prognosis of these immunologic conditions can differ. Although both entities share clinical and biochemical markers, the presence of anti-ribosomal P antibodies and liver histology features of predominant lymphoid infiltrates with lobular inflammation favor lupus hepatitis. A multidisciplinary approach involving rheumatologists, hepatologists, and pathologists can improve disease outcomes by properly differentiating the 2 entities and guiding the selection of appropriate immunosuppressive therapy.

Cerebrospinal fluid liver pseudocyst: A bizarre long-term complication of ventriculoperitoneal shunt: A case report.

BACKGROUND: Ventriculoperitoneal (VP) shunt placement has become a standard of care procedure in managing hydrocephalus for drainage and absorption of cerebrospinal fluid (CSF) into the peritoneum. Abdominal pseudocysts containing CSF are the common long-term complication of this frequently performed procedure, mainly because VP shunts have significantly prolonged survival. Of these, liver CSF pseudocysts are rare entities that may cause shunt dysfunction, affect normal organ function, and therefore pose therapeutic challenges. CASE SUMMARY: A 49-year-old man with history of congenital hydrocephalus status post bilateral VP shunt placement presented with progressively worsening dyspnea on exertion, abdominal discomfort/distention. Abdominal computed tomography (CT) scan revealed a large CSF pseudocyst in the right hepatic lobe with the tip of VP shunt catheter into the hepatic cyst cavity. Patient underwent robotic laparoscopic cyst fenestration with a partial hepatectomy, and repositioning of VP shunt catheter to the right lower quadrant of the abdomen. Follow-up CT demonstrated a significant reduction in hepatic CSF pseudocyst. CONCLUSION: A high index of clinical suspicion is required for early detection of liver CSF pseudocysts since their presentation is often asymptomatic and cunning early in the course. Late-stage liver CSF pseudocysts could have adverse outcomes on the treatment course of hydrocephalus as well as on hepatobiliary dysfunction. There is paucity of data to define the management of liver CSF pseudocyst in current guidelines due to rare nature of this entity. The reported occurrences have been managed by laparotomy with debridement, paracentesis, radiological imaging guided fluid aspiration and laparoscopic-associated cyst fenestration. Robotic surgery is an additional minimally invasive option in the management of hepatic CSF pseudocyst; however, its use is limited by lack of widespread availability and cost of surgery.

Candida Bezoar of the Bladder Resulting in Obstructive Uropathy: A Case Report.

Candida bezoar is a rare pathologic entity characterized by the colonization of a cavity by an aggregate or mass of mycelia due to local or systemic infections with Candida spp. Candida bezoar is commonly seen in immunocompromised individuals and can often present in the context of symptomatic urinary tract infection or urosepsis. The implicated risk factors for the development of Candida bezoars are anatomical urinary tract abnormalities, diabetes mellitus, indwelling urinary catheters, increased use of broad-spectrum antibiotics, and corticosteroids. Early clinical suspicion is essential for diagnosis to prevent the dissemination of disease and for a favorable prognosis. We report a case of a 49-year-old diabetic male who presents with hematuria, abnormal urinary flow, and left-sided flank pain for four days caused by a Candida bezoar of the urinary bladder resulting in unilateral obstructive uropathy despite the appropriate placement of a ureteral stent. Treatment with left nephrostomy tube, oral fluconazole, and amphotericin bladder irrigation for three days was successful. The patient's condition improved, and he was discharged on fluconazole and was recommended to follow up with urology as an outpatient.

Predicting common bile duct stones: Comparison of SAGES, ASGE and ESGE criteria for accuracy.

Objective: To determine accuracy of SAGES, ASGE and ESGE criteria for predicting presence of common bile duct (CBD) stones. Methods: In a prospective study at Jinnah Hospital Lahore from March 2021 to February 2022, patients with suspected CBD stone were stratified in High risk (HR), intermediate risk (IR) and low risk (LR) for SAGES, ASGE and ESGE criteria. All patients underwent ERCP and risk strata were analyzed using SPSS 22® for sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy. Results: In 90 patients with mean age 45.18(±14.87) and male/female ratio 0.64(35/55), area Under Curve (AUC) for predicting CBD stones was 0.75, 0.81and 0.83 for HR and 0.28, 0.52 and 0.52 for IR group while it was 0.53, 0.81 and 0.53 for absence of stone in LR group of SAGES, ASGE and ESGE criteria respectively. HR groups had accuracy of 81.1%, 86.7% and 87.8% in predicting CBD stone while LR criteria had 68.8%, 86.7% and 68.1% accuracy in predicting absence of CBD stone for SAGES, ASGE and ESGE respectively. Conclusion: HR strata of SAGES, ASGE and ESGE scores have excellent accuracy in predicting CBD stones whereas IR and LR criteria are suboptimal for excluding CBD stones.

Angiotensin converting enzyme inhibitor associated spontaneous herniation of liver mimicking a pleural mass: A case report.

BACKGROUND: Spontaneous diaphragmatic herniation of the liver is a rare entity. It may mimic pulmonary mass especially in the absence of trauma. Cough is a common side effect of angiotensin converting enzyme (ACE) inhibitors that may cause diaphragmatic rupture due to a sudden increase in trans-diaphragmatic pressure. We present a case of ACE-inhibitor associated spontaneous herniation of the liver mimicking pleural mass. CASE SUMMARY: An 80-year-old woman presented with dry cough for 1 mo and sudden onset of cramping abdominal pain for 1 d. She denied history of trauma, prior surgeries, smoking, alcohol or illicit drug use. She has a history of diabetes and was started on an ACE inhibitor 6 mo ago for the management of hypertension. Examination was remarkable for right upper quadrant tenderness. Lab work-up was unremarkable. Chest X-ray showed a right lower lung opacity suspecting right pleural mass. Chest computed tomography scan ruled out pleural mass, however, revealed herniated right lobe of the liver (3.9 cm × 3.6 cm × 3.4 cm) into the thoracic cavity through the posterolateral diaphragmatic defect. Laparoscopic repair of the diaphragmatic defect was performed and the ACE inhibitor was stopped. Patients' symptoms had completely resolved on follow-up. CONCLUSION: ACE inhibitor-associated cough may cause diaphragmatic liver herniation mimicking pleural mass. Early diagnosis, surgical repair and addressing the triggering factors improve patients' outcomes.

Comparison of mean pain score of oral non-steroidal anti-inflammatory agents and locally injectable steroid for the treatment of plantar fasciitis.

OBJECTIVE: To compare the efficacy of oral non-steroidal anti-inflammatory drugs with locally injectable steroids in the treatment of plantar fasciitis. METHODS: This comparative study was conducted from 10 May 2013 to 10 December 2013 at the Department of Orthopaedic Surgery, Punjab Medical College/Allied Hospital, Faisalabad, Pakistan, and comprised patients of either gender aged 26-60 years having unilateral plantar fasciitis who were not on any prior treatment and had moderate to severe pain intensity. The patients who received diclofenac sodium 50mg and acetaminophen 500mg twice a day for 4 weeks were assigned as Group-A, and those who received a single of 40mg (1ml) of methylprednisolone combined with 2ml of 0.5% bupivacaine into the tender most point of the inflamed plantar fascia were assigned as group - B. Pain was assessed using visual analogue scale at baseline and after 2 months of regular follow-up. Data was analysed using SPSS 10. RESULTS: Of the 140 patients, there were 70(50%) in each of the two groups. There were 102(72.9%) males and 38(27.1%) females, with an overall mean age of 42.24±9.30 years. While pain intensity decreased in both the groups, it was significant in group B (p=0.0001), but non-significant in group A (p=0.723). CONCLUSIONS: Locally injectable steroid was found to be a better modality for the management of plantar fasciitis in reducing mean pain score and sustained pain relief compared to non-steroidal anti-inflammatory drugs.

Mortality in Patients of COVID-19 Infection: Biochemical Markers and its Cut-off Values for Predicting Outcome.

OBJECTIVE: To determine the efficacy and cut-off values of C-reactive protein (CRP), lactate dehydrogenase (LDH), serum ferritin, and D-dimer for predicting mortality of COVID-19 infection. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Medicine, Jinnah Hospital, Lahore from January to May 2021. METHODOLOGY: Serum CRP, LDH, ferritin, and D-dimer were measured in patients with moderate to severe COVID-19 infection at admission. Patients were followed for in-hospital disease outcome. ROC curve was used to determine area under curve (AUC) and cut-off values of biomarkers, followed by multi-variate analysis by logistic regression. RESULTS: In 386 patients, male to female ratio was 1.47/1 (230/156); and mean age was 54.03 ± 16.2 years. Disease was fatal in 135 (35%) patients. AUC for mortality was 0.730 for LDH, 0.737 for CRP, 0.747 for ferritin and 0.758 for D-dimer. Mortality was higher with LDH ≥400 U/ml, Odds Ratio (OR) 5.37 (95% CI 3.01-9.57: p = 0.001), CRP ≥30 ng/L, OR 4.30 (95% CI 2.11-8.74: p = <0.001), serum ferritin ≥200 ng/ml, OR 4.13 (95% CI 1.05-16.2: p = 0.02), and D-dimer ≥400 ng/ml, OR 2.72 (95% CI 1.06-7.01: p = 0.03) with 2 log likelihood of 131.54 for predicting disease outcome with 71.7% accuracy in multi-variate analysis. CONCLUSION: Elevated serum CRP, LDH, ferritin and D-dimer are associated with higher mortality in patients of COVID-19 infection. Serum CRP ≥30ng/ml, LDH ≥400 U/L, ferritin ≥200 ng/ml and D-dimer ≥400 ng/ml can predict fatal outcome in COVID-19 patients. Key Words: C-reactive protein (CRP), COVID-19 infection, D-dimer, Ferritin, Lactate dehydrogenase (LDH), Mortality.

A gender-based study of symptoms and risk factors associated with mortality in COVID-19 patients in a tertiary care hospital, Lahore.

OBJECTIVE: To determine the symptoms and risk factors associated with gender-specific mortality among coronavirus disease-2019 patients. METHODS: The retrospective, descriptive, cross-sectional study was conducted at the coronavirus disease-2019 ward of the Jinnah Hospital, Lahore, Pakistan, and comprised record of confirmed cases of coronavirus disease-2019 diagnosed on the basis of characteristic clinical symptoms, radiological findings and polymerase chain reaction positivity from May 1 to August 31, 2020. Clinical symptoms, comorbidities and outcomes were extracted from the medical records. Data was analysed using SPSS 23. RESULTS: Of 337 cases, 132(39.2%) died. Among the deceased, 84(64%) were males with median age 61.5 (interquartile range: 22) and 48(36%) were females with median age 54.5 (interquartile range: 25).There were more female non-survivors who suffered from kidney disease 10(66.7%) than male non-survivors 5(33.3%) (p<0.05). Ischaemic heart disease was more common among males than females (p=1.62). CONCLUSIONS: The mortality rate in males was higher compared to females. The symptoms and risk factors associated with mortality varied between the genders.

Recurrent Dysphagia Associated with Esophageal Intramural Pseudodiverticulosis.

Esophageal intramural pseudodiverticulosis (EIPD) is a rare disorder of the esophagus characterized by the presence of outpouching flask-shaped lesions. These lesions represent false lumens that may be scattered throughout the esophageal wall. We present a rare case of EIPD complicated with esophageal strictures. The case is unique because the small lesions of EIPD remained undiagnosed for many years on prior esophagogastroduodenoscopy examinations until complicated with worsening symptoms of dysphagia due to esophageal stricture. The patient was managed with serial dilations of esophageal stricture. Diagnosing these lesions may be missed in early stages as the lesions are small and may require other radiological modalities to confirm the diagnosis. EIPD lesions itself can be managed conservatively with anti-inflammatory therapy and treatment of underlying risk factors. Those with severe disease and coexisting complications are managed with endoscopic or surgical interventions.

Endoscopic submucosal dissection using scissors-type knife for a giant solitary duodenal polyp.

Video 1.

Erratum to "Esophageal Pemphigus Vulgaris: A Rare Etiology of Upper Gastrointestinal Hemorrhage".

[This corrects the article DOI: 10.1155/2021/5555961.].

Esophageal Pemphigus Vulgaris: A Rare Etiology of Upper Gastrointestinal Hemorrhage.

Pemphigus vulgaris (PV) is an autoimmune blistering disorder of the skin and mucosal surfaces characterized by acantholysis (loss of adhesion between epidermal cells). Esophageal involvement of PV is an underdiagnosed entity as routine diagnostic endoscopy is not recommended in asymptomatic patients. Dysphagia and odynophagia are common presenting symptoms; however, upper gastrointestinal bleeding (UGIB) associated with esophageal involvement of PV without a history of mucosal blistering is extremely uncommon. We present a case of esophageal involvement of PV associated with active UGIB that was diagnosed on endoscopic evaluation. This case illustrated the importance of early endoscopy to identify the esophageal involvement of PV especially in patients with preexisting disease who present with gastrointestinal symptoms such as dysphagia, odynophagia, and hematemesis. Early recognition of esophageal involvement of PV and initiation of corticosteroid and/or immunosuppressant therapy may improve the outcome of the disease.

Endoscopic retrograde cholangiopancreatography guided interventions in the management of pancreatic cancer.

Pancreatic cancer is the leading cause of cancer-related morbidity and mortality with an overall five-year survival of less than 9% in the United States. At presentation, the majority of patients have painless jaundice, pruritis, and malaise, a triad that develops secondary to obstruction, which often occurs late in the course of the disease process. The technical advancements in radiological imaging and endoscopic interventions have played a crucial role in the diagnosis, staging, and management of patients with pancreatic cancer. Endoscopic retrograde cholangiopancreatography (ERCP)-guided diagnosis (with brush cytology, serial pancreatic juice aspiration cytologic examination technique, or biliary biopsy) and therapeutic interventions such as pancreatobiliary decompression, intraductal and relief of gastric outlet obstruction play a pivotal role in the management of advanced pancreatic cancer and are increasingly used due to improved morbidity and complication rates compared to surgical management. In this review, we highlight various ERCP-guided diagnostic and therapeutic interventions for the management of pancreatic cancer.

Association of splenic artery pseudoaneurysm with recurrent pancreatitis.

A pseudoaneurysm of the splenic artery (SAP) is a rare entity which is associated with pancreatitis in 52% of cases. In the presence of pancreatitis, the enzymatic damage to the wall of splenic artery results in pseudoaneurysm formation. The clinical presentation is variable and ranges from asymptomatic to hemodynamic instability. The diagnosis of SAP is challenging in the presence of peripancreatic fluid collection or pseudocyst, where CT abdomen can miss small pseudoaneurysms. Angiography is a useful modality to establish a definitive diagnosis. We present a 49-year-old male with a history of recurrent pancreatitis due to alcoholism who presented with acute abdominal pain and was found to have acute pancreatitis. Abdominal CT scan showed a peripancreatic fluid collection and hyperdense lesion at the splenic hilum, which was diagnosed as SAP on angiography. A transcatheter embolization was performed with complete resolution of symptoms thereafter.