Computed tomography scan imaging in diagnosing acute uncomplicated pancreatitis: Usefulness vs cost.

BACKGROUND: Literature has suggested that imaging is over-utilized in the diagnosis of pancreatitis. If the diagnosis of acute pancreatitis (AP) is established with abdominal pain and increased serum amylase or lipase activity without systemic signs of severe disease, computed tomography (CT) imaging may not be necessary. We hypothesize that among patients with uncomplicated acute pancreatitis (AUP), there is a significant number of unwarranted CT imaging studies. This imposes increased expenditure and cost in our healthcare system and does not improve hospital stay or management of AUP. AIM: To assess the overutilization and associated cost of CT imaging among patients meeting diagnostic criteria for AUP. METHODS: In this Institutional Review Board-approved retrospective, single-center study, we identified all adult patients admitted with AP from January 1, 2012 through October 1, 2017. Patients were identified via International Classification of Diseases (ICD-9) code for AP (577.0) and ICD-10 codes for different etiological AP (K85.9 unspecified, K85.0 idiopathic, K85.1 biliary, K85.2 alcohol-induced, K85.3 drug-induced, and K85.8 other). Diagnosis was confirmed by chart review using established non-imaging diagnostic criteria (presence of typical abdominal pain and elevated lipase or amylase greater than 3 times upper limit of normal). Ranson criteria and BISAP scores on presentation were calculated and patients that met scores less than or equal to 2 for both were included to suggest AUP. The utilization and cost of imaging in these patients were recorded. RESULTS: Between January 2012 and October 2017, 1305 patients presented to the emergency department with AP, and 405 patients (31%) met our inclusion criteria for AUP (201 males, 204 females; mean age 49 years, range 18-98). Of those, 210 patients (51.85%) underwent CT imaging. One patient (0.47%) had evidence of pancreatic necrosis, one patient had cyst formation (0.47%), and the remaining 208 patients (99.05%) had either normal CT scan imaging or findings consistent with mild AP without necrosis. The average cost of CT scan imaging was $4510 with a total cost of $947056. Median length of hospitalization stay was 3 d among both groups. Combining Ranson's Criteria and BISAP score identified AUP in our patient population with an accuracy of 99.5%. CONCLUSION: CT imaging is unnecessary when AUP is diagnosed clinically and biochemically. Reducing overuse of diagnostic CT scans will decrease healthcare expenditure and radiation exposure to patients.

Isolated hepatic artery thrombosis leading to multiple liver infarcts in a non-transplant patient.

BACKGROUND: Isolated hepatic artery thrombosis is an extremely rare condition with only a few cases reported in the literature. CASE REPORT: A 62-year-old woman presented with a 5-day history of right upper quadrant abdominal pain associated with nausea and vomiting. Physical examination revealed right upper quadrant tenderness. Her initial laboratory work was significant for elevated aspartate aminotransferase and alanine aminotransferase levels (745 and 431 U/L, respectively). A computed tomography of her abdomen showed a thrombus within the hepatic artery, with multiple hepatic infarcts but no evidence of portal vein thrombosis. Hypercoagulability workup was unremarkable; she did not have any evidence of atrial fibrillation on ECG or telemetry. She was treated with subcutaneous low molecular weight heparin. Over the course of her hospitalization, her AST and ALT levels peaked to 2065 and 1217 U/L respectively, and trended down thereafter. CONCLUSIONS: We believe that our case is unique for 2 reasons: 1) Our patient did not undergo any procedure that may have precipitated hepatic artery thrombosis and 2) Despite the absence of concurrent portal vein thrombosis, she had biochemical and imaging findings of hepatic ischemia.

Gastric Intestinal Metaplasia in an Underserved Population in the USA: Prevalence, Epidemiologic and Clinical Features.

Gastric intestinal metaplasia is an important stage in the development of gastric cancer. Limited data is available regarding the prevalence of gastric intestinal metaplasia in the United States. We conducted a retrospective review of esophagogastroduodenoscopies performed in our endoscopy unit between the months of April and October 2010 to evaluate the prevalence and the epidemiologic and endoscopic features of gastric intestinal metaplasia in an underserved population in the United States.

An 80-year-old female with double positive disease: Case report and brief review of literature.

BACKGROUND: Goodpasture's syndrome is a triad of alveolar hemorrhage, Glomerulonephritis and circulating anti Glomerular basement membrane antibodies, 25% of cases test positive for ANCA antibodies, this association is known as Double positive disease. This article describes a rare presentation of this entity and reviews available literature. CASE REPORT: 80 year old female presented with hemoptysis and renal failure, she tested positive for both p ANCA and anti glomerular basement membrane antibodies, and despite aggressive medical treatment, she suffered a frustrating outcome. CONCLUSIONS: Double positive disease accounts for 25% of cases of Goodpasture's syndrome, a suggested Pathophysiology of this association is the renal involvement in ANCA Vasculitis leading to the exposure of antigens from the basement membrane and the formation of antibodies. This entity is believed to carry better prognosis when compared to isolated anti glomerular basement membrane disease.