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.

Hepatitis of an Unknown Etiology with Concomitant ITP.

Alcoholic hepatitis (AH) usually presents after decades of alcohol consumption and can even manifest with recent abstinence. The clinical presentation may be compounded by underlying liver cirrhosis and liver function enzymes are not a reliable means of diagnosing AH due to poor sensitivity and specificity. One feature of alcoholic hepatitis is thrombocytopenia; however, patients may also have thrombocytopenia due to another underlying condition, such as Immune Thrombocytopenic Purpura (ITP). ITP is an autoimmune disease caused by autoantibodies against platelet glycoproteins. ITP is a diagnosis of exclusion and secondary causes of thrombocytopenia must be ruled out with persistent thrombocytopenia that is refractory to treatment for AH. Although there is limited data demonstrating a correlation between AH and ITP, both conditions respond to steroids. We present a case of a 42 YO M with an unknown cause of hepatitis and concomitant ITP who responded well to steroids.

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.

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.

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.

The Racial Divide: A Follow Up Study on Racial Disparity Amongst COVID-19 Survivors in an Urban Community.

Background: Studies have shown that COVID-19 has had a disproportionate effect on minority groups in both the clinical and social settings in America. We conducted a follow up study on patients previously diagnosed with COVID-19 one year ago in an urban community in New Jersey. The purpose of the study was to evaluate the socioeconomic impact of COVID-19 as well as assess for receptiveness towards COVID-19 vaccination amongst various ethnic groups. Methods: This was a prospective cohort study consisting of patients who had recovered from COVID-19 one year prior. The patients included in the study had a confirmed COVID-19 diagnosis in the months of March and April of 2020. This was a single institutional study conducted at St. Joseph's University Medical Center in Paterson, NJ from the months of March to April of 2021. Patients included in the study were either male or female aged 18 years or older. Patients who met criteria for inclusion were contacted by telephone to participate in a telephone survey. After informed consent was obtained, the patients completed a survey which obtained sociodemographic information pertaining to their diagnosis with COVID-19. Statistical analysis was performed using chi-square testing and multivariable logistic regression analysis. Results: Of the 170 patients enrolled in the study, the most common ethnicity was Hispanic (79/170 [46.47%]), followed by African American (46/170 [27.05%]). The gender distribution was 83 male (83/170 [48.82%]) and 87 female (87/170 [51.18%]) with a mean age of 51.5. Caucasians were the most willing to receive a COVID-19 vaccine (28/30 [93.3%]), followed by Asians (13/14 [92.8%]), Hispanics (63/78 [80.7%]) and African Americans (29/46 [63.0%]). Hispanics had the highest rate of job loss (31/79 [39.24%]), followed by of African Americans (16/46 [34.7%]). Hispanics were found to be in the most financial distress (31/79 [39.2%]), followed by African Americans (17/46 [36.9%]). Chi square analysis revealed Hispanics and African Americans were more likely to lose their jobs after being diagnosed with COVID-19 (p: 0.04). Hispanics and African Americans were also more likely to refuse vaccination with any of the available COVID-19 vaccines (p: 0.02). Multivariable Logistic regression analysis was then performed comparing both Hispanics and African Americans to Caucasians. Hispanics were more likely to lose their jobs compared to Caucasians (odds ratio, 4.456; 95% CI, 1.387 to 14.312; p: 0.0121). African Americans were also more likely to lose their jobs when compared to Caucasians (odds ratio, 4.465; 95% CI, 1.266 to 15.747; p: 0.0200). Discussion: Overall Hispanics reported the highest rates of financial distress after their diagnosis with COVID-19. Nearly 40% of the Hispanic lost their jobs following their diagnosis with COVID-19 which was the highest in our study group. African Americans were similarly affected with about 37% of all patients experiencing job loss and financial distress following diagnosis with COVID-19. Hispanics and african americans were the two ethnic groups who were least willing to receive COVID-19 vaccination. Only 63% of African Americans were willing to receive the vaccine, with 80.7% of Hispanics willing to become vaccinated. The most common reason for not receiving any of the COVID-19 vaccines was due to lack of trust in the vaccine. Both Hispanics and African Americans were more statistically likely to lose their jobs as well as refuse COVID-19 vaccination following diagnosis with COVID-19.

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.

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.

Encapsulating peritoneal sclerosis in liver transplant.

Encapsulating peritoneal sclerosis occurs due to chronic irritation of the peritoneal surface resulting in inflammation and fibrosis. Encapsulating peritoneal sclerosis usually occurs in patients requiring peritoneal dialysis (PD); however, it may also occur in liver transplant patients. The fibrosis in encapsulating peritoneal sclerosis could be severe enough to cause small bowel obstruction (SBO). Herein, we report a case of encapsulating peritoneal sclerosis secondary to liver transplantation that presented with SBO. The patient was started on Tamoxifen for encapsulating peritoneal sclerosis and evaluated at follow-up without any other intestinal obstruction episodes. This case demonstrates that encapsulating peritoneal sclerosis can occur as a liver transplant complication and present with small bowel obstruction.

Re-Educating Residents About Non-Invasive Colorectal Cancer Screening: An Approach to Improving Colon Cancer Screening Compliance.

BACKGROUND: Colorectal cancer is the third leading cause of cancer death; therefore early detection by screening is beneficial. Residents at a clinic in NJ, USA were not offering other forms of colon cancer screening when patients refused colonoscopy, which lead to the creation of the quality improvement project. METHODS: Residents practicing at the clinic were given an anonymous survey determining which method of colon cancer screening they used and which alternative method they offered when patients refused the original method. The residents were educated about all methods of colon cancer screening and the residents were resurveyed. RESULTS: A total of 64% of residents offered less invasive testing when colonoscopy was refused. Six months after education, 95% of residents offered less invasive testing when colonoscopy was refused. CONCLUSIONS: Early detection and removal of polyps by colonoscopy reduce the risk of cancer development. Colonoscopy is the gold standard for colon cancer screening; however other less invasive modalities are approved. This quality improvement project lead to offering the fecal immunochemical test or fecal occult blood test once patients refused colonoscopy at the clinic, increasing the number of patients receiving colorectal cancer screening, and thus providing better medical care.

Encapsulating peritoneal sclerosis in liver transplant

Encapsulating peritoneal sclerosis occurs due to chronic irritation of the peritoneal surface resulting in inflammation and fibrosis. Encapsulating peritoneal sclerosis usually occurs in patients requiring peritoneal dialysis (PD); however, it may also occur in liver transplant patients. The fibrosis in encapsulating peritoneal sclerosis could be severe enough to cause small bowel obstruction (SBO). Herein, we report a case of encapsulating peritoneal sclerosis secondary to liver transplantation that presented with SBO. The patient was started on Tamoxifen for encapsulating peritoneal sclerosis and evaluated at follow-up without any other intestinal obstruction episodes. This case demonstrates that encapsulating peritoneal sclerosis can occur as a liver transplant complication and present with small bowel obstruction.