Introduction Patients that are presented with acute calculus cholecystitis (AC) and elevated liver enzymes markers (LEM), often require evaluation for concurrent choledocholithiasis (CDL). Currently, evaluation guidelines follow the American Society of Gastroenterology Endoscopy (ASGE) recommendations. Objectives The aim of the study was to externally validate both ASGE and the Chisholm predictors in a community hospital patient cohort. Methods We conducted a retrospective study of patients who presented to Ascension Saint John hospital with AC and elevated LEM over a period of two years. Sensitivity (SEN), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV) were used to test the external validity of ASGE and Chisholm algorithms. Results A total of 132 patients' charts were reviewed, and 87 patients included. Chisholm predictors SEN, SP, PPV and NPV were 50%, 82%, 18%, and 95% respectively versus 100%, 19%, 8%, 100% for the ASGE predictors model. In the ASGE module, SP and PPV can be significantly improved to 60% and 13%, respectively, by changing a few risk categories including age and LEM range. Conclusions External validation of the Chisholm module in our patient cohort showed that it would lead to a low referral rate for unnecessary imaging and thus might be more cost-effective, especially when compared to current ASGE recommendations which would have a higher referral rate. On the other hand, current ASGE recommendations successively labeled all the patients with CDL, while the Chisholm module missed around 50 percent. We also observed that with the current ASGE module, the referral rate for further imaging and diagnostic tests can be possibly improved by adjusting a few of the predictors including the age and the abnormal liver transaminases range, but this observation is arbitrary and will need to be validated in a larger cohort study.
INTRODUCTION: Duodenal diverticula are relatively common findings in the small bowel with reported prevalence ranging between 0.6–22%. The vast majority of them are asymptomatic and found incidentally. We present an unusual case of hemorrhagic shock resulting from bleeding duodenal diverticula. CASE DESCRIPTION/METHODS: A 46-year-old male with history of alcohol abuse presented with 1-day history of multiple episodes of hematochezia and dark tarry emesis. He had associated lightheadedness, dyspnea, diaphoresis along with 1 episode of syncope. He did not use any medications on regular basis. His heart rate was 125 beats/minute and blood pressure 99/53 mmHg. Labs included hemoglobin (Hgb) of 4.5 gm/dL, platelets 75000/mcL, creatinine 1.81 mg/dL and lactic acid 4.4 mmol/L. Patient was subsequently intubated for airway protection due to recurrent episodes of hematemesis. An esophagogastroduodenoscopy (EGD) showed 3 large diverticula in the second portion of duodenum with active bleeding noted from a non-periampullary proximal diverticulum (Figure 1). Hemostasis was achieved with epinephrine injection followed by Hemospray. A follow up arterial angiogram was unremarkable. Patient experienced recurrent bleeding within 48 hours requiring 2 additional EGDs with therapeutic interventions (epinephrine, ablation and endoclips). Repeat angiography was done due to persistent drop in Hgb. This time, an area of irregularity in one of the gastroduodenal artery branches was identified adjacent to the previously placed endoclips. Coil embolization was performed successfully with excellent results. Patient’s condition eventually stabilized without any recurrent bleed. Upon follow up, his Hgb was 10.7 gm/dL 3 weeks after discharge. DISCUSSION: The majority of duodenal diverticula are asymptomatic. About 1% result in complications requiring definite endoscopic or surgical intervention. Potentially fatal bleeding represents minimal proportion of these complications and its management can be challenging. Our case demonstrates an extreme example of massive gastrointestinal bleeding that was difficult to control despite multiple endoscopic interventions. Initial angiography was not successful to identify the bleeding. Applying endoclips helped to subsequently localize and control the source of bleeding in the second angiogram. Using this approach can be an invaluable asset in such conditions.
INTRODUCTION: Sarcomas are a rare, heterogeneous group of neoplasms with varied histolopathological presentation, that share a common mesenchymal cell line origin. Soft tissue sarcomas tend to grow along tissue planes and can compress surrounding tissue, leading to the formation of pseudocapsules and finger-like projections that can infiltrate into adjacent tissue. Despite this, sarcomas rarely metastasize to regional lymph nodes. Sarcomas in the gastrointestinal tract encompass both gastrointestinal stromal tumors (GISTs) and leiomyosarcomas, which are rare neoplasms arising from smooth muscle cells and commonly misdiagnosed at GISTs. Mesenteric leiomyosarcomas usually present as a gradually enlarging, painless abdominal mass with associated symptoms usually arising from compression by the tumor. CASE DESCRIPTION/METHODS: A 68-year-old African-American female with history of hypertension, diabetes mellitus, and latent tuberculosis presented with decreased oral intake secondary to nausea, vomiting, and diarrhea for 2 days and unintentional 10-pound weight loss over a 2-month period. Physical examination revealed right upper quadrant tenderness. Computed tomography (CT) with IV contrast of the chest, abdomen, and pelvis showed a large right-sided solid mesenteric tumor causing extrinsic compression of the proximal and mid-portion of the right ureter with prominent right-sided hydronephrosis. CT guided biopsy revealed a smooth muscle neoplasm concerning for leiomyosarcoma with uncertain malignant potential. A right-sided ureteric stent was inserted to relieve extrinsic compression. An explorative laparotomy showed the tumor to be encasing the right ureter. Excision of the tumor along with right mid ureter was done with restoration of ureteric continuity via ureteroureteral anastomosis. DISCUSSION: Mesenteric leiomyosarcomas are rare and aggressive soft tissue tumors most commonly arising in the ileum. Biopsy is not recommended for local resectable tumors; however, it should be considered if metastatic disease is suspected or if preoperative imatinib is being considered prior to resection in the setting of a large locally advanced lesion. Treatment options depend on invasion of adjacent structures, including either local or en bloc resection. However, no nodal dissection is needed due to the rarity of nodal metastases.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.