Patient: Male, 85Final Diagnosis: Spontaneous bacterial peritonitisSymptoms: Abdomen distension • confusion • lethargyMedication: —Clinical Procedure: ParacentesisSpecialty: Gastroenterology and HepatologyObjective:Unusual clinical courseBackground:Spontaneous bacterial peritonitis is frequently described in cirrhotic patients who develop infected ascitic fluid. However, ascites can be cardiac in origin. The phenomenon of spontaneous bacterial peritonitis in cardiac as-cites is an extremely rare but deadly occurrence.Case Report:Here we present a unique case of a patient who was admitted for advanced cardiorenal syndrome in the setting of a viral colitis that likely promoted a bacterial translocation resulting in spontaneous bacterial peritonitis.Conclusions:This case tends to shed light on a few quintessential points for clinicians to be aware of, including the potential intersection between the microbiota and metabolic effects of congestive heart failure and the necessity to lower the diagnostic threshold for spontaneous bacterial peritonitis cardiac ascites in patient’s presenting for a congestive heart failure exacerbation.
Leptospirosis is a zoonotic disease caused by the spirochete Leptospira interrogans with a majority of cases occurring in the tropics. Diagnosing leptospirosis is challenging due to the variable and non-specific clinical presentation. While severe leptospirosis may present with renal failure, liver failure, and pulmonary hemorrhage, there are few described cases of renal failure and liver failure accompanied by pancreatitis and dysrhythmias, particularly in temperate climates. We present a case of severe leptospirosis presenting with bilateral calf pain, acute oliguric renal failure, acute liver failure, dysrhythmias, and pancreatitis. Clinicians must consider this diagnosis in temperate climates and consider testing and empirically treating for leptospirosis in patients with similar symptom constellations, vague symptoms, and lab abnormalities of unknown etiology.
The emerging field of immuno-oncology has brought exciting developments in the treatment of hepatocellular carcinoma (HCC). It has also raised urgent questions about the role of immunotherapy in the setting of liver transplantation, both before and after transplant. A growing body of evidence points to the safety and efficacy of immunotherapeutic agents as potential adjuncts for successful down-staging of advanced HCCs to allow successful transplant in carefully selected patients. For patients with recurrent HCC post-transplant, immunotherapy has a limited, yet growing role. In this review, we describe optimal regimens in the setting of liver transplantation.
Case Description/Methods: 66-year-old man with a history of intraductal papillary mucinous neoplasm (PMN) with high-grade dysplasia status post Whipple procedure two years previously, presented to the hospital with melena. His Whipple procedure had been complicated by splenic vein thrombosis and disease recurrence, necessitating further debridement three months prior to presentation. On examination, his vital signs were stable and there were no stigmata of liver disease. His laboratory tests were notable for a hemoglobin 8.0 g/dL (from baseline of 11 g/dL), platelets 174 3 109/L, BUN 29 mg/dL, INR 1.0. He initially underwent EGD and colonoscopy, which were unremarkable. A second look endoscopy was performed and deep intubation of the afferent limb revealed ectopic varices with stigmata of recent bleeding at the hepaticojejunostomy (Panel A). Cross-sectional imaging demonstrated a patent splenic vein but chronic occlusion of the portal and proximal superior mesenteric veins with cavernous transformation, extensive upper abdominal varices and splenomegaly (Panel B). There was no clinical or radiologic evidence of cirrhosis. After multidisciplinary discussion, an endovascular approach was deemed technically infeasible given extensive chronic mesenteric thrombus and a surgical approach was deemed prohibitively high-risk. The patient ultimately underwent endoscopic injection of 2-octyl cyanoacrylate into the ectopic varices and has remained without recurrent bleeding in over 5 months of follow-up. Discussion: Hemorrhage from ectopic jejunal varices following pancreatic surgery has previously been described in only a few case reports. Given the potential for vascular injury and local inflammation, these procedures can result in mesenteric venous thrombosis with subsequent ectopic variceal formation. If present, defining the vascular supply of varices with early multi-disciplinary involvement is paramount to their management. Multiple treatments have been reported, including portal venous stenting, embolization, and local sclerotherapy or cyanoacrylate injection as in this case.[2597] Figure 1. (A) Ectopic varices (yellow arrows) are noted in the afferent limb at the hepaticojejunostomy. (B) Coronal view of computed tomography scan of abdomen demonstrating large upper abdominal collaterals (red arrow) that drain close to the afferent limb (white arrow).
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