Bile leaks are a rare occurrence most often seen as a complication of cholecystectomy. Other less common etiologies include endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), liver surgery, percutaneous drainage of liver abscesses, living donor hepatectomy, and non-iatrogenic abdominal trauma. In this case study, we present a 67-year-old female with morbid obesity who presented with abdominal pain and was diagnosed with a spontaneous bile leak. She had no history of recent surgery or abdominal trauma. CT revealed that the patient's gallbladder was located in the right lower quadrant, most likely due to mass effect from a large ventral hernia, and possible fluid collection extending from the gallbladder along the surface of the anterior inferior right hepatic lobe. Hepatobiliary iminodiacetic acid (HIDA) was performed due to a concern for cholecystitis. HIDA demonstrated a bile leak in the right upper abdomen of unknown etiology. Initially, there was a concern for gallbladder obstruction. Gastroenterology recommended magnetic resonance cholangiopancreatography (MRCP), however, MRCP was not possible due to the patient's body habitus. The patient had normal liver function tests, was tolerating oral intake, and her abdominal pain resolved, therefore, we became less suspicious of gallbladder obstruction. This case suggests that bile leak should be included in the differential diagnosis for abdominal pain even in patients who have not had recent abdominal surgery or procedures. This case also highlights the unique anatomical finding of a right lower quadrant gallbladder secondary to mass effect from a large ventral hernia.
Plummer-Vinson syndrome (PVS) presents with the classic triad of iron-deficiency anemia, dysphagia, and esophageal webs. The mainstay treatment of PVS is iron supplementation and the dysphagia usually responds to iron supplementation before the hematologic abnormalities are corrected. This syndrome classically affects middle-aged Caucasian women and very few cases have been reported in African Americans. We present a rare case of PVS in an African-American woman. A 63-year-old woman presented with shortness of breath, dysphagia, and lightheadedness for several weeks. Chest X-ray was negative for any acute abnormalities. Initial hemoglobin was 7.0 g/dL, which improved to 7.5 g/dL after 1 unit of packed red blood cells. She had a mean corpuscular volume of 62 fL, a ferritin level of 6 ng/mL, and an iron level of 12 μg/dL. Fecal occult blood test was negative and barium swallow revealed a proximal esophageal web. Her dysphagia did not significantly improve despite intravenous iron supplementation and esophageal web dilation. Video-fluoroscopic swallow study revealed esophageal and pharyngeal phase dysphagia with food entrapment. She was discharged with plans to follow up with a primary care physician and repeat esophagogastroduodenoscopy in 1 year. This case report highlights a rare case of PVS in an African-American woman and emphasizes the importance of maintaining a comprehensive and broad differential diagnosis.
Opioid-associated amnestic syndrome (OAS) is a relatively new condition that is associated with opioid abuse and has increased in prevalence since the notable rise in opioid-related deaths and opioid-related hospitalizations of the opioid crisis. Patients often present with acute anterograde amnesia and current opioid abuse, most commonly fentanyl. OAS is frequently diagnosed when other potentially infectious or metabolic conditions such as encephalitis and seizures are ruled out, as these conditions can also present similarly to OAS. This case highlights the signs, symptoms, and hallmark characteristics of OAS, including bilateral hippocampal edema and anterograde amnesia.
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