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Acute acalculous cholecystitis is inflammation of the gallbladder without any evidence of gallstones. Although acalculous cholecystitis is less common than its calculous counterpart, it can be fatal if not treated. It is essential to rule out the cause of acalculous cholecystitis to aid in the treatment and management of the patient. We present a case of acalculous cholecystitis wherein a comprehensive workup found the etiology to be viral. Albeit rare, hepatitis A and cytomegalovirus can be causes of acute cholecystitis. Both viruses were observed simultaneously in this patient, proving it to be a unique case. This early diagnosis allowed conservative management of the patient, sparing him from unnecessary surgical intervention.

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Gastric volvulus is characterized by the abnormal twisting of the stomach along its axis. It is a rare condition that can develop secondary to an underlying gastrointestinal anatomic defect such as a hiatal hernia. Gastric volvulus may present acutely with symptoms of gastric outlet obstruction and can lead to potentially fatal complications, if not treated in a timely manner. We present the case of a 74-year-old woman who presented with an acute mesenteroaxial gastric volvulus with gastric outlet obstruction that developed secondary to a large hiatal hernia.

Hiatal translocation of the pancreas is rare because of its retroperitoneal location. Acute pancreatitis as a complication of hiatal hernia is uncommon. A 33-year-old man presented for 2 days of worsening epigastric abdominal pain and substernal chest pain. Laboratory studies were essentially unremarkable; however, computed tomography demonstrated a large right-sided hiatal hernia containing the entire stomach and the body of the pancreas, with peripancreatic edema consistent with pancreatitis. Most cases can be managed conservatively; however, elective surgical repair is suggested in severe cases or patients with low surgical risk.

Benign primary tumors are uncommon, with the majority of these tumors being leiomyomas; schwannomas of the esophagus are rare. Here, we present a case of a 78-year-old woman referred for complaints of intermittent dysphagia with a chest computed tomography scan showing a homogenous mass, compressing the esophagus. Upper gastrointestinal endoscopy revealed a submucosal mass, which was eventually diagnosed as a schwannoma after an endoscopic ultrasound with fine-needle aspiration and subsequent pathologic and immunohistochemical examination. Schwannomas could be managed conservatively.

INTRODUCTION: Median Arcuate Ligament Syndrome (MALS) is often under-diagnosed due to its rarity and overlap of symptomatology with other abdominal pathologies. The pathology involves the median arcuate ligament compressing the celiac artery leading to chronic, postprandial abdominal pain, nausea, vomiting, and weight loss. Making the diagnosis is complicated by a lack of sensitive diagnostic modalities. CASE DESCRIPTION/METHODS: A 69-year-old female with a history of emphysema, scoliosis, and interstitial cystitis presented for severe postprandial abdominal pain, nausea, vomiting, and anorexia from fear of food. She had a standing diagnosis of chronic ischemic mesenteric colitis for years. On examination, she had diffuse abdominal tenderness with radiation down to her upper thighs, nausea, vomiting, and cachexia. The initial labs were unrevealing. CT abdomen demonstrated severe arteriosclerosis of the celiac artery with 75% stenosis, as well as moderate stenosis of SMA, IMA, and bilateral renal arteries. Despite an inconsistent physical exam, vascular surgery agreed with the reading of ischemic colitis and suggested that a celiac stent be placed. Upon further review of the CT and an interdisciplinary conference, her images were determined to be consistent with celiac artery compression. The patient is to be scheduled for the release of the median arcuate ligament with a possible celiac nerve block. DISCUSSION: When suspecting MALS, a triad of postprandial abdominal pain, weight loss, and abdominal bruit may be the only findings to suggest the diagnosis. With our patient not having a bruit and imaging showing severe stenosis, this only made the diagnosis of MALS even more discrete. Imaging may show a narrowing of the celiac artery for further clues followed by confirmation testing via: • Inspiratory/Expiratory ultrasonography – may show an increased visible compression of the artery during expiration with the increased blood flow velocity. • Gastric Tonometry – physiological testing, as well as measurements of arterial PaCO2 levels before and after exercise, may also be used to predict the success of decompression. • Ganglion Nerve Block – percutaneous celiac ganglion block, using an anesthetic to block nerve fibers of celiac plexus, which may be diagnostic and therapeutic. This case presents the difficulty of diagnosing MALS due to its overlap with the more common ischemic colitis. Having a keen clinical suspicion with a better understanding of the workup for MALS may prevent misdiagnoses and misguided therapies.

INTRODUCTION: CA 19-9 is a tumor marker associated with pancreatic and biliary tumors that can be directly measured in the blood with a normal range of 0-37 units/mL. Other inflammatory conditions such as biliary obstruction can also cause an elevation, which can obfuscate the diagnostic and prognostic value of CA 19-9. CASE DESCRIPTION/METHODS: A 66-year-old male with no medical history presented with a 1-month history of abdominal pain, jaundice, and weight loss. He was febrile at 100.4 F. Bilateral conjunctival icterus, full upper body jaundice, hepatomegaly, and mild tenderness to deep palpation in the right upper quadrant and epigastric regions were noted on exam. Gallbladder ultrasound revealed significant common bile and intrahepatic duct dilation concerning for obstructive lesion with no gallstones and minimal sludge. Total bilirubin was 27 mg/dL. CA 19-9 was elevated at 9,272 units/mL. CT abdomen and pelvis with contrast confirmed severe common bile and intrahepatic duct dilation with CBD measuring up to 22 mm. MRCP revealed marked intrahepatic and extrahepatic biliary dilation with dilated CBD up to 24 mm and choledocholithiasis with the largest gallstone measuring 15 mm in the distal CBD. ERCP revealed CBD stricture and sphincterotomy was performed with temporary stent placement. Ceftriaxone and metronidazole were given for ascending cholangitis. Fine needle aspiration was done by EUS, which was negative for malignancy on pathology. Repeat MRCP showed improvement in dilation and CBD now at 14 mm. Repeat CA 19-9 was 193 units/mL. Of note, CT chest with contrast did not reveal any evidence of pulmonary metastasis, CEA level was normal, and hepatitis panel was negative. DISCUSSION: A CA 19-9 cutoff of greater or equal to 300 unit/mL have been reported to have a specificity of 87% for cancer in patients with cholangitis. However, an extremely elevated CA 19-9 level does not always equal cancer or correlate with tumor burden and should not be used as the sole criterion for a diagnosis of malignancy. Non-cancerous causes of elevated CA 19-9 include gallstones, cholangitis, bile duct obstruction, and pancreatitis. EUS was critical in obtaining tissue to exclude pancreatic and biliary cancer. CA 19-9 and total bilirubin levels dropped after CBD stent placement, supporting a diagnosis of cholangitis without tumor. This is a rare case of extreme tumor marker elevation caused by choledocholithiasis and cholangitis, which serve as a cautionary tale of not relying too heavily on numbers to treat the patient.