BACKGROUND Literature has suggested that imaging is over-utilized in the diagnosis of pancreatitis. If the diagnosis of acute pancreatitis (AP) is established with abdominal pain and increased serum amylase or lipase activity without systemic signs of severe disease, computed tomography (CT) imaging may not be necessary. We hypothesize that among patients with uncomplicated acute pancreatitis (AUP), there is a significant number of unwarranted CT imaging studies. This imposes increased expenditure and cost in our healthcare system and does not improve hospital stay or management of AUP. AIM To assess the overutilization and associated cost of CT imaging among patients meeting diagnostic criteria for AUP. METHODS In this Institutional Review Board-approved retrospective, single-center study, we identified all adult patients admitted with AP from January 1, 2012 through October 1, 2017. Patients were identified via International Classification of Diseases (ICD-9) code for AP (577.0) and ICD-10 codes for different etiological AP (K85.9 unspecified, K85.0 idiopathic, K85.1 biliary, K85.2 alcohol-induced, K85.3 drug-induced, and K85.8 other). Diagnosis was confirmed by chart review using established non-imaging diagnostic criteria (presence of typical abdominal pain and elevated lipase or amylase greater than 3 times upper limit of normal). Ranson criteria and BISAP scores on presentation were calculated and patients that met scores less than or equal to 2 for both were included to suggest AUP. The utilization and cost of imaging in these patients were recorded. RESULTS Between January 2012 and October 2017, 1305 patients presented to the emergency department with AP, and 405 patients (31%) met our inclusion criteria for AUP (201 males, 204 females; mean age 49 years, range 18-98). Of those, 210 patients (51.85%) underwent CT imaging. One patient (0.47%) had evidence of pancreatic necrosis, one patient had cyst formation (0.47%), and the remaining 208 patients (99.05%) had either normal CT scan imaging or findings consistent with mild AP without necrosis. The average cost of CT scan imaging was $4510 with a total cost of $947056. Median length of hospitalization stay was 3 d among both groups. Combining Ranson’s Criteria and BISAP score identified AUP in our patient population with an accuracy of 99.5%. CONCLUSION CT imaging is unnecessary when AUP is diagnosed clinically and biochemically. Reducing overuse of diagnostic CT scans will decrease healthcare expenditure and radiation exposure to patients.

Eosinophilic enterocolitis is a rare condition representing the least frequent manifestation of eosinophilic gastrointestinal disorders. We report a 49-year-old man who presented with abdominal pain, diarrhea, and intractable vomiting for 2 weeks. Abdominal computed tomography demonstrated gastric wall thickening with mural wall thickening of the small intestine and colon. Endoscopy revealed gastric outlet obstruction because of luminal stenosis from duodenal edema. Peripheral eosinophilia, endoscopic mucosal biopsies, and exclusion of differential diagnoses confirmed eosinophilic enterocolitis. The patient was successfully treated with a 4-week prednisone taper.

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Tuberculosis is an insidious infection that has followed human beings for centuries. Esophageal disease is an importation presentation of extrapulmonary tuberculosis that results from the proximity of pulmonary lymph nodes to the middle esophagus. It develops as a secondary infection due to mycobacterial lymphatic spread, rather than a primary infection. Mycobacterium tuberculosis complex is the most common agent seen, but M abscessus, chelonae, and avium complex have been reported. The symptoms most frequently reported are dysphagia and noncardiac chest pain. Endoscopic evaluation generally shows mucosal ulcerations (56%) or an extrinsic bulge in the middle third of the esophagus (62%).

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