Case

EAMCERC 2014

CASE 1EP, 34 Female

CC: Fever 1 month PTAFever Tmax 38.9Non-productive coughEpigastric painWorked up - normal2 weeks PTAIncreased severity of epigastric pain, with associated vomiting, no diarrheaPersistence of feverAdmission

PMHx:IgA nephropathy 2009 - on Prednisone Bronchial asthma 2012Persistent chronic epigastric pain x~1year- s/p EGD 2013: Gastritis(-) HPN, DM, PTBFHx:UnremarkablePSHx:Non-smokerNon-alcoholic beverage drinker Denies illicit drug use

PE:Conscious, coherent, not in CP distressBP 120/80 CR 90 RR 18 Temp 38.9CPink palpebral conjunctiva, anicteric scleraeSupple neck, cervical lymphadenopathiesSymmetrical chest expansion, no retractions, clear breath soundsAdynamic precordium, AB 5th ICS L MCL, no murmursGlobular abdomen, NABS, soft, tenderness at the epigastric and RUQ area, no organomegaly, no massPulses full and equal, no edemaDRE: no mass, no melena

Course in the wardManaged as a case of fever of unknown originLaboratory work ups: CBC Chest CT scan Blood CS Whole abd CT scan Typhidot Serum Galactomanan 2D echoAmylase, Lipase Urinalysis

Most common cause accounting for 40% of cases6

CBC:HGB10.2HCT0.31WBC16.83NEUTRO85.6LYMPHO4.6MONO8.6PLT385

Urinalysis:YellowClearSG 1.020PH 6.0Protein +2Glucose NegWBC 2/hpfRBC 2/hpfEpith cells 2/hpfBacteria 5/hpf

CC:Na134K4.8Cl97.0Crea176.8Amylase66Lipase18

Blood CS: no growthTyphidotIgG, IgM: Negative

Chest CT:Pulmonary tuberculosis with miliary spread and/ or pneumonia with atypical presentation

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Interpret whole abdominal CT scan

Whole abdominal CT:Ill-defined nodular density, ileo-cecal area, and mesenteric fat strandingRenal Cortical cysts, bilateralLeft adnexal cystPara-aortic and paracaval lymphadenopathy

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What is your impression? What are your differential diagnoses?What is your next diagnostic plan?Interpret EGD

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4/25Mucosa of the cardia, fundus, body was slightly edematous and erythematousNote of deep ulceration at D2 opposite the ampulla, approximately 1.5 cmNote of 0.3cm mucosal opening adjacent to the ulcer but without any evident discharge nor bleeding. Biopsy not done due to mucosal friability

Meds: Nexium 40mg IV ODDiet: Gen liqPlan: Upper GI series

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What is your impression?Interpret colonoscopy

4/25 started on Anti-Kochs

Ileocecal valve was noted to be markedly edematous with multiple circumferential ulcerations. A deep ulcer was noted at the cecal pole with multiple nodularities seen in the periphery. Multiple biopsies were taken. Terminal ileum was not visualised due to markedly edematous ileocecal valve with stenosis.16

What would be your next diagnostic plan?Interpret upper GI series

Plan: 1. Conservative management 2. Endoscopic closure of fistula using histoacryl glue and endoclip 3. Surgical correction

Soft diet

Shifted back to clear liquids; started on Kabiven20

What is your final impression?What would be your plan of management?

What is the ideal management in dealing with fistula?

4/29Duodeno-colonic fistulas/p Histoacryl instillation on the fistula TramadolMetoclopromide

Plan: Repeat upper GIS after 2 weeks

THM: 5/31: Nexium, BID Itopride 30mg TID23

Colonic-duodenal fistulas are rare, and may be secondary to benign or malignant conditionsMost common lesion - carcinoma of the transverse colon

Xenos E S, Halverson J D. Duodenocolic fistula: case report and review of the literature. J Postgrad Med 1999;45:87

Carcinoma of the gallbladder and pancreas has also been cited as a causative factor.' 26

Of the reported cases of benign duodenocolic fistula, 30 have followed disease primarily in the duodenum - peptic ulcer, diverticulum and as a sequel to gastrectomyColonic disease - regional enteritis, ulcerative c olitis, appendicitis, diverticulosis coli and typhoid fever accounted for 20

Benign Duodenocolic FistulaA Report of 3 CasesJ. R. McQUAIDE. G. NAIDOOSouth African Medical Journal p600-604. Apr 7 1979

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Gallbladder - cholecystitis and biliary tract surgery for 17The origin was uncertain in 23 cases-developmental, tuberculosis, foreign body, etc.

J. R. McQuaide. G. Naidoo. Benign Duodenocolic Fistula, A Report of 3 Cases.South African Medical Journal. 1979.600-604

Clinical Presentation

Diarrhea - occasionally bloody and often intermittentWeight loss Upper abdominal colicky painVomiting or foul eructations

1. The diarrhoea, which is a constant feature, was originally attributed to the direct passage of duodenal contents to the colon, thus bypassing the small bowel. Most evidence now favours the theory that retrograde passage of colonic contents into the duodenum with inevitable bacterial contaminationcauses jejunitis and intestinal hurry. (The diminution of symptoms after proximal colostomy, or after the use of antibiotics capable of controlling colonicbacteria, supports this theory.)

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Symptoms tend to be episodic, with short exacerbations and long remissions.Emaciation follows, with electrolyte imbalanceSuperimposed on these basic features may be other signs and symptoms due to the primary condition

2. Emaciation follows, with electrolyte disturbances due to the diarrhoea, oedema due to hypoproteinaemia, and anaemia which may be hypochromic or macrocytic.3. . There may be a long history of postprandial dyspepsia due to a peptic ulcer, jaundice and severe colic in cholecystitis, or symptoms suggesting granulomatous colitis.

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TreatmentCurrent therapeutic options include medical treatment and surgical management.Spontaneous healing of fistulas without treatment is rare.Various placebo-controlled clinical trials of medical treatment have shown a fistula self-closure rate of only 6% to 13%.

The goal of treatment should be permanent closure of the fistula.

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For symptomatic internal fistulas, surgical resection of the affected bowel segments was required. Small fistulas can be occluded with fibrin glue or clipping by endoscopy whereas in large fistulas, endoscopic therapy with a detached endoloop and hemoclips is an alternative bridging method until final surgical repair.

10. von Renteln D, Denzer UW, Schachschal G, Anders M, Groth S, Rosch T. Endoscopic closure of GI fistulae by using an over-the-scope clip (with videos). Gastrointest Endosc 2010;72:1289- 1296. 11. Caruso A, Manta R, Melotti G, Conigliaro R. Endoscopic treatment of a large post-surgical fistula using combined fibrin glue spray and vicryl mesh. Dig Liver Dis 2012;44:85-86. 12. Park MS, Kim WJ, Huh JH, et al. Crohns duodeno-colonic fistula preoperatively closed using a detachable endoloop and hemoclips: a case report. Korean J Gastroenterol 2013;61:97-102. 13. El-Hajj II, Abdul-Baki H, El-Zahabi LM, Barada KA. Primary 32

A review of the English literature showed only sixty-three cases of CD with coloduodenal fistula. Surgery remains the mainstay of therapy. Meng-Tzu Weng, Shu-Chen Wei, Yu-Wen Tien, I-Lun Shih, Jau-Min Wong. Crohns Disease Complicated with Duodenocolic Fistula: A Case Report

Case series have described the successful use of cyanoacrylate glues for the endoscopic treatment of refractory bile leaks, pancreatic fistulae and a variety of other GI tract fistulae; however, there are no controlled trials.

Seewald S. et.al. Endoscopic treatment of biliary leakage with n-butyl-2-cyanoacrylate. Gastroint Endosc 2002; 56:916-9

Seewald S. et.al. Endoscopic treatment of biliary leakage with n-butyl-2-cyanoacrylate. Gastroint Endosc 2002; 56:916-934

A recent randomized trial comparing fibrin glue with observation only for Crohns patients with anal fistulae found higher closure rates in the glue patients (38% vs 16%, P Z.04)Numerous case series report achieving prompt closure with the use of fibrin glue for enterocutaneous fistulae, including persistent gastrocutaneous fistulae after gastrostomy tube removal.

Fibrin glue has been used to close esophageal perforations in case reports.A single case report exists with successful closure of a duodenal perforation with fibrin glue.

A case report in which a covered colonic stent was used successfully to close the fistula by using an anooral guide wire (body floss technique).Shubhang Kulkarni, et.al. Covered Stent Placement for Duodenocolic Fistula: A Novel Use of the Body Floss Technique. Journal of Vascular and Interventional Radiology.Pages729730, May 2011

End of first case

Case 2EB, 38 MaleCC: Jaundice and melena7 years PTA: JaundiceLocal hospital:SGPT = 177SGOT = 151ALP= 441HBsAG = NRUTZ: enlarged left liver lobelow normal sized right liver lobe with several parenchymal calcificationleft intrahepatic duct calculi Intrahepatic ducts are mildly dilated 4.6x3.8 cm hyperechogenic focus at region of porta hepatisHepatobiliary TBTB-DOTS x 6monthsLost to follow-up

5 years PTA: Persistence of jaundiceHematocheziaEGD: UnremarkableColonoscopy: Not consentedCT SCAN whole abdomen: enlarged left liver lobeatrophied right liver lobe with several parenchymal calcifications segmental narrowing over D1-D3 and sigmoid areaTreated with anti-kochs for 6 months but lost to follow up

2 days PTA: Melena 2x/day ~ 50ml per episodeEpigastric pain 8/10 no radiation to the backNo hematocheziaStill with jaundiceAt the ER: Hematochezia ~400mLBP 80/50 mmHg, CR 110/minAdmission

PPMHx:(+) Hepatobiliary TB treated x 6 months 2007(-) HPN, DM, dyslipidemia, hepatitis(-) renal disease(-) allergies, asthma(-) cancer, stroke, heart attack(-) trauma and surgeryPSHx:Non-smokerNon-alcoholic beverage-drinkerPrevious use of illicit drugs stopped 4 years agoFHx:No liver disease, cancer, stroke, DM(+) HPN

ROS:(-) cough(-) dyspnea, chest pain, palpitations(-) constipation, diarrhea(-) dysuriaPE:Awake, alert, coherentBP= 80/50, CR= 110/min, RR= 18 Temp= 37; BMI= 22Pale palpebral conjunctiva, icteric sclera, no active dermatosesNon-hyperemic PPW, supple neck, no cervical LADSymmetrical chest expansion, clear breath soundsAdynamic precordium, AB 5th LICS MCL, (-) murmursAbdomen flabby, normoactive, soft, no masses and tenderness. liver span 10 cm from MCL, traubes space obliterated, no caput, no spider angiomaPulses poor and equal, no edema and cyanosisDRE: red stool tactating finger

CBC:6/277/4HGB8666HCT269197WBC7.910.8NEUTROPHILS6480LYMPHOCYTES3017PLT191298

CC:6/277/4NA134135K3.83.9BUN5.8CREA12288

6/27PT INRTB5 mg/dlDB3 mg/dlIB1.1mg/dlalbumin25.47AST114ALT113ALP 620HBsAgNRAnti-HBSNRAnti-HCVNR

What are your differential diagnoses?What is your diagnosis?What is your next diagnostic plan?Interpret the endoscopy

What is your next diagnostic plan?Interpret duodenoscopy

What is your diagnosis?What is your next diagnostic plan?Interpret CT angiogram

Lobulated vascular structure within dilated CHD ( consider a vascular malformation or pseudoaneursym from a branch of right hepatic artery)Mildly dilated IHD, CBD, distended GB & cystic duct secondary to iso to hyperdense foci in CHD & CBD (most likely blood clots)Contracted right liver lobe and enlarged left liver lobe with chronic liver parenchymal disease and calcificationsDistented GB with thickened walls and soft calculiTiny CHD calculusProminent spleenParaesopahgeal,perigastric,peripancreatuc and perisplenic varices

HEPATIC ARTERY ANEURSYM12% of visceral aneurysm20% Intrahepatic 30% right hepatic artery 2nd to common hepatic arteryTuberculosis incidence?

Abbas J Vasc Surg 2003Taylor Postgrad Med J 1986

80% extra, 64 common hepatic, left 4, both right and left 2, multiple Atherosclerosis 32%, acquired degeneration of media 24%, iatrogenic and trauma 22%, less common syphilis, tb, PN, cholecystitis60

TUBERCULOSISMost saccular, pseudoaneurysm and rapid growthMechanismErosion of vessel wall by contiguous focus of TBDirect seeding of the intima, adventitia or media via vasa vasorum

TSURUTANI Int. Med 2000Husen annals Saudi Med 1997

HEPATIC ARTERY ANEURSYMQuinckes triad of hemobilia (jaundice, right upper quadrant pain, bleeding) 1/3 of cases Risk of rupture 14%Rupture biliary tree 41%Mortality 40%Angiography gold standard

Trauman Mays Surg Clinics of N.A. 1977Harlaftis Amer Journal of Surg 1977Singh world Journal of Gastroenterology 2006

Majority asymptomatic, abd pain 55%, hemorrhage 46%, peritonela cavity 43% rapidly fatal, stomach or duodenum 11%, portal vein 5%Rupture multiple, non atherosclerotic, size? 2cm range previously (erskine 1977), PN UTZ and CT may be diagnostic62

HEPATIC ARTERY ANEURSYM - TREATMENTEndovascular technique (preferred) (Lumsden 1996)Coils (large feeding vessel), particular embolics, glue, or Onyx )Complications (Abbas 2003)Short term hepatic ischemia, abcess and cholecystitisLong term- recanalization

Surgery risk of hepatic necrosis small26 collaterals liver (Michles 1966)Ligation, excision, endoaneurysmorrhaphy, wrapping. Wiring, hepatic lobectomy, suture of aneurysm to liver (Ariyan 1975)High risk post operative complications (Ikeda 2010)

What would be the more appropriate diagnostic imaging for hemobilia, endosonography or CT angiography? site sensitivity, specificity , accuracy of each testTo close case, presently , patient has no recurrence of bleeding. Awaiting fundsWhat would be the management options for this case?

End of second case

NW, 47 Male7 days: Epigastric pain3 days: FeverAnorexiaMalaise2 days: MelenaDizzinessSEHx:Non-smoker1 bottle of gin daily x 10 yearsMarijuana useGarbage collector, fruit sorterCase 3CC: Melena PPMHx: (-) HPN, DM, TB, CVA, CAD(-) previous surgery(-) intake of NSAID, ASA, steroid

Awake, coherent, cooperative, weak-looking, not in CP distress100/60, 100-110/min, 37-38.6CPale palpebral conjunctivae, anicteric scleraeClear breath sounds, no spider angiomaFlat abdomen, NABS,, direct tenderness at the epigastric area, hepatomegaly 14cm, (+) obliterated traubes space, no ascites, no caput medusa, no spider angiomaGood sphincteric tone, no mass, melenaCBCHgb62 g/LHct0.190WBC15.4 x109/LNeutro84%Lympho12%Mono4%Platelets401

CCCrea63umol/LBUN6.7umol/LNa132K3.3

What is your impression?What is your next diagnostic plan?What are your differential diagnoses?Interpret endoscopy

During endoscopy, what would you do next?

Would you revise your impression?What would be your next diagnostic examination?

What is your final impression?What is your next diagnostic examination?

Endoscopic drainage

Ultrasound-guided aspiration of the right liver lobe abscessHow would you manage the right liver lobe abscess?

Gastric ulcer perforating to liverPyogenic liver abscess penetrating to stomachincidence6 case reports3 case reportspresentationMelena +/- epigastric pain, then fever, +/- jaundiceFever, +/- jaundice, +/- epigastric pain, then melenaDiagnosticsChronic looking ulcerMultiple ulcersTreatmentSurgicalmedical

Spontaneous fistulization of a liver abscess into the stomachS. Leite, A. P. Silva, et al.Unusual cases and technical notes, Endoscopy 2009, 41:E260Liver Abscess Complicated by a Hepatogastric FistulaEun-Sun Kim, et alJournal of gastroenterology and hepatologyHepatogastric fistula: a rare complication of pyogenic liver abscess.Gandham VS, Pottakkat B, Panicker LC, Hari RVBMJ Case Rep.2014 Jul 17;2014.bcr-2014-204175.Gastric Ulcer Penetration into the Liver MimickingMalignancy on Endoscopic UltrasoundD. Kypraios, P. Fusaroli, S. Artuso, F. Poli, G. Calettihttp://www.eusjournal.comGiant benign gastric ulcer penetrating into the liver, pancreas and mesocolon. Zanotti M, Amboldi A, Musazzi M, et al. Minerva Chir 1999; 54: 415-9.Endoscopic diagnosis of gastric peptic ulcer penetrating into the liver. Jimnez-Prez FJ, Muoz-Navas MA. Endoscopy 1991; 23:98-9.Penetrating gastric ulcer presenting as a subcapsular liver abscess. Venkatesh KR, Halpern A, Riley LB. Am Surg 2007; 73: 82-4.Case of Ulcer of Stomach, Penetrating into the liver. Mackenzie JI. Br Med J 1880; 1: 692.

Gastric ulcer penetrating to liver diagnosed by endoscopic biopsyE. Kayacetin, S. KayacetinWorld J Gastroenterol 2004;10(12):1838-1840

Follow-up EGDbeforeafter

End of third case

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Post-ERC