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Aim Acute pancreatitis is a diagnosis established by fulfillment of at least two out of three clinical features, including epigastric pain, elevated lipase, and/or radiographic evidence of acute pancreatitis. Computed tomography of the abdomen and pelvis (CTAP) is the gold standard imaging modality for evaluating acute pancreatitis. Although abdominal ultrasound (AUS) is increasingly utilized given the widespread availability and high sensitivity and specificity for detecting gallstone-related complications, including gallstone pancreatitis, the leading cause of acute pancreatitis in the US. However, recent literature has concluded that performing AUS following a negative CTAP rarely led to changes in management and imparted an increased length of service (LOS) in the ED. Our study investigated whether a similar relationship was observed when managing acute pancreatitis in the inpatient setting. We aimed to quantify how performing AUS influenced inpatient LOS for patients admitted for acute pancreatitis without radiographic evidence of acute pancreatitis on CTAP. We also aimed to quantify how AUS influenced the likelihood of subsequent intervention via endoscopic retrograde cholangiopancreatography (ERCP) or cholecystectomy, including the relative impact of certain demographic or clinical features. Methods A retrospective analysis was performed using a cohort of 6069 patient encounters extracted via the HCA Healthcare enterprise data warehouse (EDW) database. Inclusion criteria were all adult patients with an index admission for acute pancreatitis between January 1 and December 31, 2019, who underwent CTAP during admission. Patients younger than 18 years, with prior cholecystectomy, or without documentation of demographic or clinical data of interest were excluded. The primary outcome was to quantify how performing AUS within 48 hours impacted LOS for patients admitted for acute pancreatitis following negative CTAP. Secondary outcomes examined whether AUS changed management (i.e., per likelihood of subsequent ERCP or cholecystectomy). This included determining the influence of various demographic or clinical characteristics on the likelihood of intervention via ERCP or cholecystectomy. Linear regression was used to determine the effect of performing AUS on the duration of LOS. Logistic regression was used for covariate analysis based on demographic (BMI, sex, race, age) and clinical data (comorbid conditions, abnormal labs, and vital signs). Results Patients with acute pancreatitis who underwent AUS within 48 hours had a reduced LOS of 1.099 days. Patients who underwent AUS were 1.126 times more likely to undergo subsequent ERCP than those who received CTAP alone. Patients who received AUS following CTAP were also 2.711 times more likely to undergo subsequent cholecystectomy. Increasing age and BMI were correlated with an increased likelihood of ERCP and cholecystectomy. Males were less likely to undergo cholecystectomy (OR = 0.753) and ERCP (OR = 0.815) compared to females. Conclusion Performing AUS within 48 hours following negative CTAP in this cohort of patients admitted for acute pancreatitis was associated with a decreased LOS. Furthermore, patients who underwent AUS were more likely to undergo ERCP and even more likely to undergo cholecystectomy. The likelihood of ERCP and cholecystectomy increased proportionally to both age and BMI. Females were more likely than males to undergo subsequent ERCP or cholecystectomy.
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Mucormycosis is a rare opportunistic fungal infection with a high degree of morbidity and mortality. It classically presents with rapidly progressing, necrotic rhinocerebral mucocutaneous lesions in the setting of an immunocompromised host, especially with concomitant uncontrolled diabetes. We report the case of a 67-year-old man with well-controlled non-insulin dependent diabetes and brief steroid exposure who presented in sepsis with a tender posterior shoulder skin lesion. The initial lesion enlarged and progressed over several days, developing central areas of ecchymosis and bullae, with several other large lesions appearing at various distant sites. He also experienced an array of systemic symptoms, including fever, malaise, weakness, and acute encephalopathy. A diagnosis of mucor was made by histopathological examination of the initial skin lesion. Despite initiation of amphotericin B and aggressive surgical debridement including transfer to specialist tertiary burn center, the patient passed away less than a week after definitive diagnosis. This is a unique case of disseminated mucormycosis given his lack of chronic immunosuppression or uncontrolled diabetes, and with no risk factors for inoculation except for pacemaker placement 2 months prior to admission. The case highlights the importance of considering mucormycosis in the early differential diagnosis of rapidly progressing skin lesions, as rapid detection and treatment is critical to mitigate the deadly effects of this fast-moving fatal fungus. Moreover, the case serves as a testament to the unpredictable progression of disseminated disease, while also demonstrating an unusual potential mode of introduction and a rare but fatal consequence of prescribing corticosteroids in an infected host.
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Introduction: and Importance: Melanomas are capable of metastasizing to both regional and distant sites and are notably known to metastasize to the skin, lungs, brain, liver, bone, and gastrointestinal tract. Metastatic melanoma is infrequently diagnosed in vivo, and usually found only on post-mortem evaluation at autopsy. Case Presentation: Here we present the case of a 64-year-old male who originally presented with melena, fatigue, exertional dyspnea and one episode of near-syncope. He was found to have a hemoglobin of 5.4 gm/dL on initial presentation with largely unremarkable abdominal examination. CTAP demonstrated an area of circumferential small bowel wall thickening, concerning for malignancy. The patient underwent an EGD that was noted for mild gastric fundal erosions, which failed to explain his presenting symptoms. VCE was later performed following discharge to visualize the small bowel, which revealed two bleeding lesions within the small bowel. This was complicated by the device becoming lodged on the more proximal mass, and he was admitted again for push-enteroscopy and device retrieval. At the time of this admission, he continued to be symptomatic and was profoundly anemic with a hemoglobin of 4.7 gm/dL. Clinical Discussion: EGD with push enteroscopy was performed, revealing two small masses in the mid-distal duodenum and jejunum, which were tattooed and biopsied. He underwent robotic-assisted laparoscopic small bowel resection of the affected portions of the small bowel, without complications. Surgical samples were consistent with melanoma, and further dermatologic examination revealed a suspicious lesion located on the patient's posterior right shoulder was biopsied and also consistent with melanoma, confirming the suspicion for metastatic process from primary cutaneous lesion. Conclusions: We present this case as a rare diagnostic opportunity to observe metastatic melanoma of the small bowel, including a review of pertinent symptomatology and epidemiological data from previous literature. Our case serves as a reminder to consider metastatic melanoma as a rather uncommon cause of severe blood loss anemia, while also providing an overview of endoscopic modalities available for visualizing the small bowel in the management of suspected small bowel malignancy.
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Gastric diverticula are the least common gastrointestinal diverticula. Patients can be diagnosed incidentally on EGD or present with variable symptoms such as abdominal fullness, anorexia, and perforation. Gastric diverticula can be acquired from malignancy, peptic ulcer disease, or prior surgery or be congenital. Treatment varies based on symptomatology ranging from conservative medical management with proton pump inhibitors to surgical treatment with open or laparoscopic resection. We present a case of a 73-year-old female with acquired gastric diverticulum presenting as a gastric outlet obstruction who was successfully treated with conservative medical therapy.