Andrew J. Kruger

Unexpected outcome following radiofrequency ablation of a malignant biliary stricture

We present a case of a 60-year-old woman with extrahepatic cholangiocarcinoma and recurrent malignant biliary strictures status post placement of two overlapping distal bile duct uncovered self-expandable metal stents (SEMSs) who presented with biliary obstruction due to tumor/tissue ingrowth. She subsequently underwent radiofrequency ablation (RFA) through SEMS to improve biliary stent patency. Post-RFA, thermal injury was observed in the periampullary mucosa. She later developed acute pancreatitis. This is the first case of RFA-induced acute pancreatitis with endoscopic evidence of thermal injury. It should be noted that RFA-induced acute pancreatitis is a potential adverse effect as RFA through SEMS is being used more widely.

Index Severity Score and Early Readmission Predicts Increased Mortality in Ulcerative Colitis Patients

BACKGROUND Readmissions are common after hospitalization related to ulcerative colitis (UC). A risk score to stratify the severity of UC hospitalizations and risk of colectomy has been previously reported. Our aim was to predict hospital-related outcomes after hospitalizations for UC utilizing this severity score. METHODS We utilized the Nationwide Readmissions Database (2010-2014) for hospitalized patients with UC and differentiated patients by index severity (low, intermediate, high). Baseline characteristics, surgical rates, readmissions, mortality, and hospital outcomes were collected. The primary outcomes of interest included readmission and mortality rates. RESULTS There were 133,819 patients admitted with UC with 22,762 (17%) readmitted within 30 days. Those readmitted within 30 days had a 4.5% calendar year mortality rate, compared with 0.45% in those not readmitted within 30 days (P < 0.001). Index surgery rates (19.2% vs 12.3%), length of stay (6.9 vs 5.4 days), and hospital costs (

A rare case of spontaneous hepaticoduodenal fistula and management of biliary obstruction in metastatic cholangiocarcinoma

13,530 vs

Development of Mucormycosis Colitis during Prolonged Hospitalization

10,366; P < 0.001 for all) were higher in those readmitted within 30 days. Patients with high-severity presentations had higher surgical rates (31.6%), higher 30-day and calendar year readmission rates (24.3% and 46.0%, respectively), increased index and calendar year mortality (2.5% and 2.0%, respectively), longer length of stay (15.1 days), and increased costs (

Cirrhosis Is Associated with Increased Mortality in Patients with Diverticulitis: A Nationwide Cross-Sectional Study

31,136) compared with those with low severity (P < 0.001 for all). Calendar-year survival rates in those with intermediate and high scores were significantly lower than in those with low scores. CONCLUSIONS An index severity score of intermediate or high and early readmissions are predictors of calendar year mortality. Future efforts should emphasize more focused care in high-risk patients, as this may reduce readmissions and improve outcomes.

Cholecystectomy During Index Admission for Acute Biliary Pancreatitis Lowers 30-Day Readmission Rates

A 60-year-old woman with a history of breast cancer presented with jaundice, epigastric pain, and fever for 1 week. Laboratory results revealed a total bilirubin of 14.9mg/dL and alkaline phosphatase of 365U/L. Abdominal computed tomography revealed a 6.1 ×2.8-cm hilar liver mass with intrahepatic biliary dilatation (▶Fig. 1; ▶Video1); subsequent abdominal magnetic resonance imaging demonstrated an infiltrative soft tissue mass encasing the common hepatic and central intrahepatic ducts, suggestive of intrahepatic cholangiocarcinoma (▶Fig. 2). Endoscopic ultrasound (EUS) demonstrated a fistulous tract, which was draining into the duodenal bulb (▶Video1). EUS-guided fine needle aspiration (FNA) of the liver mass was performed. During endoscopic retrograde cholangiopancreatography (ERCP), despite cannulation of the major papilla, the guidewire could not be advanced to the proximal common hepatic duct; a cholangiogram revealed complete obstruction of the proximal common bile duct (▶Fig. 3). Contrast injection through the fistulous tract in the duodenal bulb confirmed a hepaticoduodenal fistula with marked intrahepatic duct dilatation. The fistula tract was dilated and two plastic biliary stents were placed with their proximal ends in the right and left main hepatic ducts and good flow resulted (▶Fig. 4 and ▶Fig. 5 a). After 2 weeks, the patient’s liver enzymes had notably improved and the plastic stents were exchanged for a covered metal stent (▶Fig. 5 b and ▶Fig. 6). Pathology from the EUS-FNA demonstrated adenocarcinoma morphologically favoring a cholangiocarcinoma, and ▶ Fig. 1 Computed tomography scan of the abdomen/pelvis (coronal view) demonstrating a large hilar liver mass with intrahepatic biliary dilatation (arrow). ▶ Fig. 2 Magnetic resonance imaging of the abdomen/pelvis (T2-weighted, coronal view) demonstrating a hilar liver mass with marked intrahepatic biliary dilatation (arrow). ▶ Fig. 3 Cholangiogram demonstrating complete obstruction of the proximal common bile duct (arrows).

Early Readmission Predicts Increased Mortality in Cirrhosis Patients After Clostridium difficile Infection

A 50-year-old woman with previously well-controlled type-2 diabetes developed hematochezia during hospitalization for cerebral vasculitis. She had been treated with intravenous methylprednisolone (1,000 mg) for three days, requiring an insulin drip before transitioning to daily maintenance prednisone (60 mg). She was hemodynamically stable with a soft, tender abdomen on exam. An abdominal/pelvic computed tomography (CT) scan demonstrated mucosal and colonic wall thickening with edema around the transverse, descending, and rectosigmoid colon. Colonoscopy revealed multiple non-bleeding ulcers 10–18 mm in size in the rectum, sigmoid, and descending colon, with normal surrounding tissue (Figure 1); the procedure was aborted given the extent of ulceration. Pathology from biopsies taken during the procedure confirmed mucormycosis (Figure 2). Amphotericin B and caspofungin were initiated, while prednisone was tapered off to minimize further immunosuppression. The patent experienced recurrent hematochezia with progressively worse pancolitis on repeat CT of the abdomen and pelvis. Given her increasingly worse prognosis despite medical management and the unlikelihood of surviving an aggressive colectomy, colorectal surgeons recommended against surgical intervention. She ultimately chose to transition to hospice care.