Zubair Khan

Diagnosis of Pseudomyxoma peritonei via endoscopic ultrasound guided fine needle aspiration: a case report and review of literature

Abstract Introduction: Pseudomyxoma peritonei (PMP) is a rare condition caused by mucinous adenocarcinoma cancerous cells that produce abundance of mucin or gelatinous ascites. This cancer can cause tissue fibrosis and can impair normal organ function. Diagnosis can involve multiple imaging modalities including CT scan. There have been few cases of endoscopic ultrasound (EUS) being used as a means for diagnosis of this condition. Here we report a second case of PMP with a previous history of appendectomy diagnosed with EUS guided fine needle aspiration (FNA) biopsy. Case study: A 66-year-old male with a history of an appendectomy presented with intermittent abdominal pain for two years and weight loss of 40 pounds over two months. EGD and colonoscopy performed at an outside hospital was unremarkable. CT abdomen revealed perigastric ascities and lesions of the liver. ESR was elevated at 75. At our facility, EUS was performed revealing a peri-gastric and omental mass measuring 36.6 mm × 25.5 mm. FNA performed of both mass and ascetic fluid revealed low grade mucinous adenocarcinoma with mucinous deposits in the peritoneum consistent with PMP. Conclusions: Endoscopic ultrasound guided FNA, although very rarely used, can be a reliable and safe technique in diagnosis of PMP.

Diagnosis of Splenic Lymphoma by Endoscopic Ultrasound Guided Fine Needle Aspiration: A Case Report and Review of the Literature

Introduction. Splenic tumor is usually found as an incidental finding on CT of abdomen. Traditionally, ultrasound (US) or computed tomography (CT) guided biopsies were employed for the purpose of sampling; however they have been reported to have a complication rate of 5.3%. Endoscopic ultrasound-fine needle aspiration (EUS-FNA) has been recently utilized for the purpose of sampling splenic tumors. In literature there are 7 reported instances where splenic lymphoma was diagnosed using EUS-FNA. We present a case of follicular B cell lymphoma of the spleen diagnosed using EUS-FNA. Case Report. 58-year-old female presented to her primary care physician for left upper quadrant abdominal pain for one week. Physical exam was significant for left upper quadrant tenderness. Her laboratory tests were within normal limits. She underwent CT scan of abdomen which revealed approximately 5 cm × 5 cm mass in spleen. EUS-FNA of the spleen revealed a large hypoechoic, heterogeneous, well-demarcated mass measuring 54.7 mm × 43.0 mm. Fine needle aspiration was performed, and the sample was submitted for cytology and flow cytometry. Flow cytometry revealed a lambda monotypic population of B cells displaying dim CD19 and CD10. Diagnosis of B cell non-Hodgkin low grade follicular lymphoma was made. Conclusion. Endoscopic ultrasound with fine needle aspiration is a very rare but safe, reliable method of diagnosis of splenic lymphomas.

Unusual Clinical Presentation of Hemobilia with Recurrent Vasovagal Episodes

Hemobilia is caused by the abnormal connection between a blood vessel and the bile duct, which is usually iatrogenic and caused by hepatobiliary procedures. The classic triad of hemobilia includes biliary colic, obstructive jaundice, and gastrointestinal bleeding. We present the case of an 80-year-old man who had laparoscopic cholecystectomy complicated by hemobilia. He had an unusual presentation of hemobilia in the form of transient vasovagal episodes in addition to abdominal pain and hematochezia.

Transient Descending Colocolonic Intussusception Due to a Large Fecaloma in an Adult

Intussusception typically occurs in infants and children, with adults representing 5% of cases. A 53-year-old African American woman presented with lower abdominal pain and tenderness. Computed tomography of the abdomen and pelvis demonstrated a 3.5 cm colocolonic intussusception in the descending colon. Emergent colonoscopy found solid stool in the mid descending colon. Water-soluble rectal enema showed a filling defect in the mid descending colon. Repeat colonoscopy demonstrated presence of a large fecaloma in left colon. Laxatives were initiated, and abdominal pain subsided. To our knowledge, this is the first report of colocolonic intussusception secondary to fecaloma.

Primary purulent bacterial pericarditis due to Streptococcus intermedius in an immunocompetent adult: a case report

BackgroundAcute purulent bacterial pericarditis is of rare occurrence in this modern antibiotic era. Primary involvement of the pericardium without evidence of underlying infection elsewhere is even rarer. It is a rapidly progressive infection with high mortality. We present an extremely rare case of acute purulent bacterial pericarditis in an immunocompetent adult patient with no underlying chronic medical conditions.Case presentationA 33-year-old previously healthy white man presented with the complaints of chest pain and dyspnea. He was diagnosed as having acute pericarditis and was discharged home on indomethacin. Over a period of 2 weeks, his symptoms worsened gradually and he was readmitted to our hospital. He was found to have large pericardial effusion with cardiac tamponade. An urgent pericardiocentesis was done with drainage of 550 ml of purulent material. Cultures grew Streptococcus intermedius confirming the diagnosis of acute purulent bacterial pericarditis. No other focus of infection was identified on imaging workup suggesting primary infection of the pericardium. His clinical course was complicated by development of constrictive pericarditis for which he underwent surgical pericardiectomy. He received a total of 7 weeks of intravenously administered antibiotics with complete clinical recovery.ConclusionsAcute purulent bacterial pericarditis, although rare, should always be kept in mind as a possible cause of pericarditis. Early recognition and prompt intervention are important for a successful outcome.

Right-sided hemothorax from leaking saphenous vein right coronary artery bypass graft aneurysm due to incomplete coiling masquerading as right lower lobe pneumonia

A 76-year-old man presented to the hospital with complaints of right-sided chest pain and gradually worsening dyspnea for past 1 week. He had a history of coronary artery disease, and had a coronary artery bypass graft in 2009 and right coronary stent placement in 2012. He was diagnosed with pseudoaneurysm of the saphenous vein graft (SVG) to the posterior descending coronary arteries (PDA) in 2016, and underwent percutaneous coiling for that. His other significant past medical conditions included sick sinus syndrome s/p pacemaker placement, dyslipidemia, chronic kidney disease and chronic obstructive pulmonary disease. Vital signs at the time of presentation were: temperature of 36.7°, heart rate of 90 bpm, blood pressure of 130/60 mmHg, respiratory rate of 25 per min and oxygen saturation (SpO2) of 94% on 2 l of oxygen by nasal cannula. Precordial examination showed normal S1 and S2 without any murmur on auscultation. Pulmonary examination showed decreased breath sounds with scattered crackles on auscultation in the right lower lung zone. There was 1+ pedal edema in bilateral lower extremities. Electrocardiogram showed ventricular paced rhythm with no ST or T wave abnormality. Chest radiograph showed opacification of the right lower lung zone, and the radiologist interpretation was a right lower lobe pneumonia with adjacent pleural effusion (Fig. 1a). Initial laboratory workup showed a white blood cell count of 9.8 cells/mm3, hemoglobin of 8.3 g/dl, hematocrit of 24%, platelets of 107/mm3, serum creatinine of 1.8 mg/dl, serum blood urea nitrogen of 31 mg/dl, serum lactate of 1.7 mmol/l. Electrolytes and liver function tests were normal. Two sets of troponins done over 8 h were normal. The patient was diagnosed with community acquired pneumonia, and was started on antibiotics (IV ceftriaxone and azithromycin). Over the course of 2 days, his hemoglobin dropped gradually to 6.2 g/dl. He continued to complain of dyspnea and chest pain with no improvement in symptoms, and required 2 l of oxygen via nasal cannula to keep the SpO2 above 90%. A chest CT scan was done that showed a moderate to large right sided pleural effusion with Hounsfield units between 25 and 35 suggestive of a hemothorax along with a large heterogeneous rounded mass adjacent to the ascending aorta suggestive of a mediastinal hematoma. A chest CT Angiography confirmed the presence of a mediastinal hematoma adjacent to the ascending aorta causing a mass effect on the right atrium and superior vena cava along with aneurysmal dilatation of the SVG graft with presence of coils within it (Fig. 1b). Percutaneous coronary angiography was performed, which showed evidence of an occluded SVG graft to the PDA with a ruptured aortic pseudoaneurysm with a leak at the site of the anastomosis of the prior SVG graft to the PDA. Percutaneous embolization was performed along with closure of the ruptured pseudoaneurysm with a VSD occlusion device. Thoracostomy with chest tube placement was done on the right side for the hemothorax. The patient’s vital signs and hemoglobin levels were closely monitored. He reported improvement in his symptoms, and the hemoglobin level remained stable over the course of the hospital stay. The chest tube was taken out 1 week later. The patient was discharged home in a stable condition.

Esophago-pericardial fistula with development of hydro-pneumo-pericardium resulting in hemodynamic instability: an unusual complication of esophageal cancer

A 75-year-old man, known to have advanced esophageal adenocarcinoma stage T4N7M0 since January 2015 previously treated with chemotherapy and radiation, presented with altered mental status and a 2-day history of worsening central chest pain associated with shortness of breath. His past medical history was significant for insulin dependent diabetes mellitus type 2 and hypertension besides the esophageal carcinoma. On presentation, the vital signs were temperature 37.3 °C, pulse 114 beats/min, blood pressure 82/54 torr, respiratory rate of 26 breaths/min, and oxygen saturation (SpO2) of 92% on 6 l of oxygen by nasal cannula. On examination, he was barely arousable and confused. Precordial examination showed muffled heart sounds without any murmurs or added sound on auscultation. Pulmonary examination showed decreased breath sounds in the left lower zone. There was 1 + pedal edema in both lower extremities and the jugular venour pressure (JVP) was found to be elevated on neck examination. In the emergency department (ED), the patient became hemodynamically unstable, and his blood pressure dropped to 60/40 torr with further deterioration of level of consciousness. He was intubated, and required mechanical ventilation for protection of his airways. He was subsequently transferred to the intensive care unit (ICU) for further management. The initial laboratory workup showed a white blood cell count of 16.9 cells/mm3 with neutrophils 80% and bands 5%, hemoglobin of 10.1 g/dl, hematocrit of 33%, platelets of 149/mm3, serum creatinine of 1.4 mg/dl, serum blood urea nitrogen of 47 mg/dl, serum lactate of 3.6 mmol/L, ALT 254 U/l, AST 231 U/l, alkaline phosphatase 146 IU/l, bilirubin 1.6 mg/dl, albumin 2.1 g/ dl. Electrolytes panel showed serum sodium 141 mEq/l, serum potassium 3.4 mEq/l, serum bicarbonate 21 mEq/l, and serum chloride 102 mEq/l. An initial chest X-ray study showed a large left pleural effusion and air overlying the heart within the pericardial sac (Fig. 1a). A CT scan showed erosion and fistula formation between the esophageal lumen and posterior pericardium (Fig. 1b) with subsequent development of a complex pericardial effusion with the air. The patient required vasopressors, and was placed on broad spectrum antibiotics. Interventional gastroenterology was consulted for placement of an esophageal stent to control the esophageal leak, as the patient was not a good surgical candidate. Before placement of the stent, cardiothoracic surgery was consulted to place a pericardial catheter to drain air and fluid from the pericardial sac. As the catheter entered the pericardial sac, a significant amount of the air was released along with light yellow colored fluid. Fluid analysis revealed that the fluid was transudative in nature. A left side chest tube was also placed for the complicated pleural effusion. Pericardial catheter placement was also intended to prevent cardiac tamponade that might result from air insufflation during the stent placement. Patient remained in the ICU for 5 days. Because of a good functional status of the patient before admission and advanced directive to continue with life sustaining measures, the family was reluctant to opt for comfort measures from the beginning. Vasopressors were weaned off, but patient remained dependent on the mechanical ventilator. He remained oliguric during his stay in the ICU, and his creatinine continued worsening and reached 4.6 mg/dl. The nephrology service recommended hemodialysis, but the family opted to withdraw life-sustaining treatment after being counselled and convinced by the palliative care team about the overall poor prognosis of the patient. * Zubair Khan zubair.khan@utoledo.edu

Pyocholethorax secondary to biliopleural fistula: a rare complication of percutaneous transhepatic biliary drainage

A 62-year-old woman presented to the hospital with the complaints of right upper abdominal pain and dyspnea for the past 3 days. She described the pain as dull, constant, and radiating to her back and right side of the chest. She also complained of progressive dyspnea, both on rest and on exertion. She has been feeling nauseated, but denied any vomiting. She had a past medical history of stage-IV adenocarcinoma of the pancreas diagnosed 3 years prior, and had received palliative chemoradiation treatment. She also had recurrent episodes of biliary obstruction with jaundice with the evidence of common bile duct (CBD) obstruction by the mass on previous imaging. One week prior, she underwent percutaneous transhepatic biliary drain (PTBD) catheter and endoscopic retrograde cholangiography (ERCP) guided self-expandable metallic stent (SEMS) placement in the common bile duct (CBD) to relieve biliary obstruction. The PTBD catheter was removed following the stent placement. Vital signs at the time of presentation were temperature 37 °C, heart rate 76 beats/min, blood pressure of 135/99 mmHg, respiratory rate 22 breaths/min, and oxygen saturation 98% on 3 l of oxygen by nasal cannula. Physical examination showed a thin, cachectic female in moderate distress. Precordial examination showed normal S1 and S2 without any murmurs. Pulmonary examination showed dullness to percussion on the right side along with decreased breath sounds in the right-middle and -lower quadrant on auscultation. Abdominal examination showed a soft, nondistended abdomen with a gastrostomy tube, and tenderness to palpation in the right upper quadrant. A chest radiograph showed opacification of the right-mid and -lower lung zone consistent with a moderate-to-large right-sided pleural effusion (Fig. 1a). A CT scan of the chest confirmed the presence of a large right-sided pleural effusion (Fig. 1b). A thoracentesis was performed, and the drained fluid appeared grossly bilious (Fig. 1c). The metallic biliary stent is not visible in the images. Fluid analysis showed total bilirubin to be 16 mg/dl in the pleural fluid with a serum total bilirubin of 0.9 mg/dl. The fluid was an exudate by Light’s criteria with an LDH of 4446 U/l, glucose of 10 mg/dl, and pH of 6.92. A video-assisted thoracotomy was done with the drainage of pleural fluid and decortication of the adjacent right lung. Gram’s stain and cultures from the pleural fluid and lung tissue showed polymicrobial infection with Klebsiella and Streptococcus. A diagnosis of pyocholethorax was established resulting from the penetration and injury of the pleura by the PTBD catheter with the formation of a biliary pleural fistula and superimposed infection. The patient was started on i.v. ceftriaxone and metronidazole. Repeat chest radiographs showed improvement in the pleural effusion with re-expansion of the right lung. She recovered well, and was discharged home.

On-Demand Therapy with Proton Pump Inhibitors for Maintenance Treatment of Nonerosive Reflux Disease or Mild Erosive Esophagitis: A Systematic Review and Meta-Analysis

Background Proton pump inhibitors (PPIs) are widely used for the long-term management of gastroesophageal reflux disease (GERD). However, concerns about the cost and/or inconvenience of continuous maintenance PPI treatment have led to the evaluation of various alternative approaches. Aim To assess the effectiveness of on-demand PPI therapy in the maintenance treatment of nonerosive reflux disease (NERD) or mild erosive esophagitis (EE). Methods We searched MEDLINE, EMBASE, Web of Science, and Cochrane Library from inception until October 2, 2017, for randomized controlled trials (RCTs) comparing on-demand PPI versus placebo or daily PPI in the management of NERD or mild EE (Savary-Miller grade 1). Discontinuation of therapy during the trial was used as a surrogate for patient dissatisfaction and failure of symptomatic control. We calculated pooled odds ratios (OR) to evaluate the efficacy of on-demand PPI treatment. Separate analyses were conducted for studies comparing on-demand PPI with daily PPI and with placebo. Subgroup analysis was done based on NERD studies alone and on studies of both NERD and mild EE. These were analyzed using a random effects model. Results We included 10 RCTs with 4574 patients. On-demand PPI was superior to daily PPI (pooled OR = 0.50; 95% confidence interval (CI) = 0.35, 0.72). On subgroup analysis in NERD patients only, pooled OR was 0.44 (0.29, 0.66). In studies including patients with NERD and mild EE, pooled OR was 0.76 (0.36, 1.60). For studies comparing on-demand PPI with placebo, pooled OR was 0.21 (0.15, 0.29); subgroup analyses of studies evaluating NERD only and studies conducted in NERD and mild EE showed similar results (pooled OR was 0.22 (0.13, 0.36) and 0.18 (0.11, 0.31), resp.). Conclusions On-demand PPI treatment is effective for many patients with NERD or mild EE. Although not FDA-approved, it may be adequate for those patients whose symptoms are controlled to their satisfaction.

Renal Cell Carcinoma Presenting as an Ampullary Mass: A Case Report and Review of Literature

We present a case of a 60-year-old female patient who has significant medical history of renal cell carcinoma diagnosed 2 years back and had undergone right nephrectomy and chemotherapy. She presented to the hospital with complaints of abdominal pain and jaundice of 2 weeks duration and was found to have periampullary mass lesion causing compression of distal common bile duct on imaging with computed tomography of abdomen. Endoscopic retrograde cholangiography and endoscopic ultrasound showed ampullary mass lesion causing biliary obstruction along with abdominal lymphadenopathy. A temporary plastic stent was placed to relieve obstruction. Fine needle aspiration cytology of the periampullary mass along with immunohistochemical staining confirmed the diagnosis of metastatic renal cell carcinoma.