Splenic vein aneurysms are a rare and incidental occurrence. Most patients are asymptomatic. Etiologies can include portal hypertension or congenital weakness in the vessel wall. Diagnosis can be made via duplex ultrasonography or computed tomography scanning. A 68-year-old female presented to our Emergency Department with a 3 day history of severe lower abdominal pain and constipation. She had been seen one week prior for lower back pain and was given a prescription for Oxycodone. On admission her blood pressure was 135/78 mmHg with a heart rate of 85. Abdominal exam revealed a nondistended abdomen with mild tenderness to palpation in the left lower quadrant. Labs were significant for a leukocytosis of 16,500 and a creatinine of 1.69 (increased from baseline of 0.6 ). A CT Abdomen Pelvis without contrast was performed which showed “extensive jejunal diverticulitis and an indeterminate 2.5 cm mass like density in the pancreatic tail”. CA 19-9 was normal. The patient underwent an MRI Abdomen which showed a hyper-vascular lesion in the pancreatic tail. This was followed by a labeled RBC Scan which showed the pancreatic tail lesion to have increased blood volume. The patient received I/V antibiotics while in hospital for her jejunal diverticulitis. She was discharged home with oral antibiotics to complete a total course of 2 weeks. EUS was done as an outpatient for further characterization which showed a dilation in the splenic vein. To confirm findings on EUS, patient underwent CT angiogram of the abdomen which re-demonstrated a splenic venous varicosity. The patient's case was discussed with Vascular Surgery who recommended repeating serial CT Angiogram to assess for enlargement which would necessitate intervention. Splenic vein aneurysms are uncommon. Complications of splenic vein aneurysms can include compression of adjacent structures, thrombosis or rupture. Management of splenic vein aneurysms can be conservative with serial non-invasive imaging versus plication and aneurysm excision. Because the incidence of these aneurysms is low, exact treatment is not well defined and each case needs to be individually evaluated. Our patient remains asymptomatic and continues to be followed.2926_A Figure 1. Computed tomography scan demonstrating a 2.5 cm density in the pancreatic tail2926_B Figure 2. Endoscopic Ultrasound demonstrating a 15 x 21 mm dilation in the splenic vein.2926_C Figure 3. CT Angiogram of the abdomen showing splenic veins showing an area of enlargement measuring 2.9 cm.
Background: The 2014 ACC/AHA guidelines on perioperative evaluation recommend differentiating patients at low-risk (<1%) versus elevated-risk (≥1%) for cardiac complications to guide appropriate preoperative testing. Among the tools recommended for estimating perioperative risk is the National Surgical Quality Improvement Program (NSQIP) Myocardial Infarction and Cardiac Arrest (MICA) risk calculator. The NSQIP MICA risk calculator showed good discriminating power when introduced in 2011, but has yet to be externally validated. The aim of the study was to investigate whether the NSQIP MICA risk calculator could accurately discriminate the incidence of major adverse events following elective hip and knee surgery. Methods: We reviewed 1,098 consecutive, elective orthopedic surgeries performed at Hershey Medical Center from January 2013 through December 2014, including 412 total hip replacements and 686 total knee replacements. Sufficient data were present to estimate risk using the NSQIP MICA risk calculator in 1,091 patients. Major adverse events were defined as myocardial infarction, cardiac arrest, or death within 30 days of surgery. A receiver operating characteristic curve was plotted from the estimated risk and adverse outcomes data. Results: Eight out of 1,091 procedures (0.7%) were complicated by a major adverse event. The mean estimated risk for adverse events using the NSQIP MICA risk calculator was 0.54% with a standard error of 0.018%. There was no significant difference (p=0.59) when comparing the observed versus expected incidence of major adverse events by chi-square test. The area under the curve (AUC) was determined to be 0.85 with a 95% confidence interval of 0.79-0.91 (see plot below). Conclusion: The NSQIP MICA risk calculator is a good discriminator of major adverse events following elective hip and knee surgery. Our study supports its use as a predictive tool for preoperative evaluation in this setting.
Clostridium difficile infection (CDI) is a significant cause of morbidity and mortality. Fecal microbiota transplant (FMT) is effective for treatment of recurrent CDI, but has not been well studied in immunocompromised (IC) patients. New data shows that FMT may be safe in this population, but has not gained widespread acceptance. This is the case of a 67-year old male with recurrent CDI and immunocompromised state due to myelodysplastic syndrome transformed to acute myeloid leukemia, who was treated with FMT. This case contributes to the growing body of evidence on the outcomes of FMT on CDI in IC patients. The patient is a 67-year old male with past medical history significant for clostridium difficile colitis who was diagnosed with myelodysplastic syndrome with progression to acute myeloid leukemia. He developed diarrhea with ten loose, bloody bowel movements a day. Vitals on admission were unremarkable. On exam, he displayed left lower quadrant tenderness. Labs displayed WBC 1.43, hemoglobin 8.1, and platelets 126. He was treated initially with vancomycin, with the addition of metronidazole after minimal improvement. Stool studies were negative for infectious cause. Flexible sigmoidoscopy revealed the presence of pseudomembranes. Figures 1 and 2 show the heaped, necrotic epithelium characteristic of pseudomembranes in CDI. Due to the refractory CDI, the patient underwent FMT with improvement in his bowel movement frequency to three loose bowel movements a day. Conditioning therapy in preparation for stem cell transplant was initiated, but the patient suffered cardiorespiratory distress and died. FMT is an established treatment for recurrent CDI. One population in which FMT has not been well studied is in IC patients due to the high theoretical risk of complications. Recent studies have shown that FMT in IC patients results in resolution or decrease in diarrhea frequency with few adverse effects. Our patient met inclusion criteria for many of these studies with his history of immunosuppression and refractory CDI. After FMT, the patient's diarrhea frequency decreased from ten loose bowel movements to three a day. The patient was able to undergo conditioning therapy in preparation for stem cell transplant. Although our patient succumbed to cardiorespiratory distress, this case provides valuable insight into a patient population that is not normally treated with FMT and furthers the discussion on FMT in IC patients.1464_A Figure 1. Heaped, necrotic epithelium characteristic of pseudomembranes in clostridium difficile infection1464_B Figure 2. Magnification of Image 1
Acute esophageal necrosis (AEN), also known as ‘black esophagus’ or ‘necrotizing esophagitis’, is a lifethreatening condition which causes diffuse circumferential black appearance of the distal esophagus. This condition is often seen in the critically ill and may be attributed to a vascular watershed area in the distal esophagus. The incidence of AEN varies in endoscopic series from 0.01 to 0.28%, thus signifying a very rare condition. A 73-year-old male with a past medical history of Stage IIIC rectal adenocarcinoma status post low anterior resection and diverting ileostomy presented with intractable nausea, vomiting and malaise. On admission, vitals showed blood pressure of 160/110 and heart rate of 110. Physical examination revealed epigastric abdominal tenderness with no peritoneal signs. Given mild leukocytosis of 11,000 and positive urinalysis patient was started on empiric antibiotics for presumed urinary tract infection. During the hospital course, patient developed acute change in mental status with 1300 milliliters of melenic ostomy output. Repeat vitals showed persistent hypertension and tachycardia with bloodwork showing hemoglobin drop of 2 grams from 14g to 12g with concomitant elevation of BUN to 100. Patient was started on intravenous protonix drip and taken for emergent upper endoscopy which showed diffuse severe mucosal changes characterized by circumferential mucosal necrosis in the entire esophagus extending from 15 cm from the incisors to the gastro-esophageal junction. Exam also revealed gastric erosions and multiple duodenal ulcers. Given the esophageal findings, patient was referred to cardiothoracic surgery for evaluation. Initial plan was to pursue an emergent esophagectomy however patient's family requested hospice care given the overall poor prognosis. Acute esophageal necrosis is associated with several comorbidities including multiorgan dysfunction, persistent hypoperfusion to internal organs, severe vasculopathies, sepsis, gastric volvulus, alcohol abuse or neoplastic diseases. The most frequent clinical presentation is melena, hematemesis, chest pain or dysphagia. Treatment is mainly supportive to maximize organ perfusion, optimize acid suppression and treat any underlying sepsis. Early surgical intervention may be required in cases of perforation, abscess or extent of injury. Clinicians should be aware of AEN in order to appropriately diagnose and manage the disease entity.1838 Figure 1. Diffuse severe mucosal changes seen in the lower third of the esophagus on EGD
Hepatic cysts are a relatively benign and asymptomatic group of disorders, which are usually found incidentally during imaging studies. We present a case of a large hepatic cyst causing intra-cardiac shunting during a workup of hypoxemia. A 68 year old male, with recently diagnosed marginal zone lymphoma of the lung, presented to the ED for dyspnea on exertion and hypoxia requiring 100% FiO2 by high-flow nasal cannula. ABG showed severe A-a gradient with PaO2 of 42 and SaO2 of 82, concerning for cardiac shunt. Transesophageal echocardiogram showed right to left inter-atrial shunt, across a patent foramen ovale (PFO), following injection of agitated saline. Further workup with CT Chest PE protocol ruled out pulmonary embolus and right-sided cardiac catheterization did not show evidence of pulmonary hypertension. Interestingly, the patient would desaturate when laying on his right side. The CT Chest and echocardiogram caught a portion of a hepatic cyst near the right atrium. A dedicated abdominal CT scan showed multiple complex cystic lesions within the liver, largest in the dome and right lobe of liver measuring 21.7x14.8 cm. The lesion in the dome of the liver caused mass effect on the right atrium. Differential of the cystic lesions were benign hepatic cysts, hydatid disease or biliary cyst adenomas. Cardiology attempted catheter-based closure of the PFO, but were unsuccessful due to the high-pressure gradient. Hepatobiliary surgery consult did not suggest resection given medical comorbidities; thus, percutaneous drainage was recommended. There was hesitation to drain the hepatic cysts percutaneously due to the possibility of echinococcus. The patient had a travel history outside of the United States and was recently exposed to farm animals. Echinococcus serum antibody IgG was tested and returned negative. Percutaneous drain was placed in the largest cyst by Interventional Radiology with 600 mL of brown serosanguinous fluid drained upon insertion. Patient had immediate symptomatic relief and oxygen requirements were weaned to room air within hours. There have been cases where large hepatic cysts caused compression of the right atrium as well as causing cardiac arrhythmias, which resolved with surgical cyst resection. There has been one other reported case of a hepatic cyst causing intra-cardiac shunting across a PFO with symptomatic relief through surgical cyst resection. We present a case in which a large hepatic cyst causing cardiopulmonary abnormalities was successfully treated with non-surgical and minimally invasive techniques.Figure 1Figure 2Figure 3
