ABSTRACT
Background: A 54-year- old male presented to our centre with a chronic non-productive cough and breathlessness. Recent history of COVID treated and resolved few months back. He had a history of brain surgery performed five years back but details not known. Physical examination revealed no oedema and bilateral coarse creps with bronchiolar breathing. Laboratory findings indicated neutrophilic leucocytosis, elevated inflammatory markers, with elevated troponin I and D dimers. Urine analysis suggested microscopic haematuria with sediments. While 24 hour quantification revealed sub nephrotic proteinuria. As auto immune workup and vasculitis profile was negative and patient has not improved in spite of standard of therapy hence we went ahead with CT-Chest indicating ground-glass opacities in bilateral lung parenchyma and prominent interlobular/intralobular septal thickening. Then Bronchoscopy done which revealed the blood-stained secretions in the main stem bronchi and diffuse alveolar haemorrhage in bilateral bronchial segments indicating an inflammatory study, while tuberculosis diagnostic panel and infective bio fire panel in BAL was negative. Meanwhile, his repeat BAL culture suggested Carbapenem resistant Acinetobacter baumannii complex infection. As the patient did not respond to the standard of care for vasculitis. Probability considered was a small vessel vasculitis (namely Granulomatous polyangiitis) was considered due to lung manifestation involving upper respiratory tract with epistaxis, neutrophilic leucocytosis, elevated acute reactive protein, and renal manifestation including microscopic haematuria and proteinuria. However he responded poorly to conventional standard of treatment including pulse steroids and IVIG. Hence after MDT discussion we proceeded with lung biopsy which showed linear cores of lung tissue infiltrated by a malignant neoplasm and acinar pattern suggesting Invasive mucinous adenocarcinoma. Hence we went ahead with the biopsy diagnosis for the treatment plan. As he was to be started on chemotherapy, but he suddenly collapsed and went into hypotension, bradycardia, and cardiac arrest. In spite of high supports and post 4 cycles of CPR, was unable to revive and sadly succumbed to his illness. Discussion(s): In this rare case, the original diagnosis pointed to the pulmonary-renal syndrome, an autoimmune disease characterized by diffuse pulmonary haemorrhage and glomerulonephritis. However, negative autoimmune antibodies and vasculitis profile along with lung biopsy results indicated an unusual case of malignant lung adenocarcinoma presented with pulmonary renal syndrome. Conclusion(s): In cases suggesting pulmonary-renal syndromes, if autoimmune work up is negative and response is suboptimal relook the diagnosis.
ABSTRACT
DDW 2022 Author Disclosures: Maaz Sohail: NO financial relationship with a commercial interest ;Andrew Mims: NO financial relationship with a commercial interest ;James Pitcher: NO financial relationship with a commercial interest ;William Oelsner: NO financial relationship with a commercial interest ;George Philips: NO financial relationship with a commercial interest Background: Biliary stone disease is a common cause of inpatient hospitalization, and many cases require an endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC). As these procedures are done by different departments, coordination can be challenging and both interventions are therefore not usually done on the same day. In the COVID-19 pandemic era, we have seen a greater need to decrease length of stay for patients in the hospital thereby reducing overall costs to both hospitals and patients, increasing bed availability as well as decreasing the exposure of easily transmissible diseases such as COVID-19. Aim: To show that same day ERCP and laparoscopic cholecystectomy can be performed at similar volumes to different day procedures in a teaching hospital and that this would allow for a shorter length of stay for these patients. Methods: A retrospective cohort study was done to identify all patients carrying the diagnosis of gallstone pancreatitis, cholangitis, choledocholithiasis, or a positive intraoperative cholangiogram who also underwent an ERCP and cholecystectomy during that same admission from November 2017 to October 2021 at our hospital. A total of 385 patients were found. These patients were divided into those that underwent an ERCP and cholecystectomy on the same day (n = 158) and those that had each procedure on a different day (n = 227). An ad hoc analysis of 170 patients (same day n = 77, different day n = 93) was done for further chart analysis to find total hospital length of stay, age, Body Mass Index (BMI), and comorbidities. Results: Same-day ERCP and LC comprised a significant volume (41.1 %) of the total procedures done for these diagnoses. In the subset data, hospital length of stay of patients who received ERCP and LC procedure on the same day is significantly shorter than that of patients who received these procedures on different days (median (IQR)= 4(3, 5) vs 5(4, 6), p=0.0001). Both groups had similar mean age and BMI. Post operative complications were found in 5.2% of the same day group and 3.2 % of the different day group. Similarly, post ERCP complications were found in 3.8% of patients in the same day group and 4.3 % of patients in the different day group. Conclusion: We show that in our teaching hospital, a significant number of patients regardless of age or BMI can undergo both ERCP and cholecystectomy in the same day and decrease their length of stay. This will also lead to decreased costs for patients and the hospital. Effective and early communication between the Gastroenterology, Anesthesia, and Surgery departments of a hospital may be a key in achieving these results. [Formula presented]