ABSTRACT
Introduction: Congenital choledochal cyst (CCC) is a rare cystic dilatation of intrahepatic or extrahepatic biliary ducts. We present a case of a type IVb choledochal cyst presenting as recurrent acute pancreatitis in a young healthy female with initial negative screenings. Case Description/Methods: An 18-year-old-female with a history of COVID-19 presented to the emergency department with one month of persistent abdominal pain, nausea, and vomiting. She was hospitalized once prior for similar symptoms and was diagnosed with acute pancreatitis. This admission, blood work showed elevated lipase, elevated liver enzymes, mild bilirubinemia with a normal lipid panel and urine was significant for infection. She received fluids, antiemetics and was started on prophylactic antibiotics for ascending cholangitis. A right upper quadrant ultrasound ruled out cholelithiasis or acute cholecystitis, but showed dilation of the common bile duct. MRCP confirmed dilation with bulbous termination in the periampullary region diagnosed as type IVb choledochal cyst. Discussion(s): CCCs are rare in Western countries with an incidence between 1 in 100,000 to 150,000. 80% of these cysts are diagnosed in patients under the age of 10. They are difficult to diagnose due to variable clinical presentations. A study of 214 CCC patients demonstrated the most common symptom was abdominal pain, followed by jaundice and fever. When cysts are found in adults, symptoms resemble atypical acute biliary tract disease. Surgical cyst removal may be needed for patients with significant risk factors such as older age and age of symptom onset, due to increased risk of malignant transformation. Longer periods of observation have been documented to be associated with an increased chance of developing late complications, such as anastomotic stricture, biliary calculi and recurrent cholangitis. Type IVb CCCs, as seen in this case, consist of multiple extrahepatic cysts and hepaticojejunostomy is the treatment. This patient's young age and recurrent acute pancreatitis combined with her lab and imaging findings strongly suggest the diagnosis of CCC. The anatomical location of the CCC impeded flow of pancreatic enzymes through the ampulla of vater, leading to recurrent pancreatitis in an otherwise healthy young female. CCC, although very rare, should be considered in the differential of acute pancreatitis when other causes such as gallstones and heavy alcohol consumption cannot be identified, as prompt diagnosis and surgical removal is imperative.
ABSTRACT
SESSION TITLE: Medical Student/Resident Signs and Symptoms of Chest Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: There are recent reports of neurological manifestations (NMs) from COVID-191. We present a healthy male who developed multiple strokes likely from direct endothelial dysfunction (ED). CASE PRESENTATION: 66M with GERD presents with 5 days of cough, fever, and chills. He was febrile and hypoxic. Work-up revealed CRP 19 mg/dL, ferritin 594 ng/mL, D-dimer 2.01 mg/L, positive COVID-19 PCR, and normal lipid panel. He had wheezing and no NMs. He was treated with antibiotics, enoxaparin, and oxygen. On day 14 he acutely developed altered mental status, aphasia, and unilateral weakness. CT head revealed acute left ischemic infarct. CTA head/neck revealed proximal left ICA dissection. Aspirin and Atorvastatin were given. Further studies revealed D-dimer 0.4 mg/L, no inheritable hypercoagulopathy, and negative TTE and lower extremity venous duplex. MRI brain confirmed multiple acute infarcts. Left ICA thrombectomy and stent placement were performed. It was found that there was a pseudo-dissection with a ruptured plaque and an overlying thrombus resulting in a 75% stenosis. DISCUSSION: Arterial complications from COVID-19 have recently been reported.3 Studies from Wuhan, China showed that 36.7% of COVID-19 patients had NMs, most commonly dizziness (16.8%) and headache (13.1%);5.7% had acute ischemic stroke. These patients had severe respiratory symptoms and developed neurologic signs in 1-2 days.1 Another study revealed that stroke occurred in elevated CRP (51.1 vs 12.1 ng/L) and D-dimer (6.9 vs 0.5 mg/L)2. It is believed that the virus directly invades and injures endothelial cells (ECs), changes prothrombotic factors, and promotes a hypercoagulable state secondary to a profound inflammatory response4. ACE-2-receptors on ECs are used for viral adhesion. Viral replication causes EC apoptosis, which promotes vasoconstriction, organ ischemia, tissue edema, and microvascular prothrombotic sequelae.5 In our case, COVID-19 had profound ED distal to the carotid artery bifurcation. Arterial bifurcations are sites of turbulent blood flow that are athero-prone.6 The stroke occurred in the setting of moderate elevations of D-dimer, suggesting an alternate mechanism.2 Plaque rupture occurred with prophylactic anticoagulation and normal lipid panel. At the time of the stroke, D-dimer and inflammatory markers largely normalized. His late onset NMs indicate that prothrombotic sequelae and ED persist after the cytokine storm has improved.1 Further studies are needed to investigate the duration of cytokine storm and prothrombotic state, and appropriate screening measures. CONCLUSIONS: Clinicians must be cognizant of NMs from COVID-19 such as thromboembolic strokes from direct ED. Reference #1: 1. Mao L et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. Epub 2020 Apr 10. Reference #2: 2. Li Y, Wang M, Zhou Y, Chang J. Acute Cerebrovascular Disease Following COVID-19: A Single Center, Retrospective, Observational Study. Available at SSRN: https://ssrn.com/abstract=3550025. 2020 Mar 3. Reference #3: 3. Oxley, Thomas et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. N Engl J Med. Epub 2020 Apr 28. 4. Connors JM, Levy JH. COVID-19 and its implications for thrombosis and anticoagulation. Blood. Epub 2020 Apr 27. 5. Ferrario CM et al. Effect of angiotensin-converting enzyme inhibition and angiotensin II receptor blockers on cardiac angiotensin-converting enzyme 2. Circulation. 2005;111:2605-10. 6. Ku DN, Giddens DP, Zarins CK, Glagov S. Pulsatile flow and atherosclerosis in the human carotid bifurcation: positive correlation between plaque location and low oscillating shear stress. Atherosclerosis. 1985 May-Jun;5:293-302 DISCLOSURES: No relevant relationships by Krishna Akella, source=Web Response No relevant relationships by Luke Alessi, source=Web Response No relevant relationshi s by David Capone, source=Web Response No relevant relationships by Olga McAbee, source=Web Response No relevant relationships by Heidi Roppelt, source=Web Response No relevant relationships by Fredric Weinbaum, source=Web Response No relevant relationships by Daisy Young, source=Web Response
ABSTRACT
SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: We sought to perform a meta-analysis using retrospective studies comparing non-sedation with traditional sedation methods in the ICU. Traditional sedation methods have risk of side effects that may prolong time on the ventilator and in the ICU. The clinical utility of non-sedation as an alternative remains unknown. In the current climate of COVID-19 where there is a finite supply of sedatives, non-sedation can prove to be a non-inferior alternative. METHODS: We performed a comprehensive literature search using Pubmed and Google Scholar for studies comparing non-sedation and traditional sedation methods between January 1, 2010 and April 14, 2020. Outcomes included hospital LOS, ICU LOS, ICU mortality, ventilator days, overall mortality, and self extubation. Results were reported as an odds ratio (OR) with 95% CI. A total of 3 retrospective and prospective studies were included comparing non-sedation and sedation in the ICU. A total of 904 patients were enrolled (average age 66.08 +/- 7.04 years, 45.8% males). These patients were divided into two groups: a sedation group (n=437) and non-sedation group (n=467). RESULTS: Reduction was found with non-sedation in Hospital LOS (3 studies), ICU LOS (2 studies), ICU mortality (2 studies), and ventilator days (3 studies). Non-sedation was non-inferior in overall mortality and self-extubation. CONCLUSIONS: Non-sedation appears to be a superior alternative to traditional sedation methods in the ICU. CLINICAL IMPLICATIONS: Non-sedation appears to be a superior alternative to traditional sedation methods and can minimize medication side effects, hospital LOS, ICU LOS, ICU mortality, and ventilator days. DISCLOSURES: No relevant relationships by Krishna Akella, source=Web Response No relevant relationships by Charles Arcoleo, source=Web Response No relevant relationships by Akella Chendrasekhar, source=Web Response No relevant relationships by Priscilla Chow, source=Web Response No relevant relationships by Kashif Hussain, source=Web Response No relevant relationships by Samer Ibrahim, source=Web Response No relevant relationships by Gunjan Joshi, source=Web Response No relevant relationships by Ghulam Mujtaba, source=Web Response No relevant relationships by Haaris Naji, source=Web Response No relevant relationships by Heidi Roppelt, source=Web Response No relevant relationships by Nandini Seshan, source=Web Response No relevant relationships by Howard Sklarek, source=Web Response No relevant relationships by Liana Tatarian, source=Web Response No relevant relationships by Daisy Young, source=Web Response