COVID Cholangiopathy Can Occur Despite Mild COVID

Introduction/Objective Post-COVID-19 cholangiopathy is a novel entity first noted in patients recovering from critical COVID-19 infection. Since its initial description in May 2021, all cases reported to date have been in patients with a history of critical COVID-19, defined as requiring ICU admission, the development of respiratory or circulatory failure requiring intubation or ECMO, or vasopressor support. Here we report three cases of post-COVID-19 cholangiopathy arising in patients who recovered from non-severe COVID-19. Methods/Case Report Six cases of COVID-19-related cholangiopathy were identified by retrospective review, three of which involved patients who verifiably did not develop critical COVID-19. Histology slides for each case were reviewed and all showed features of secondary sclerosing cholangitis. Patient 1 is a 41yo female who developed COVID-19 after liver transplant (LT). Despite administration of monoclonal antibodies, she required re-transplantation 6 weeks later. Explant histology showed bile infarcts, severe hepatocytic and canalicular cholestasis, ductular reaction, organizing portal vein thrombi, and necrotic bile ducts accompanied by bile lakes. Patient 2 is a 47yo male with alcoholic cirrhosis who was diagnosed with COVID-19 at the time of LT workup, and underwent LT 90 days later. In addition to alcohol-related cirrhosis, explant histology showed dilated bile ducts with periductal fibrosis, as well as severe ductular reaction with proliferating ductules containing thick, inspissated bile. Patient 3 is a 54yo male with history of LT for PSC who developed mild COVID-19 five years after LT. Allograft function subsequently worsened and biopsy 6 months later showed bile duct damage and loss of ~35% of bile ducts;repeat biopsy 14 months after his COVID diagnosis showed periportal fibrosis with edema, ductular reaction, marked hepatocellular and canalicular cholestasis, and ductopenia with loss of 60% bile ducts. Average time between COVID-19 diagnosis and onset of COVID-related cholangiopathy was 3 months (range: 6 weeks-6 months). These patients were also all immunocompromised with two due to prior LT and one being cirrhotic. Results (if a Case Study enter NA) NA. Conclusion Although previously reported only in patients with severe COVID-19, the cases described represent the first evidence that cholangiopathy, manifested by sclerosing cholangitis, can arise even in patients who were not critically ill, although this may require an immunocompromised state to develop.

A case report of multiple artery pseudoaneurysms associated with SARS-CoV-2.

Arterial pseudoaneurysms are rare vascular abnormalities that can occur as a complication of infections. Artery pseudoaneurysms associated with SARS-CoV-2 are a rare occurrence in COVID-19 patients, and their rupture can result in significant hemorrhage and sudden death. Few cases of SARS-CoV-2-associated artery pseudoaneurysms have been reported, and their underlying pathophysiological mechanisms remain unclear. This study presents the first reported case of a patient who developed both pulmonary and gallbladder artery pseudoaneurysms following SARS-CoV-2 infection. We investigate the potential pathogenesis of these pseudoaneurysms and aim to improve the understanding of this rare complication.

SARS-CoV-2-related injury of biliary tract

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), which causes coronavirus disease-2019 (COVID-19), affects several organs and systems. The ways of the virus penetration into tissues have been studied. Liver is affected in 15 — 53 % of cases. Data on the RNA-seq sequencing in the Human Protein Atlas database con-firm the expression of ACE2 (angiotensin 2 converting enzyme receptor) in the liver and epithelium of the bile ducts and gallbladder. At the same time, a high frequency of ACE2 expression is observed only in cholangiocytes, but not in hepatocytes, Kupffer cells or endothelial cells. The amount of ACE2 in bile duct cells is significantly higher than in hepatocytes, and is comparable to the level in type 2 alveolar cells in the lungs, which makes the biliary tract a potential target for the virus. Binding of SARS-CoV-2 to gallbladder epithelial cells can lead to mucosal inflammation. A systematic review describes the formation of bile clots in small bile ducts. Presence of COVID-19 in the wall of the gallbladder (qrt-RCR) has been revealed. With this, acute cholecystitis develops clinically, and radiological investigations show thickening of the gallbladder wall, biliary sludge and perivesicular fluid. Onset of acute gangrenous cholecystitis as a late complication of COVID-19 infection is described. Histologically, inflammatory infiltrates are found in the gallbladder wall, which diffusely affect medium-sized arteries with obliteration of their lumen, ischemia of the bladder wall;the perineural inflammation take place. These features indicate vasculitis with thrombosis. Thus, despite the theoretical information about the biliary tract injury by the COVID-19 virus, this aspect of the infection has not been clinically studied, and the published papers are limited to the description of single clinical cases. In our opinion, a deeper and long-term study of the biliary tract pathology in COVID-19 infection is needed to provide rationale for the treatment with ursodeoxycholic acid. © 2020, Publishing Company VIT-A-POL. All rights reserved.

Pediatric Inflammatory Multisystem Syndrome (Pims) and Dengue Fever during Sars-Cov-2 Pandemic

Intro: The COVID-19 pandemic continues to spread worldwide, and it is likely to overlap with the dengue epidemics in tropical countries. Although most children and young people who develop COVID-19 have no symptoms or very mild ones at the time, we now know that a small number develop Paediatric Inflammatory Multisystem Syndrome (PIMS) a few weeks afterwards. Due to overlapping of clinical and laboratory features, it may be difficult to distinguish PIMS from dengue fever. So this study was undertaken to analyse the clinical features and laboratory investigations in these patients. Method(s): We retrospectively studied the case records of 21 patients diagnosed as pediatric inflammatory multisystem syndrome (based on WHO case definition) and dengue fever (either NS1 antigen positive or IgM antibody positive). A total of 106 patients were diagnosed with dengue fever. Out of these SARS-CoV-2 antibodies were positive in 57 patients. However, only 21 patients full filled the case definition for multi-inflammatory syndrome in children (MIS-C). Clinical features and laboratory investigations were entered in a proforma and results analysed. Finding(s): Out of 21 children's maximum children were older than 10 years age (76.2%). Commonest finding on abdominal sonography was gall bladder wall edema followed by ascites. Thrombocytopenia was seen in 18 (85.7 %) patients at admission and in 14 (66.7%) platelets were less than 50000/mm3.LDH was raised in 19 (90.4%), Ferritin in 18 (85.7%) and D-Dimer in 13 (61.9%) of patients (Table 2). Fever was seen in all the patients,17 (80.9%) patients had shock on admission. Rash was seen in 15 (71.4 %) of the patients. All the patients were discharged. Conclusion(s): Many of clinical features are common to both diseases. However, increased levels of serum ferritin, d-dimer and CRP are more commonly seen in pediatric inflammatory multisystem syndrome due to covid as compared to lower platelet counts which are more frequently seen in dengue fever patients.Copyright © 2023

Cholelithiasis Causing Asymptomatic Cholecystoenteric Fistula

Introduction: Biliary fistulas are a rare complication of gallstones. Fistula formation can occur in a number of adjacent sites;even more rare complication is the formation of a cholecystocolonic fistula. Case Description/Methods: A 74-year-old man who had recently undergone an extensive hospitalization secondary to inflammatory demyelinating polyneuropathy (IDP) and COVID-19 infection. During his hospitalization, he required ICU admission and mechanical ventilation with subsequent PEG tube placement. He was discharged to an inpatient rehabilitation facility when he developed worsening respiratory distress. Laboratory examinations were pertinent for ALT of 252, AST of 140 and ALP of 401 without hyperbilirubinemia. Blood cultures revealed Escherichia coli bacteremia. Given transaminitis and bacteremia, an MRCP was performed which demonstrated evidence absent space between gallbladder and hepatic flexure of the colon suggesting a CCF (Figure A). An ERCP with sphincterotomy was performed which showed extravasation of contrast from the gallbladder into the colon at the hepatic flexure (Figure B). He underwent cholecystectomy and fistula repair without any complications and gradual improvement in liver function test. He was discharged to a rehabilitation facility. Discussion(s): Complications of gallstones are well established, which include the common bile duct obstruction, but also include the rare occurrences of acute cholangitis, malignancy, and fistula formation. CCF is a rare complication of gallstones which can occur in the stomach, duodenum, or colon with a variable clinical presentation. Complications from an undiagnosed fistula can be life threatening including colon perforation and fecal peritonitis. This case highlights the diagnostic challenge and the high degree of clinical suspicion involved in establishing the diagnosis of CCF in patient without abdominal symptoms suggestive of gallbladder disease. We hypothesize that stone formation resulting in the development of the fistula may be secondary to the underlying history of IDP and subsequent immobility. Although rare, CCF should be considered in patients presenting with unexplained pneumobilia and bacteremia. A timely diagnosis should be made to proceed with immediate treatment including cholecystectomy and fistula closure to prevent fatal complications.

EFFECT OF THE COVID-19 PANDEMIC ON THE CLINICAL EVOLUTION OF ACUTE APPENDICITIS AND ACUTE CHOLECYSTITIS: A URUGUAYAN EXPERIENCE

Background: The World Health Organization declared a worldwide Coronavirus (COVID-19) pandemic on March 11, 2020. In Uruguay, unlike most countries, a mandatory confinement was not declared. On the contrary, an extensive education and prevention campaign was carried out associated with measures to reduce social mobility, such as prohibiting meetings and closing bars.Objectives: The aim of the present study was to evaluate the COVID-19 pandemic in Uruguay and its repercussion on the clinical evolution of the two most common surgical pathologies: acute appendicitis (AA) and acute cholecystitis (AC).Methods: A retrospective comparative cohort study was performed at the Emergency Department of the University Hospital "Hospital de Clinicas Manuel Quintela,” the most important tertiary referral hospital in the city of Montevideo, capital of Uruguay. Two cohorts were identified: 13th of March 2019 to 13th of June 2019 [Pre-Covid period (PCP)] and the same period in 2020 [Pandemic Covid period (PCVP)]. Demographic and clinical data were analyzed.Results: A total of 118 cases were registered in 2019 and 109 in 2020. There were 43 cases (36.4%) of acute appendicitis in the pre-Covid period and 42 cases (36.5%) in Pandemic Covid period (p = 0.745). Acute cholecystitis cases differed significantly between cohorts, with a raise of cases in the Pandemic Covid period (14 vs 25) (p = 0.027). The surgical approach (Laparoscopy vs Open) did not change significantly (p = 0.207). A significant increase in complicated cases (AA + AC) was found during the pandemic (PCP 57 cases vs PCVP 67 cases) (p < 0.001). The sub-analysis of AA and AC showed a significant increase in AA's complicated cases during PCVP (14 vs 25;p < 0.001) and no significant changes in the AC group (p = 0.99).Conclusion: An increase of complicated cases of AA was observed with maintenance of the number of consultations that might be explained by the excellent pre-hospital care system and absence of lock-down measures. The results are contradictory in some aspects, which calls for a deeper analysis, comparing different realities and longer periods of time in order to be able to draw conclusions that are representative for the Coronavirus pandemic in Uruguay.

Covid-19 Infection Presenting as Acute Pancreatitis

Purpose of study Introduction COVID-19 emerged at the end of 2019 as an epidemic of respiratory disease in Wuhan, China that later spread globally and was declared as pandemic. The common clinical manifestations of COVID-19 infection include fever, cough, myalgias, headache, sore throat, anosmia, nasal congestion, fatigue and chest pain. The most serious complications include bilateral multifocal pneumonia and acute respiratory distress syndrome. Acute pancreatitis is rarely reported in association with COVID-19 infection. We report a case of acute pancreatitis secondary to COVID-19 infection. Case Report: A 69-year-old man with past medical history of hyperlipidemia and seizure disorder presented with two days of epigastric pain radiating to back. The patient reported fever, malaise and dry cough for the last 3 days. Home medication included atorvastatin and carbamazepine for 10 and 15 years respectively. The patient denied smoking and alcohol use. COVID- 19 PCR was positive. Labs showed WBC of 3800/muL, hgb 11.8 g/dL, calcium 8.4 mg/dL , lipase 426 U/L, D-Dimer 179 ng/ml DDU, High sensitivity C-reactive protein 27.5 mg/L (normal <5 mg/L) ALT 26 U/L, AST 31 U/L, alkaline phosphatase 103 U/L and total bilirubin 0.3 mg/dL. Ultrasound of the right upper quadrant and CT abdomen showed normal pancreas, common bile duct and gallbladder with no evidence of gallstones. Triglyceride level was 70 mg/dL (<149 mg/dL) on the lipid panel. The patient was diagnosed with acute pancreatitis and received treatment with IV fluids and pain medication. The symptoms improved gradually and the patient was discharged home with resumption of home medications. Methods used Case Report Summary of results The common differentials for acute pancreatitis include alcohol use, gallstones, hypertriglyceridemia, viral infections like mumps and measles, hypercalcemia and medication-related, etc. Normal AST, ALT, alkaline phosphatase and total bilirubin along with absence of gallstones and normal common bile duct ruled out alcoholic and biliary pancreatitis. Normal calcium level and triglyceride level rule out hypercalcemia and hypertriglyceridemia as the cause of pancreatitis. Carbamazepine has rarely been reported to cause acute pancreatitis typically soon after the initiating the therapy or with increase in the dose. The use of carbamazepine for more than 15 years without any recent dose change makes this unlikely as the cause of pancreatitis. The onset of acute pancreatitis during the timeline of COVID-19 constitutional symptoms and absence of other risk factors suggests that COVID-19 infection is responsible for acute pancreatitis in our patient. Conclusions We report a case of acute pancreatitis secondary to COVID-19 infection. Further studies are warranted to better understand the etiology and the pathophysiology of acute pancreatitis secondary to COVID-19 infection.

Acute acalculous cholecystitis as a rare gastroenterological association of COVID-19: a case series and systematic review.

Background and Aim: Acute acalculous cholecystitis (AAC) is an acute inflammatory disease of the gallbladder in the absence of cholecystolithiasis. It is a serious clinicopathologic entity, with a high mortality rate of 30-50%. A number of etiologies have been identified that can potentially trigger AAC. However, clinical evidence on its occurrence following COVID-19 remains scarce. We aim to evaluate the association between COVID-19 and AAC. Methods: We report our clinical experience based on 3 patients who were diagnosed with AAC secondary to COVID-19. A systematic review of the MEDLINE, Google Scholar, Scopus, and Embase databases was conducted for English-only studies. The latest search date was December 20, 2022. Specific search terms were used regarding AAC and COVID-19, with all associated permutations. Articles that fulfilled the inclusion criteria were screened, and 23 studies were selected for a quantitative analysis. Results: A total of 31 case reports (level of clinical evidence: IV) of AAC related to COVID-19 were included. The mean age of patients was 64.7 ± 14.8 years, with a male-to-female ratio of 2.1:1. Major clinical presentations included fever 18 (58.0%), abdominal pain 16 (51.6%), and cough 6 (19.3%). Hypertension 17 (54.8%), diabetes mellitus 5 (16.1%), and cardiac disease 5 (16.1%) were among the common comorbid conditions. COVID-19 pneumonia was encountered before, after, or concurrently with AAC in 17 (54.8%), 10 (32.2%), and 4 (12.9%) patients, respectively. Coagulopathy was noted in 9 (29.0%) patients. Imaging studies for AAC included computed tomography scan and ultrasonography in 21 (67.7%) and 8 (25.8%) cases, respectively. Based on the Tokyo Guidelines 2018 criteria for severity, 22 (70.9%) had grade II and 9 (29.0%) patients had grade I cholecystitis. Treatment included surgical intervention in 17 (54.8%), conservative management alone in 8 (25.8%), and percutaneous transhepatic gallbladder drainage in 6 (19.3%) patients. Clinical recovery was achieved in 29 (93.5%) patients. Gallbladder perforation was encountered as a sequela in 4 (12.9%) patients. The mortality rate in patients with AAC following COVID-19 was 6.5%. Conclusions: We report AAC as an uncommon but important gastroenterological complication following COVID-19. Clinicians should remain vigilant for COVID-19 as a possible trigger of AAC. Early diagnosis and appropriate treatment can potentially save patients from morbidity and mortality. Relevance for Patients: AAC can occur in association with COVID-19. If left undiagnosed, it may adversely impact the clinical course and outcomes of patients. Therefore, it should be considered among the differential diagnoses of the right upper abdominal pain in these patients. Gangrenous cholecystitis can often be encountered in this setting, necessitating an aggressive treatment approach. Our results point out the clinical importance of raising awareness about this biliary complication of COVID-19, which will aid in early diagnosis and appropriate clinical management.

A surprising culprit for delayed gastrointestinal bleeding after endoscopic ultrasound-guided cholecystoduodenostomy: the double-pigtail stent.

Endoscopic ultrasound-guided gallbladder drainage using a lumen-apposing metal stent has emerged as an accepted option for the treatment of acute cholecystitis in patients unfit for surgery. While metal stents carry a risk of intra- and post-procedural bleeding, the coaxial placement of a double-pigtail stents through lumen-apposing metal stents has been proposed to lower the bleeding risk by preventing tissue abrasion against the stent flanges. We present a case of an 83 year-old male who had previously undergone uncomplicated endoscopic ultrasound-guided cholecystoduodenostomy with this technique. Six months later, he presented with upper gastrointestinal bleeding due to a duodenal pressure ulcer from the coaxial 10-Fr double-pigtail stent originally employed to prevent such bleeding. The 10-Fr stent was replaced with two 7-Fr stents whose increased flexibility and distribution of pressure across multiple points of contact with the duodenal wall was theorized to reduce the likelihood of erosion or perforation. Following the procedure, the patient's clinical course improved significantly with complete resolution of his symptoms of choledocholithiasis and cholecystitis. While 10-Fr double-pigtail stents are generally preferred for this indication due to their stiffness that reduces out-migration, use of more flexible 7-Fr stents may be advisable in thin-walled structures such as the duodenum.

Clinical Course of SARS CoV-2 Infection in Hospitalized Pregnant Patients

Objective: To determine the clinical course and outcome of hospitalized pregnant patients with laboratory-confirmed SARS-CoV-2 (COVID-19) infection Study Design: Prospective longitudinal study Place and Duration of Study: Obstetrics Units of Pak Emirates Military Hospital and Combined Military Hospital, Rawalpindi Pakistan, from May to Jun 2020. Methodology: All patients reporting for childbirth were tested for SARS-CoV-2, and those testing positive were included. The primary outcome was virus clearance time and categorization according to the severity of the disease into asymptomatic, mild, moderate, severe and critical. Furthermore, a comparison was made between the presence of comorbid conditions and symptoms in the category of COVID-19. In addition, neonatal sample evaluation for SARS-CoV-2 was done. Results: Out of the 881 women giving birth, 41(4.6%) tested positive for SARS Cov-2. Majority were asymptomatic 28(68.3%) followed by mild 8(19.5%), moderate 4(9.8%) and severe 1(2.4%) category. There was a significant association of the COVID categories with symptoms (p-value<0.005) and comorbid condition (p-value<0.001). The mean virus clearance time was 8.20±1.66 days. During hospital stay 34(82.9%) delivered. All 34(100%) delivered babies had no evidence of vertical transmission. Conclusion: Pregnant women with COVID-19 infection have a nearly similar clinical course to non-COVID women in this study. There is also no evidence of vertical transmission to the neonate.

Management of Hepato- biliary-pancreatic Surgery during the COVID-19 Pandemic

Purpose: We examined the effect of COVID-19 on diseases treated with hepato- biliary- pancreatic surgery from the experience of nosocomial infection at our hospital. Method(s): We examined the treatment of 106 patients admitted by the Division of Hepato- Biliary- Pancreatic Surgery to The Jikei University Hospital for elective surgery from January through May 2020. Result(s): Of the 106 operations, 90 (85%) were performed as scheduled and did not include COVID-19-positive patients. Operations for 16 patients (15%) were postponed, but 5 (31%) of these operations were urgent or quasiurgent and were performed during the study period. Of 95 patients who underwent surgery, 50 (53%) had a malignant tumor, 3 (3%) had a borderline malignant tumor, and 42 (44%) had a benign lesion, of which 41 were gallstones or gallbladder polyps and 1 was an intraductal papillary mucinous neoplasm that caused pancreatitis. Surgery for the latter tumor was postponed while conservative treatment improved conditions, but pancreatitis recurred 2 weeks after discharge, leading to a quasiurgent surgery. Conclusion(s): Owing to COVID-19, 15% of the scheduled elective hepato- biliary- pancreatic operations were postponed. Even lesions considered benign or not requiring emergency surgery should be treated promptly. Thus, the timing of treatment should be determined so that the risks of exacerbation and COVID-19 can be balanced.Copyright © 2022 Jikei University School of Medicine. All rights reserved.

Predicting acute cholecystitis on final pathology to prioritize surgical urgency: an evaluation of the Tokyo criteria and development of a novel predictive score

Background: The COVID-19 pandemic has compounded limitations in access to the operating room, highlighting the need for improved surgical prioritization rules for common pathologies, including acute cholecystitis. The objective of this study was to compare the performance of our institution's surgical prioritization rules to the Tokyo diagnostic criteria and to develop a novel decision rule to predict acute cholecystitis on surgical pathology. Methods: All consecutive adult patients undergoing emergency cholecystectomy at a single academic institution between April 2017 and April 2021 were reviewed. The primary outcome was diagnosis of acute inflammation on final pathologic analysis. Multiple logistic regression was performed with a training subset using relevant clinical variables that were selected a priori. A simple weighted decision rule was created and compared with the Tokyo diagnostic criteria and the institution's existing prioritization rules via an analysis of receiver operating characteristic curves on a second subset of the population. Results: Among 756 patients undergoing emergency cholecystectomy, 97.6% met criteria for acute cholecystitis as per Tokyo diagnostic criteria. Tokyo criteria (area under the curve [AUC] 0.51, sensitivity 99%, specificity 3%) poorly discriminated for acute inflammation on final pathology. Discrimination of the hospital's case prioritization rules was moderate (AUC 0.63, sensitivity 48%, specificity 78%), and a new simple decision rule incorporating fever, Murphy sign, leukocytosis and inflammation on imaging was significantly higher (AUC 0.69, sensitivity 72%, specificity 64%, p < 0.003). Conclusion: In this large cohort of emergency cholecystectomies, the Tokyo diagnostic criteria were highly sensitive but nonspecific for acute cholecystitis on final pathology. An existing institutional case prioritization rule showed moderate discrimination for these outcomes but was outperformed by a novel parsimonious score incorporating readily available preoperative variables. These findings may be useful in the prioritization of emergency cholecystectomies at busy centres but remain to be validated in outside cohorts.

COVID-19 associated spontaneous hemorrhagic cholecystitis

Hemorrhagic cholecystitis is a rare disorder associated with considerable morbidity and mortality. The clinical presentation of hemorrhagic cholecystitis is non-specific and imaging findings can be difficult to accurately interpret without a high level of suspicion. Most recent reports of hemorrhagic cholecystitis have been associated with concurrent therapeutic anticoagulation. Here, we report imaging findings of a case of acute, spontaneous hemorrhagic cholecystitis in a 67-year-old male patient admitted for hypoxic respiratory failure secondary to COVID-19 pneumonia. © 2022

An Unusual case of epstein-barr virus hepatitis mistaken for multisystem inflammatory syndrome in children

Case Report: As COVID-19 infections became more common, children began presenting with multisystem inflammatory syndrome (MIS-C). It can be difficult to distinguish rare presentations of common diseases from MIS-C, especially when there has been a close contact with COVID-19. Epstein-Barr virus (EBV) is a universally common infection with 90% of individuals showing serological signs of past infection. Both MIS-C and EBV can present with similar signs and symptoms. Our case aims to remind the reader to keep in mind uncommon presentations of common viral infections which may mimic MIS-C. Case Presentation: A previously healthy 5-year-old girl presented with persistent fevers for 12 days, associated with stomatitis, vomiting, and diarrhea. Physical exam was significant for a moderately ill-appearance, small (<1 cm) left posterior cervical lymphadenopathy, and soft palate and buccal oral ulcers. Initial labs (see Table) revealed leukocytosis with reactive lymphocytes and cholestatic hepatitis with mild coagulopathy. Although she had no respiratory symptoms, CT chest revealed left upper lobe pneumonia. Abdominal ultrasound showed diffuse hepatosplenomegaly, gallbladder wall thickening, and enlarged epigastric lymph nodes. Echocardiogram showed normal systolic function and coronary arteries without dilation. Extensive viral and bacterial nasal swab and serologic testing, including for SARS-CoV-2 antibodies, was negative. On Day 2, her Monospot was positive, along with EBV viral capsid antigen IgM and IgG with the absence of EBV nuclear antigen IgG. In addition, serum PCR was positive for EBV. Management and Outcome: Due to persistent fevers on Day 3 of broad-spectrum antibiotics, coupled with a close contact with active COVID infection, she was treated with the MIS-C protocol of intravenous immunoglobulin G (IVIG), prednisone, and aspirin. Within a day of IVIG, she improved clinically and fever resolved. By discharge on Day 8, her lab values had begun to normalize. Discussion(s): EBV is known to present in children with typical infective mononucleosis symptoms such as fever, sore throat, and lymphadenopathy. However, these can be lacking which makes the diagnosis challenging. Although hepatitis is a common sequalae of EBV, EBV induced pneumonitis and stomatitis are rare, especially in immunocompetent individuals. While our patient improved after treatment with IVIG, suggesting MIS-C, we still attribute her illness to EBV, as IVIG has been shown to provide antiviral and anti-inflammatory benefit in EBV infections. This case highlights the challenge of recognizing and overtreating rare presentations of common viral infections in the face of an emerging disease such as MIS-C. Significant Laboratory Values [Table presented] Copyright © 2023 Southern Society for Clinical Investigation.

Abdominal Imaging Findings in Patients with COVID-19 Part 2: Solid Organs

[...]although solid abdominal organs are rarely affected by COVID-19, clinicians must be familiar with the manifestations since they are associated with the disease severity and poor outcome. Keywords: COVID-19, Abdominal, Imaging, Computed tomography, Ultrasonography Introduction The world has been confronting the upsurge of coronavirus disease 2019 (COVID-19) since the first novel coronavirus infection (SARS-CoV-2) initially emerged in China in December 2019.1 The most common symptoms reported in COVID-19 are related to respiratory system involvement, including fever, dry cough, fatigue, and dyspnea.2 Angiotensin-converting enzyme 2 (ACE2) plays a significant role in mediating the inflammation of COVID-19, which can contribute to COVID-19 manifestations.3 ACE2 receptors are found in various cells, including hepatocytes, cholangiocytes, podocytes, and enterocytes.2,3 Forty percent of infected patients have shown gastrointestinal (GI) manifestations, including loss of taste, nausea, vomiting, diarrhea, and abdominal pain.4 A significant number of patients have GI symptoms, and sometimes it is the only presentation of the disease without respiratory manifestations.2 The reverse-transcriptase polymerase-chain-reaction (RT-PCR) diagnostic test and chest computed tomography (CT) were reported to be highly sensitive in the early diagnostic stage of suspected COVID-19.5 Cross-sectional abdominal imaging is not usually used in COVID-19.6 Nevertheless, abdominal CT may be performed if specific symptoms exist, such as abdominal pain. Radzina et al found that multiparametric ultrasonography may be more sensitive than CT and Magnetic resonance imaging in assessing liver damage at the cellular level in patients with COVID-19 before progressing into liver cirrhosis.37 Pancreas Given the fact that ACE2 receptors are vastly expressed in pancreatic islet cells, COVID-19 can induce islet cell damage presenting with acute diabetes.38 The pancreatic involvement can occur through the direct invasion by SARS-CoV2, a systemic response to pneumonia, or a destructive immune reaction due to viral stimulation.19 According to Wang and colleagues, the pancreas was affected in 17% of patients with COVID-19 pneumonia.19 In reported cases of SARS-CoV-2 infection, abdominal CT revealed features of acute pancreatitis, including edema and inflammation of the pancreas with surrounding fluid collections and fat stranding30-39 (Figure 3). Kidney According to Pei et al, the most prevalent renal abnormalities in the setting of COVID-19 were proteinuria and hematuria, with acute kidney injury (AKI) happening less often.50 Renal infarct might occur because of hypercoagulation.6 The possible mechanisms of AKI in COVID-19 might be related to a variety of factors, including cytokine release syndrome, hypoxia, endotoxin produced by superimposed infections during ICU admission, and rhabdomyolysis.51 Different studies have established that AKI considerably increased the mortality rate in admitted patients with COVID-19.20 Renal parenchymal hypodensity and perirenal fat stranding on non-enhancement CT in patients with COVID-19 represent severe renal impairment.52 Like the spleen, the most common renal finding in abdominal tomograms was infarction.12 In such conditions, the affected kidney presents with patchy, sharply demarcated heterogeneous areas with hypoenhancement.6 A summary of renal imaging findings is shown in Table 6.

General surgery telemedicine clinics: Here to stay post-pandemic?

Background: The telemedicine clinic in general surgery has become widespread since the onset of the COVID-19 pandemic and has remained so following relaxation of restrictions on conventional face-to-face appointments. However, there has been significant scepticism regarding its continued utility. In particular, there is a concern that patients cannot be adequately assessed and counselled for invasive procedures, which may result in high cancellation rates on the day of procedure. The aim of this study was to assess the cancellation rate on the day of surgery for procedures booked in telemedicine clinics. Method(s): We conducted a retrospective analysis of surgical procedures booked via hepatopancreatobiliary (HPB) and general surgery telemedicine clinics from March 2020 to November 2021. From September 2020 onwards, telemedicine clinics were only run for laparoscopic cholecystectomies for benign gallbladder disease. The primary outcome was the cancellation rate of surgical cases booked from telemedicine clinics. Statistical analysis was done using JASP 0.16.2 software. Result(s): We identified 240 cases booked for surgery from telemedicine clinic. 162 patients (68%) were female;the median age of the study population was 51 (16-81). 186 (78%) patients had gallstones, 19 (8%) gallbladder polyps, 13 (5%) secondary liver tumour, 5 (2%) liver cyst, 5 (2%) pancreatic tumour, 4 (1.7%) primary liver tumour, 2 (0.8%) gallbladder tumour and 6 (2.5%) other pathologies. 225 patients (94%) underwent surgery on their first admission. Procedures included 192 cholecystectomies, 10 open segmental liver resections, 6 laparoscopic segmental liver resections, 4 distal pancreatectomies, 3 open right hepatectomies, 2 Whipple procedures, 2 laparoscopic deroofing of the liver cyst, 2 laparoscopic lymph node biopsy, 1 extended right hepatectomy, 1 left hepatectomy, 1 small bowel resection and 1 exploratory laparotomy. 15 (6%) patients had surgery cancelled on the day of surgery, 14 of those were for laparoscopic cholecystectomy, 1 for laparoscopic liver resection. Only one such cancellation was deemed avoidable as it may have been prevented by a face-to-face assessment. The majority 212 (88%) of patients were ASA class 1-2;only 28 (12%) were ASA class 3. There was no significant association between high ASA (3) and cancellation rate (Chi square test 5% vs 14% p=0.062). Conclusion(s): Telemedicine clinic in general surgery was often the only option to assess and plan operative management for newly referred patients during the COVID-19 pandemic. Our series showed that it was feasible to assess and counsel patients on the phone even for major HPB procedures with a minimal cancellation rate on the day of operation.

Is there still a role for routine histology in cholecystectomies for benign disease?

Background: A movement towards selective histology for benign gallbladder disease is evolving in the United Kingdom (UK). Studies propose the reliance on macroscopic features to identify incidental gallbladder cancer (IGBC). We aimed to investigate the rate of dysplastic gallbladder histology, the rate of subtotal cholecystectomy and identify any selection criteria for selective histology. Method(s): A retrospective observational study examining patients who underwent a cholecystectomy, amid the COVID-19 pandemic, between January 2020 and June 2021. This study was carried out in a large Trust in the West Midlands, UK. Multivariate logistical regression models were used to identify patient factors associated with IGBC and compare outcomes between total and subtotal cholecystectomy. Result(s): There were 959 patients;631 (65.8%) elective and 328 (34.2%) emergency cholecystectomies. Median age was 48 (35-59) years, and 724 (75.5%) patients were female. 27 (2.8%) patients had a subtotal cholecystectomy with worse post-operative complications (Clavien-Dindo grade 3+, OR 4.69, p=0.026), however no patient suffered a common bile duct injury. Eight (0.8%) patients had IGBC of which 6/8 were diagnosed as cholelithiasis on ultrasound. Five IGBCs had no macroscopic features. One patient needed further surgery and chemotherapy. Gallbladder polyps on ultrasound was the only patient factor associated with increased likelihood of IGBC (OR 14.49, p=0.014). Conclusion(s): We support the current recommendation of the UK Royal College of Pathologists to routinely examine all cholecystectomies removed for benign disease, given that macroscopic features may be absent in IGBC and no clear patient factors to support a selective approach.

Elective versus Emergency management of gallstone disease at a tertiary referral centre amidst the COVID-19 pandemic-should the protocol be altered?

Background: Gallstones are a common pathology affecting approximately 15% of The population in UK, 20% of which are symptomatic. It is suggested symptomatic patients undergo cholecystectomies. Guidelines recommend this is performed within one week of initial Emergency presentation or 52 weeks for elective case. Surgical capacity to manage Emergency cholecystectomies was limited due to The COVID pandemic. We assessed wait time discrepancy between elective and Emergency cholecystectomies. Method(s): A retrospective review of all patients undergoing cholecystectomies between January and November 2021 in a major tertiary referral centre in London was undertaken. Initial pathology at The time of presentation, elective vs Emergency presentation, pre-surgical Biliary complications along and wait times were reviewed. Result(s): 219 (74 elective, 145 emergency) patients underwent surgery, mean age 48 years (23% Male and 77% Female). Average wait times for elective cholecystectomies were 69.7 days (min 0, max 246) in Comparison to 68.9 days (min 1, max 253) for Emergency surgery. 22 (15%) of The patients of initial Emergency presentation re-attended hospital and 6 (4%) had adverse events such as gallbladder perforation or pancreatitis due to delayed treatment. Comparatively, 9 (12%) elective patients attended A&E due to pain, with no adverse outcomes. Conclusion(s): Overall wait time of Emergency vs elective cholecystectomies were similar. This review indicates Emergency cases require prioritisation over elective cholecystectomies due to The higher number of re-attendance and adverse events. Emergency cases need to be prioritised to meet guidelines, which could also reduce complication rates whilst awaiting Surgery and lead to fewer adverse outcomes.

Increased incidence of gallbladder dysplasia and Cancer during COVID19 pandemic

Aims: Cholecystectomy is one of The most frequently performed operations in The United Kingdom. Following The spread of COVID19 infection, reduced operational capacity has led to lengthen The waiting time for cholecystectomy, which leads to significant readmission rate, growing financial burden and increased complexity of The surgical intervention. Our study aims to identify changes in gallbladder (GB) histopathological findings before and during COVID19 pandemic. Method(s): Data was collected retrospectively on 337 patients who underwent cholecystectomy between 01/2019-12/2019 (pre-COVID19) and 296 patients between 09/2020-10/2021 (during COVID19) at Princess Alexandra Hospital, including preoperative clinical-radiological, Surgery waiting time, operation details, postoperative histology and complications. Statistical analysis performed using chi-square tests (p-value<0.001). Result(s): A total of 2 (0.6%) female cases (average age 75.6) had gallbladder dysplasia (GD) and 1 of them had GB adenocarcinoma found pre-COVID19 versus 8 (2.7%) (7F:1M, average age 46.6) with GD and 5 (1.7%) (3F:2M, average age 72.6) with adenocarcinoma during pandemic. Other histopathological findings were 153 (45.4%) GB with chronic inflammation, 2 (0.5%) with necrosis or perforation pre-COVID19 versus 127 (42.9%) and 6 (2%) respectively during pandemic. The average Surgery waiting time for patients with GD or adenocarcinoma was 135 days before COVID19 versus 224.21 (33-676) during pandemic. Conclusion(s): GD is associated with increased Cancer risk at GB and other biliary tract sites. Our data demonstrated a statistically significant increase of incidence of GD and adenocarcinoma (p-value<0.00089) in patients who underwent cholecystectomy during pandemic versus pre-COVID19. Further ongoing study is recommended to understand The correlation with prolonged Surgery waiting time.