IT'S NEXT TO THE PLEURA

SESSION TITLE: Pneumothorax, Chylothorax, and Pleural Effusion Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Chest tube placement is generally done to drain air (Pneumothorax) or fluid (Effusion or Hemothorax) from the pleural cavity. The incidence of complications related to such intervention varies between 1 to 6 percent (1), and includes but not limited to malposition, injuring chest wall structures, injuring intrathoracic structures, bleeding, and infection. In this case we present an unusual complication to surgical chest tube placement. CASE PRESENTATION: Our patient is a 59-year-old male, long term resident of a nursing facility with past medical history of alcohol use disorder in remission, alcoholic cirrhosis, seizure disorder, protein-calorie malnutrition and a recent COVID-19 infection. He presented with worsening shortness of breath and was admitted with acute hypoxemic respiratory failure. Initial CT scan showed fibrotic, reticular and cystic changes, traction bronchiectasis and diffuse bilateral ground glass opacities. He was admitted to the medical ICU;he was treated initially with broad spectrum antibiotics and diuresis with minimal response. Eventually steroid therapy was started for Covid related organizing pneumonia, and he improved. Later in his hospital state he developed bilateral small pneumothoraxes that enlarged overtime and a surgical chest tube was placed on the right side. Post procedure chest x ray showed that the tube was kinked, and the pneumothorax was still present. A follow up CT chest confirmed the presence of an extra-pleural hematoma with the tube kinked inside it. CT angiography of the chest was done and showed active extravasation of contrast into the extra-pleural space likely from the intercostal arterial branches. Interventional radiology took the patient to see if they could cauterize the bleeding vessel but they were unable to identify the source of bleeding. Thoracic surgery was also consulted and was planning to take the patient to the OR, remove the tube, evacuate the hematoma and control the bleeding. However, the patient opted against this. DISCUSSION: Extra-pleural hematoma is a rare complication of surgical chest tube placement. It is usually seen after blunt trauma or rib fracture, but can still occur after subclavian vein central line placement or chest tube placement. Bleeding is usually arterial in origin and treatment is often surgical. Radiological characteristics include biconvex shape and the extra-pleural fat sign (2,3,);hypodense rim medial to the hematoma due to the inward displacement of the extra-pleural fat by the hematoma. CONCLUSIONS: Chest tube placement remains a routine procedure that is done in emergency departments and hospital wards. Generally, a safe intervention but clinicians should be aware of the possible complications and their management including extra-pleural hematomas. Reference #1: Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010 Tom Havelock1, Richard Teoh2, Diane Laws3, Fergus Gleeson4 on behalf of the BTS Pleural Disease Guideline Group. Correspondence to Dr Tom Havelock, Wellcome Trust Clinical Research Facility, Southampton General Hospital, Southampton SO16 6YD, UK;t.havelock@soton.ac.uk Reference #2: Journal of Trauma and Injury 2017;30(4): 202-205. Published online: December 30, 2017 DOI: https://doi.org/10.20408/jti.2017.30.4.202 Traumatic Extrapleural Hematoma Mimicking Hemothorax Yong Seon Choi, M.D., Soon Jin Kim, M.D., Sang Woo Ryu, Seung Ku Kang Department of Thoracic and Cardiovascular Surgery, Mokpo Hankook Hospital, Mokpo, Korea Correspondence to: Soon Jin Kim, M.D., Department of Thoracic and Cardiovascular Surgery, Mokpo Hankook Hospital, 483 Yeongsan-ro, Mokpo 58643, Korea, Tel: +82-61-270-5574, Fax: +82-61-277-0199, E-mail : innocent-blood@hanmail.net Reference #3: The Journal of Emergency Medicine Volume 51, Issue 2, August 2016, Pages 159-163 Nonoperative Management of a Large Extrapleural Hematom after Blunt Chest Trauma LuisGorospe MD, María Ángeles Fernández-Méndez MD, AnaAyala-Carbonero MD, AlbertoCabañero-Sánchez MD, Gemma MaríaMuñoz-Molina MD, PhD DISCLOSURES: No relevant relationships by Ahmad Allaham No relevant relationships by Elyce Sheehan

The Course of Alcoholic Cirrhosis of The Liver in a Patient with COVID-19

This article presents the features of the course of liver cirrhosis (LC) in a patient with a new coronavirus infection. The patient had no specific respiratory symptoms of COVID-19 (CoronaVirus Disease 2019), and the reason for outpatient examination for SARS-CoV-2 (severe acute respiratory syndrome coronavirus) RNA was the presence of these symptoms in relatives. Previously, patient E. had been undergoing in-patient examination and treatment for abdomen volume build-up against the background of prolonged alcoholization, and was diagnosed with alcoholic class B LC according to Child-Pugh classification. Conservative therapy was administered, and the patient was discharged with regression of ascites. Within a week after SARS-CoV-2 identification, patient E. showed signs of LC decompensation in the form of increasing abdominal volume, which required repeated inpatient treatment, during which portal vein thrombosis (PVT) and progression of chronic liver disease (CLD) in the post-coid period were revealed. Literature data on 30-day mortality in patients with LC against COVID-19 background are presented, as well as my own observations on the example of 580 case histories. Complications of new coronavirus infection in patients with CLD, methods of their correction are considered here. This observation demonstrates the social significance of the problem of COVID-19 incidence in patients with LC, the necessity for screening for COVID-19 in case of the presence of decompensation episodes, as well as active prevention of infection in these patients.

A case series of drug induced liver injury leading to ACLF after complementary & alternative medicine over-use for COVID-19

Background and Aims: ACLF is a condition in which 2 insults to liver operate simultaneously, 1 being chronic, and other acute. Complementary & alternative medicine (CAM) are important causes for ACLF. India is the birth place of Ayurveda & CAM is considered safe by the common population with around 80% of the population relying on it. CAM consumption has increased in recent years. Due to the pandemic and the focus on improved immunity, the consumption of CAM has gone up. India has reported 4.8 lakh COVID 19 related deaths till December 2021. However, WHO has estimated 4.7 million deaths directly or indirectly related to COVID-19. We documented a case series of CAM related DILI-ACLF, with CAM being consumed for COVID prevention Methods: ACLF established with APASL defining criteria. USG was done to assess for features of CLD. Liver biopsy was done where feasible. Results: Case 1-39-year-old diabetic taking Giloy Kwath for 2 months for COVID prevention. Presenting with jaundice & ascites having MELD score 18 and CTP class B, he had NASH related cirrhosis on biopsy and is still on follow up. Case 2- f/u/c of CTP A alcoholic cirrhosis who consumed a crushed herb for protection against COVID given by a quack for 3 months, with no alcohol intake in 2 years. He presented with jaundice and encephelopathy, had MELD score 38 & CTP C & succumbed to illness. Case 3 49-year-old lady consuming Giloy Kwath for 4 months for COVID prevention. She was diagnosed with AIH type 1 with MELD score 39. She succumbed to illness with post-mortem liver biopsy showed features of AIH cirrhosis Conclusion: CAM is the most common cause of drug induced ACLF. CAM consumption increased during the pandemic and may have lead to increase in indirect COVID related deaths

THE IMPACT OF COVID-19 ON ALCOHOLIC LIVER DISEASES IN A PREDOMINANTLY AFRICAN AMERICAN AND HISPANIC COMMUNITY

BACKGROUND Alcohol misuse is a major public health concern in the United States. Centers for Disease Control reported 261 deaths per day due to excess alcohol consumption. National Institute of Alcohol Abuse and Alcoholism reports a significant increase in alcohol sale during the current Covid-19 pandemic. We aim to study the impact of alcohol misuse during the current pandemic in inpatient admissions. METHODS We retrospectively reviewed all the hospitalizations at BronxCare Health System, a safety-net community hospital in New York City, between March and September during the years of 2017 to 2020. All adult inpatient encounters with an admitting diagnosis of decompensated alcoholic liver cirrhosis (DALC) and alcoholic hepatitis (AH) were included in our study. RESULTS We compared two groups based on time periods: pre-pandemic and pandemic. There was a significant increase in admissions in the pandemic group. We ed a total of 64 admissions for DALC and 51 for AH in the pre-pandemic group and 90 hospitalizations for DALC and 69 hospitalizations for AH in the pandemic group. The mean age of patients admitted for DALC 57 years (SD ±11) and 54 years (SD ±9) respectively, p=0.036. We observed a decrease in the number of female hospitalizations (26.3% vs 18.8%, p=0.1829) and an increase in-hospital mortality (8.7% vs 12.0%, p=0.394) related to DALC. However, these findings did not reach statistical significance. The mean age of patients admitted for AH was 48 years (SD ±10) in both the groups, p=0.34. There were no statistically significant differences in gender (24.8% vs 23.2%, p=0.8666) or in-hospital mortality (1.9% vs 4.3%, p= 0.3779). Figures 1 and 2 illustrate an increase in the number of hospitalizations related to DALC and AH during the COVID-19 pandemic. CONCLUSION There was a significant increase in admissions for DALC and AH during the Covid 19 pandemic at our safety net hospital serving a community where alcohol misuses was high. There has been disproportionate impact of Covid 19 in terms of higher mortality in safety net populations. Our study highlights the broader impact of Covid 19 on other major public health concerns including stress, anxiety further exacerbating alcoholism and alcohol abuse which may explain some of the disparities in Covid 19 related mortalities. (Figure Presented)

Considerations for Transplant Risk Assessment in the Setting of Co-occurring Alcohol Use Disorder and Eating Disorder

Background: Rates of alcohol use disorder amongst women have increased markedly since the start of the Covid-19 Pandemic with some studies showing as much as a 41% increase in heavy drinking days (1). Among women with alcohol use disorder, there is a high degree of comorbidity with eating disorders (ED) with studies suggesting rates of co-occurring disease as high as 23-50%(2). However, there is little data on the assessment of transplant recipients presenting with co-occuring ED and AUD. Case: A 34-year-old woman with no known past psychiatric or substance use history presented to our hospital in acute hepatic failure (MELD Score 34) in the context of escalating alcohol use over the course of the COVID-19 Pandemic. As the patient did not respond to multiple medical therapies, evaluation for liver transplantation was initiated. The patient was assessed using the Stanford Integrated Psychosocial Assessment for Transplant (SIPAT), and found to be a high risk candidate. During the course of our evaluation, the patient demonstrated a lack of interest in eating food, refusing to eat food that required chewing, and expressed multiple consequences about the aversive consequences of eating. She described extremely restrictive eating patterns with her lowest weight being 95 lbs (BMI < 16), leading to nutritional deficiencies, peripheral neuropathy and anemia. Given the absence of excessive concern regarding appearance or body weight, a diagnosis of avoidant restrictive food intake disorder (ARFID) was made. Despite efforts to engage the patient, she demonstrated little understanding of her ED. The patient was declined for listing and medically stabilized. She was declined by all inpatient substance use programs given the extent of her ED and rejected recommendations for targeted ED treatment. She was ultimately discharged to an intensive outpatient program for AUD. Discussion: There is a paucity of information regarding liver transplantation in patients with co-occurring AUD and EDs. However, there are many unique considerations in the management of this patient population in both the pre- and post- transplant period. Existing screening methods such as the SIPAT do little to evaluate transplant risk in patients with EDs relative to other psychiatric illnesses. And while predictive risk factors for recurrence of alcohol use after transplant have been identified, little is known about the risk factors for ED relapse. It appears that the emphasis on abstinence from alcohol in the post-transplant period can be a potent trigger for ED relapse(3). Post-transplant, patients with ED have an increased risk of relapse to alcohol and poorer retention in residential treatment(4). Conclusion: Patients with co-occurring ED and AUD requiring liver transplantation are a challenging patient population with complex pre- and post-transplant considerations. References: 1. Pollard M, et al. "Changes in Adult Alcohol Use and Consequences During COVID-19 Pandemic in the US." JAMA Netw Open. 2020;3(9). 2. Bulik, Cynthia, et al. “Alcohol Use Disorder Comorbidity in Eating Disorders: A Multi-center Study.” Journal of Clinical Psychiatry. 65:7, July 2004. 3. Coffman K L, et al. Treatment of the Postoperative Alcoholic Liver Transplant Recipient With Other Addictions." Liver Transpl Surg. 1997;3:322–327. 4. Elmquist, J. et al., "Eating Disorder Symptoms and Length of Stay in Residential Treatment for Substance Use: A Brief Report." Journal of Dual Diagnosis, 11(3-4), 233–237. https://doi.org/10.1080/15504263.2015.1104480.2015.

INCREASE IN ALCOHOLIC HEPATITIS CASES DURING COVID PANDEMIC IN THE US

Background: The COVID-19 pandemic changed the way Americans live and behave. Social isolation, financial crisis, and loss of loved ones add to the stressors. Research has shown increased alcohol consumption as a coping mechanism. Several reports indicate an increase in alcohol sales during the pandemic. Short term and long-term complications of this are unknown currently. We sought to determine the number of hospitalizations for alcoholic hepatitis during the COVID-19 pandemic in the United States. Method: This is a retrospective cohort study comparing hospitalizations for alcoholic hepatitis/ alcoholic hepatic failure during February 2019 to September 2019 and from February 2020 to September 2020. We analyzed HCA Healthcare’s Physician Services clinical data warehouse which aggregates data from 185 hospitals in the US. Patients were identified retrospectively using ICD-10 codes. Patient characteristics, labs, and discharge information were also collected. Categorical variables were compared using the Chi-square test and continuous variables were compared using the t-test. Results: The total number of hospitalizations for alcoholic hepatitis and alcoholic liver failure in February through September was 57,171 in 2020 vs 61,356 in 2019. This represented 7.4 % of all admissions in 2020 vs 6.5% in 2019. Admissions in Q1 (excluding January), Q2, and Q3 were 6.02%, 8.55%, and 7.74% respectively in 2020, and 6.63%, 7.05%, and 6.08% respectively in 2019. The mortality rate in 2019 was 1.35%, it increased to 2.04% in 2020 (p=0.01). There is also a 7% increase in cases among women in 2020. Conclusions: This study shows that there is a relative increase in hospitalizations for alcoholic hepatitis and alcoholic hepatic failure during the COVID-19 pandemic compared to the year before, especially in the second and third quarters of the year. Interestingly at the beginning of the pandemic when many states issued stay-at-home orders there was a 10% decrease in alcoholic hepatitis hospitalizations versus the previous year. As the prolonged uncertainty and chaos continued the hospitalizations increased by 21% in the second quarter and by 27% in the third quarter versus the prior year. We assume that as uncertainties prevailed, alcohol use increased, resulting in alcohol-related liver injuries. Additionally, the COVID-19 pandemic has seen increased alcoholic hepatitis mortality and an increase in female patients. The results shed light on a different public health aspect of the pandemic which has gone unnoticed and needs to be addressed.