Compliance to endoscopic retrograde cholangiopancreatography according to current guidelines and adverse outcomes of suspected choledocholithiasis in an acute care setting.

INTRODUCTION: Common bile duct (CBD) stones are common among patients who underwent cholecystectomy. However, few studies have investigated the compliance with the guidelines for the prediction of choledochlithiasis (CL). Therefore, we aim to study the compliance with the American Society for Gastrointestinal Endoscopy (ASGE) guidelines for the identification of CL in a major hospital in Saudi Arabia's capital. METHODS: We conducted a retrospective chart review on adult patients admitted to emergency department at King Abdulaziz Medical City, Riyadh with gallstones between January 2016 and January 2019. Our data collection includes demographics and level of suspicion based on Transabdominal Ultrasound, liver function, amylase, and lipase tests. We then determined the likelihood of CL based on ASGE guidelines in order to assess the adherence to ASGE guidelines, the procedure's outcomes and adverse outcomes. RESULTS: We identified 826 patients who met the study's criteria: 384 (46.4%) were compliant, while 442 (53.6%) were non-compliant with ASGE guidelines. There was a significant association between compliance and the presence of stones on ERCP in high likelihood patients. 48 (21.3%) of total ERCP procedures among all the likelihoods had adverse outcomes. 13 (40.6%) of non-compliant ERCP performed in intermediate likelihood have experienced adverse outcomes. There was a significant association between having adverse outcomes and being non-complaint with ASGE guidelines. CONCLUSION: Despite ASGE guidelines' recommendations, a third of high likelihood cases and the majority of intermediate likelihood cases were non-compliant. Additionally, the current guidelines for the intermediate group are somewhat vague, giving ample leeway for patients to be placed in the intermediate group, which might subject them to unnecessary interventions. To conclude, there was a great lack of compliance with ASGE guidelines that is significantly associated with adverse outcomes. Hence, reassessing the current guidelines and monitoring healthcare facilities' compliance with the updated guidelines is highly recommended.

An insidious case of infectious mononucleosis presenting with acute appendicitis diagnosed postoperatively: a case report.

Infectious mononucleosis (IM) is a syndrome caused by the Epstein-Barr virus. IM typically presents with fever, pharyngitis and lymphadenopathy. Rarely, it can cause acute appendicitis. We report the case of a 19-year-old female presenting with a chief complaint of colicky, non-radiating abdominal pain for 2 days. Abdominal examination revealed rebound tenderness in right iliac fossa tenderness and splenomegaly. The diagnosis of acute appendicitis was confirmed by computed tomography. She underwent laparoscopic appendectomy and mesenteric lymph node biopsy. She was later diagnosed with IM based on laboratory findings and histopathology results. She received a course of intravenous acyclovir and was discharged. This shows that IM may present with acute appendicitis as the initial presentation and may not be accompanied by any other significant symptoms of IM.

Multiple Primary Malignancies of the Colon, Stomach, and Kidney in a Patient with Bowel Obstruction Requiring Emergency Surgery: A Case Report.

BACKGROUND Multiple primary malignancy (MPM) is defined as 2 or more primary malignancies diagnosed in the same patient. Even though MPMs are rare, various associated tumors have been reported in the literature. We report the first case of triple synchronous primary malignancies: gastrointestinal stromal tumor, colon adenocarcinoma, and renal cell carcinoma. CASE REPORT A 63-year-old man presented to our emergency department with a 7-day history of diffuse abdominal pain and constipation. Examination revealed a distended abdomen and diffuse tenderness. Enhanced computed tomography showed a high-grade large bowel obstruction with the transitional zone seen at the splenic flexure, which was suspicious for primary colon cancer, and a hypodense lesion on the left mid-pole of the kidney. An emergency exploratory laparotomy revealed a splenic flexure mass, which was resected, and a left renal mass, which was excised. A stomach mass at the greater curvature was an incidental intraoperative finding; a wedge resection was performed for it. The pathology for each of the masses showed a primary malignancy. CONCLUSIONS Multiple primary cancers are rare and a multidisciplinary team approach is essential for management of these patients, be it preoperative, intraoperative, postoperative, or long-term surveillance.