Inferior Pancreaticoduodenal Artery Pseudoaneurysm Causing Biliary Obstruction: A Case Report.

Introduction: Visceral arterial aneurysms and pseudoaneurysms are rare but dangerous pathologies, with reported incidence of 0.01-0.2% of the worldwide population, as found on autopsy. Pancreaticoduodenal artery pathology accounts for approximately 2% of all visceral aneurysms; it is commonly caused by chronic inflammatory processes, such as pancreatitis or adjacent pseudocysts. Morbidity and mortality commonly result from rupture of the aneurysm itself, leading to life-threatening hemorrhage into the peritoneum or gastrointestinal tract. Case Report: Here we present the case of a 64-year-old male patient with previous history of alcohol use disorder leading to chronic pancreatitis and prior embolization of an inferior pancreaticoduodenal pseudoaneurysm, who presented to the emergency department (ED) with abdominal pain, nausea, and vomiting, and was found to have a large recurrent inferior pancreaticoduodenal pseudoaneurysm with associated obstructive cholangitis and pancreatitis via contrast-enhanced computed tomography (CT) of the abdomen and pelvis. The patient was managed emergently by interventional radiology angiography with embolic coiling and percutaneous biliary catheter placement, and he subsequently underwent biliary duct stenting with gastroenterology. The patient was successfully discharged after a brief hospitalization after resolution of his pancreatitis and associated hyperbilirubinemia. Conclusion: Pancreaticoduodenal artery aneurysms and pseudoaneurysms are rare and dangerous visceral pathologies. Patients can be diagnosed rapidly in the ED with CT imaging and need urgent endovascular management to prevent morbidity and mortality.

Refeeding Syndrome in Emergency Department Boarders: How COVID-19 Can Reshape Patient Care in the Emergency Department.

Emergency departments (EDs) in the United States are the primary drivers of hospital admissions. As the nation continues to experience unrestrained spread of the severe acute respiratory syndrome coronavirus 2, causing coronavirus disease 2019 (COVID-19), EDs, hospitals, and testing centers are overwhelmed with patients. The consequence of "boarding" admitted patients in EDs leads not only to longer ED wait times for all patients but also delays the medical practice of intensivists and internists while patients await an inpatient bed. Here, we describe the case of an ED boarder with severe COVID-19 who developed refeeding syndrome while boarding in the ED, ultimately requiring in-depth electrolyte and renal management by the ED team before intensive care unit admission.

Exaggerated Arthropod Bite: A Case Report and Review of the Mimics.

Exaggerated arthropod bite reactions causing hemorrhagic or necrotic bullous lesions can mimic other serious conditions such as cutaneous anthrax, brown recluse spider bite, and tularemia. A 55- year-old, healthy woman presented to the emergency department with a 3.5-centimeter painless, collapsed hemorrhagic bulla at the left costal margin. She was afebrile and had no systemic symptoms. Laboratory evaluation was unremarkable. She was prescribed silver sulfadiazine cream and mupirocin ointment. The area denuded two days later and the lesion completely healed. This case illustrates the broad differential to be considered when evaluating patients with hemorrhagic bullous lesions.