Acute Pancreatitis in the Transgender Population.

Hypertriglyceridemia (HTG) is an uncommon but well-established etiology of acute pancreatitis (AP) leading to significant morbidity and mortality. Hormone replacement therapy in the transgender population is an underrecognized cause of elevated triglyceride (TG) levels and may put this group at a higher risk for severe pancreatitis. We present a case of AP in a genetically male patient receiving hormone therapy for female gender transformation.A 51-year-old with a past medical history of type 2 diabetes mellitus presented with severe epigastric abdominal pain associated with nonbilious, nonbloody vomiting and anorexia for two days. The patient was diagnosed with hypertriglyceridemia-induced acute pancreatitis (HTG-AP) in the setting of elevated lipase levels of 2,083 u/L and TGs of >5,000 mg/dL. In addition, a computerized tomography scan of the abdomen showed pancreatitis without evidence of necrosis. The patient was admitted to the medical intensive care unit for the management of AP in the setting of elevated TG levels. She was treated with intravenous fluids and an insulin drip. Her home medications including estradiol and Aldactone were held. Once the TG levels were reduced to <500 mg/dL, she was taken off the Insulin drip and transitioned to a subcutaneous insulin regimen along with gemfibrozil and omega-3 fatty acid over the next three days, and then discharged to home. HTG accounts for only about 7% of pancreatitis cases and increases in severity as TG levels increase. The clinical presentation of patients suffering from HTG-AP is similar to patients with AP from other etiologies and presents in a relatively younger population compared to AP from other causes. Treatment options for HTG-AP usually utilize insulin and heparin; however, plasma exchange and venovenous filtration may be used for severe cases of HTG-AP. The goal of treatment is to lower the TG levels. Physicians should be aware of such complications and should counsel patients while utilizing hormone replacement therapy, especially in patients with a prior family history of dyslipidemia.

Pharmacobezoar: An Unusual Cause of Large Bowel Obstruction.

Large bowel obstruction (LBO) is an abdominal emergency with high morbidity and mortality rates if left untreated. LBO is four to five times less frequent than small bowel obstruction (SBO) and the causes of LBO and SBO differ substantially. Colonic malignancy remains the most common cause of LBO (> 60%). Additional causes of LBO include entities such as diverticulitis, colonic volvulus, and adhesion. Herein we present a case of acute LBO caused by pharmacobezoar.

Multiple left anterior descending coronary artery to left ventricular fistula - A case series and literature review.

Coronary artery fistulas (CAFs) are found in 0.3-0.8% of patients who undergo coronary angiography. CAFs are defined as single or multiple, small or large direct communications that arise from one or more coronary arteries and enter into one of the four cardiac chambers or major vessels. We present two cases of multiple coronary artery fistulas arising from diagonal and left anterior descending (LAD) branches of left coronary artery draining into the left ventricle. In both the cases, No intervention was performed. Of the congenital fistulas, two major groups are identified: solitary CAFs or coronary artery-left ventricular multiple micro-fistulas (CALVMMFs). Noninvasive techniques such as transthoracic echocardiography, transesophageal echocardiography and magnetic resonance imaging are becoming increasingly popular for diagnosis and follow-up of CAFs. Despite the advent of these newer non-invasive modalities, coronary angiography remains the gold standard for diagnosis. Treatment of CAFs is indicated when the patients are symptomatic with left ventricular volume overload, myocardial ischemia, left ventricular dysfunction or in the presence of a large or increasing left-to-right shunt. If the fistula is small and hemodynamically insignificant, it can be managed with conservative management. Multiple left anterior descending to left ventricle (LV) fistulas are extremely rare and, as per our literature review, we noted only a few case reports of coronary artery fistulas between branches of LAD and left ventricle.

Splenic Abscess: An Unusual Complication of Colon Cancer.

Colon cancer is among the common malignancies. Common cancer-related complications are regional tumor extension, obstruction, and tumor perforation. Abscess formation is among the rare complications. We report a case of a 60-year-old female who presented with shortness of breath and left upper quadrant pain and was diagnosed with splenic abscess associated with colon cancer. This type of presentation necessitates an early surgical intervention.

Diffuse parenchymal lung disease with micro aspirations in presence of hiatal hernia.

There has been controversy regarding the relationship between gastroesophageal reflux, microaspiration, and idiopathic pulmonary fibrosis (IPF). In the last decade, there is increasing evidence supporting a relationship between gastroesophageal reflux, microaspiration, and IPF. The presence of hiatal hernia further propagates microaspirations. Surgical management of hiatal hernia plays a vital role in the treatment.

Lack of Association Between the Clinical Outcome of Clostridium difficile Infection and Current Steroids Use.

BACKGROUND: The purpose of this study was to compare the outcome of Clostridium difficile infection (CDI) in patients on systemic steroids for various indications to patients not on steroids in term of disease severity, and associated morbidity and mortality. METHODS: We retrospectively reviewed records of all patients with CDI at our hospital from January 2011 to December 2016. Patients were evaluated for baseline characteristics, comorbidities, medications, disease severity, disease-related length of stay (LOS) from the diagnosis of CDI to discharge, need for surgical intervention, and disease-related mortality. Based on systemic steroids use, patients who were using steroids for different indications constituted the study population, and those with no steroids use were clustered as a control group. RESULTS: Of the 258 patients included, males were 127 (49%). Severe and severe-complicated CDI developed in 21/63 (33.3%) and 1/63 (1.6%) of patients on steroids (average daily dose of 20 mg), and in 73/195 (37.4%) and 5/195 (2.6%) of patients with no steroids use (P = 0.56 and P = 0.66, respectively). Surgical intervention was not required in the steroids group and 5/195 (2.7%) of patients not on steroids underwent bowel surgeries (P = 0.38). Mean LOS (days) was 11.6 ± 1.5 in the steroids group and 10.4 ± 0.7 in the no-steroids group (P = 0.4). CDI-related mortality occurred in 9/63(14.3%) of patients on steroids, and in 15/195 (7.7%) of patients not on steroids (P = 0.12; odds ratio (OR): 2; 95% confidence interval (CI): 0.8 - 4.8). CONCLUSION: There was no significant difference in the severity of CDI, need for surgical interventions, disease-related LOS and mortality in systemic steroids users compared to patients not on steroids.

A remarkable case of rhabdomyolysis associated with ingestion of energy drink 'neon volt'.

Rhabdomyolysis is defined as a syndrome characterized by muscle necrosis and the release of intracellular muscle constituents into the circulation. We present a case of a 35-year-old male who exercised for 2 h after ingesting energy drink and subsequently presented with rhabdomyolysis. After excluding common and uncommon causes of rhabdomyolysis, we reached the conclusion that the likely cause was the ingestion of energy drink 'NEON VOLT' in a setting of mild dehydration. Increasing physical activity and intense exercise is becoming a trend in many countries, due to its many health-related benefits such as prevention of obesity. This renewed focus toward optimal fitness has spawned many supplements that aid in improvement of the performance, muscle growth, and recovery. Energy drinks predominantly contain caffeine that is often combined with other supplements to form what manufacturers have termed an 'energy blend'. Studies have shown that excessive caffeine intake from energy drinks can cause arrhythmias, hypertension, dehydration, sleeplessness, nervousness, and in rare instances, rhabdomyolysis. As per Drug Abuse Warning Network report, there is a sharp increase in the number of emergency department visits involving energy drinks from 1,128 visits in 2005 to 16,053 and 13,114 visits in 2008 and 2009, respectively. Due to emergence of energy drink abuse as a national health problem, Food and Drug Administration has launched a dietary supplement adverse event reporting system for surveillance of any adverse events linked to these agents.