implemented. Additionally, all home dopaminergic agents (Symmetrel, Sinemet, and Mirapex) were promptly reinstated and dantrolene was started after the patient developed chills and substantial muscle rigidity. On hospital day 2, Symmetrel, Mirapex, Dantrolene, and all antibiotics were discontinued. The patient’s symptoms improved initially but by hospital days 4-6, the patient's mental status and mobility worsened. Reintroduction of Symmetrel and Miraplex led to gradual improvement in alertness, along with decreased dysarthria, dysphagia, bradykinesia, and cogwheel rigidity. The patient's condition improved by the time of discharge and he was placed in a long- term acute care facility for continued rehabilitation.
conditions. Establishing the diagnosis of PHS often requires a comprehensive investigation into the patient's history. Although the exact underlying mechanism remains unclear, dysregulation within the hypothalamus, nigrostriatal system, and the mesocortical dopaminergic pathways is believed to be involved. Left untreated, PHS can lead to serious complications, including acute respiratory and renal failure, aspiration pneumonia, deep venous thrombosis/pulmonary embolism, heart failure, and potentially death. The management is mainly centered around supportive measures and restarting antiparkinsonian drugs. PHS requires prompt recognition and management to prevent serious complications. Health education plays a crucial role in preventing PHS by emphasizing medication adherence and awareness of early symptoms.
Discussion: The clinical presentation of PHS may mimic and overlap with other medical
A RARE COMPLICATION OF BILIARY STENT MIGRATION: CHOLEDOCHODUODENOPYELO FISTULA James Gore DO, Paula Cacioppo MD, Department of Internal Medicine, Ochsner Clinic Foundation, New Orleans, LA. Section of Gastroenterology, Ochsner Clinic Foundation, New Orleans, LA
Introduction: Biliary and pancreatic stents have become universally recognized in the management of numerous pancreatico-biliary diseases. The most common complication after stent placement is obstruction with resultant cholangitis, pancreatitis, or jaundice. Biliary stent migration is rare, occurring in 5% of cases. Most migrating stents are passed through the stool, without causing any complications. In some patients the stent does not pass and causes complications such as perforation, fistula, and abscess formation. Case: A 51-year-old male with choledocholithiasis (status post endoscopic retrograde cholangiopancreatography (ERCP) with stone removal, sphincterotomy, and biliary stent placement at that time; patient lost to follow up for removal of stent) and status post cholecystectomy and ventral hernia repair who presented with 1 day of diffuse abdominal pain, worsened with movement and eating. The patient stated he was having increasing symptoms of intermittent fevers, night sweats, dark colored urine, and right sided flank pain for several months. Vitals showed revealed fever (101.2oF), tachycardia (125 bpm), and hypotension (95/60 mmHg). Labs significant for leukocytosis,
elevated ALT, elevated AST, and hyperbilirubinemia. Computed Tomography of the abdomen/pelvis with contrast showed distal migration of the prior biliary stent through the duodenum and penetrating the inferior pole of the right kidney with concerns for a choledochoduodenopyelo fistula. Esophagogastroduodenoscopy discovered biliary stent in the ampulla perforating through the diverticula. Stent removal was accomplished with a Raptor grasping device. A non-bleeding perforation was found in the second portion of the duodenum. Two hemostatic clips were successfully placed to repair the perforation. On ERCP, choledocholithiasis was found leading to removal by balloon extraction. One pancreatic stent was placed into the ventral pancreatic duct. One covered metal stent was placed into the common bile duct. Discussion: Although biliary stenting is generally considered safe, migration can occur, and perforation has been reported. This case shows a rare complication of a migrated biliary stent and highlights the need for proper follow up and quick action once discovered. Dislocated stents should be removed immediately, through endoscopy or emergent surgery, to reduce the risk of complications.
26
Made with FlippingBook Digital Publishing Software