WHY IT IS ESSENTIAL TO THINK TWO MOVES DOWN THE CHESS GAME
BLOOD, BILE, AND BLOCKAGE: AN ATYPICAL CAUSE OF PANCREATITIS
due the proximity of the intrahepatic bile duct, hepatic artery, and portal vein. Hemobilia can lead to thrombus formation and pancreatitis due to biliary tract obstruction. Classically this presents as Quincke’s triad of right upper quadrant pain, jaundice, and gastrointestinal hemorrhage. Removal of the obstruction and arterial embolization are regarded as the standard of care. This case represents the importance of understanding the diseases. While hemobilia pancreatitis is rare, the pathophysiology is similar to the common etiology of gallstones. Both are obstructive processes that initiate an inflammatory cascade within the pancreas. By recognizing that the patient had an obstructive process, she was able to receive proper evaluation and therapy.
C. Feng; A. Sutherland Department of Medicine, Tulane Health Sciences Center, New Orleans Case: A 64 year-old woman with a history of essential thrombocytosis presented with dyspnea. The clinical examination was consistent with a diagnosis of acute CHF. A peripheral smear revealed thrombocytosis with blasts, raising concern for acute myeloid leukemia with blast crisis. Given the risk for hyperuricemia secondary to tumor lysis, rasburicase was prescribed. On the next day, she developed hypoxia refractory to diuresis. Initially ascribed to worsening heart failure, however, an ABG revealed a PaO2 of 300 mmHg despite an arterial saturation of 80%. The discordance between the PaO2 and the arterial saturation combined with recent rasburicase exposure indicated methemoglobinemia. Methylene blue and ascorbic acid were administered. On hospital day three, an acute drop in her hemoglobin concentration suggested hemolytic anemia. G6PD deficiency was confirmed as the cause and was thought to be precipitated by methylene blue. Attempts were made to establish an exchange transfusion, but her condition deteriorated rapidly, resulting in cardiac arrest and death. Discussion: Tumor lysis is a common complication, especially for patients with high tumor burden or myeloproliferative disorder. Given the frequency that these patients are admitted to the hospital, the prophylactic administration of agents like rasburicase is often done without consideration for potential side effects. Methemoglobinemia occurs in less than one percent of patients who take rasburicase. The treatment for methemoglobinemia is methylene blue. Patients with G6PD deficiency are highly susceptible to acute hemolytic anemia post methylene blue administration.
M. Marak; L. Miles; R. Thibodaux Department of Internal Medicine, LSU Health Sciences Center - Baton Rouge Introduction: Acute pancreatitis is a common clinical diagnosis that often presents with abdominal pain, systemic inflammatory symptoms, and an elevation inpancreaticdigestiveenzymes. Most cases are alcohol or gallstone related. However, there are numerous pathophysiological mechanisms that can contribute to pancreatitis including metabolic, infectious, obstructive, autoimmune, and toxic related processes. This case reviews a typical presentation of obstructive pancreatitis with an atypical etiology. Case: A 61-year-old woman with a past medical history of HIV and Hepatitis C presented with a chief complaint of right- upper-quadrant pain. Two days prior, she underwent a transjugular liver biopsy for cirrhosis staging. On initial presentation, she was afebrile with severe right- upper-quadrant tenderness. Laboratory evaluation revealed a lipase of 3174 U/L, total bilirubin of 3.4mg/dL, AST of 183 U/L, and ALT of 117 U/L. RUQ ultrasound was consistent with choledocholithiasis suggesting a diagnosis of gallstone pancreatitis. Subsequent ERCP revealed a thrombus extruding from the ampulla, and a sphincterotomy was performed and thrombus extracted. She clinically improved and was discharged with a diagnosis of hemobilia pancreatitis. Five days later she returned after a syncopal episode with a hemoglobin of 5.1 g/dL. Without a definitive source for bleeding, she underwent an interventional angiogram revealing a right hepatic artery to portal vein arteriovenous fistula that was subsequently coiled. The final diagnosis was hemobilia pancreatitis secondary to arteriovenous fistula leading to biliary tract obstruction. Discussion: Transjugular biopsy is a procedure that offers patients with coagulopathy or ascites an alternative to percutaneous liver biopsy. Benefits include avoiding peritoneal and liver capsule injury. Manipulation of the portal vein during biopsy is associated with hemobilia and fistula formation
20 J LA MED SOC | VOL 171 | NO. 1
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