Publications by authors named "Gabriel Melki"

22 Publications

  • Page 1 of 1

Hemosuccus Pancreaticus: Challenging Diagnosis and Treatment.

Eur J Case Rep Intern Med 2022 11;9(5):003337. Epub 2022 May 11.

St Joseph's University Medical Center, Paterson, NJ, USA.

Hemosuccus pancreaticus (HP) is defined as bleeding from the ampulla of Vater through the pancreatic duct. It is a rare complication associated with acute or chronic pancreatitis. The source of bleeding can be from the pancreas itself or surrounding vessels, with the splenic artery most commonly involved. Diagnosing HP is challenging and computed tomography angiography remains the gold standard for diagnosis. We present the case of a 62-year-old male with recurrent pancreatitis complicated with HP. Imaging and endoscopy were consistent with bleeding from the section portion of the duodenum, which resolved without intervention.

Learning Points: Hemosuccus pancreaticus is a rare complication associated with acute or chronic pancreatitis.CT angiography is the gold standard for diagnosing hemosuccus pancreaticus.Arterial embolization is the first-line treatment of hemosuccus pancreaticus.
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http://dx.doi.org/10.12890/2022_003337DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9239023PMC
May 2022

A Case of a gastropancreatic fistula in the setting of intraductal papillary mucinous neoplasms.

Radiol Case Rep 2022 Aug 11;17(8):2874-2877. Epub 2022 Jun 11.

St. Joseph's University Medical Center, Department of Gastroenterology, 703 Main Street, Paterson, NJ 07503 USA.

Intraductal papillary mucinous neoplasms (IPMN) are mucin producing tumors which arise from epithelial cells of the main pancreatic duct, pancreatic branch ducts, or both. They are characterized by mucin-producing columnar cells, papillary ductal proliferation, cyst formation, and varying degrees of dysplasia. IPMNs are classified as main duct or branch duct based upon the pancreatic duct anatomy which the IPMN is arising from. Additionally, they can be classified based on their histologic subtypes, which carry varying associations with dysplasia and/or malignancy. Many patients have incidentally identified IPMNs, which are asymptomatic. However, patients may also present with pancreatitis, elevation of liver enzymes, dilation of the pancreatic duct or bile duct as well as distention of the ampullary pancreatic orifice(s), due to impaction and obstruction with mucus. This is known as an endoscopically visualized "fish eye" sign. Patients may also develop exocrine and endocrine pancreatic insufficiency and maldigestion. Some studies also suggest that patients with IPMNs may also be at increased risk for gastric, colorectal, biliary, renal cell, and thyroid malignancies. Rarely, IPMNs can be complicated by fistulation between the main pancreatic duct and neighboring organs. Herein, we present an unusual case of simultaneous fistulation to both the gastric body and the duodenum.
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http://dx.doi.org/10.1016/j.radcr.2022.05.046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9198267PMC
August 2022

Liver Abscess Secondary to Crohn's Disease: A Case Report.

Cureus 2022 Mar 14;14(3):e23157. Epub 2022 Mar 14.

Gastroenterology, St. Joseph's Regional Medical Center, Paterson, USA.

Crohn's disease (CD) is a type of inflammatory bowel disease (IBD) and extra-intestinal manifestations are common. Although common features of CD include fistulation and abscess formation, they typically manifest exclusively in the lower gastrointestinal (GI) tract and in patients who do not have adequate control over their disease. Pyogenic liver abscess is rare in the general population and is an unusual and extra-intestinal manifestation of CD. Herein, we present a patient with Crohn's ileo-colitis who presented with generalized abdominal pain and fevers and was found to have multiple pyogenic liver abscesses biopsy-proven to be secondary to CD. The patient's liver abscesses were refractory to repeated CT-guided drainage and antibiotic therapy. This paper illustrates a rare condition in the general population and those with CD. We intend to discuss the differences of pyogenic liver abscesses in CD compared to the general population, the rarity of this presentation and propose a unique mechanism by which the patient may have developed this liver abscess. It is common for clinicians to mistake the diagnosis of febrile illness with or without abdominal pain as a simple reactivation of CD, and thus it is important to keep pyogenic liver abscess on the differential even if their disease state is otherwise well controlled.
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http://dx.doi.org/10.7759/cureus.23157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9007572PMC
March 2022

Isolated IgG4 Autoimmune Cholangitis in the Absence of Pancreatitis.

Cureus 2022 Mar 1;14(3):e22754. Epub 2022 Mar 1.

Interventional Gastroenterology, St. Joseph's Regional Medical Center, Paterson, USA.

The IgG4-related disease is an uncommon immune-mediated condition affecting multiple organ systems concomitantly; however, it is very rare for a patient to have isolated IgG4 autoimmune cholangitis or IgG4-related disease confined to the hepatobiliary system. The majority of cases are associated with pancreatitis and are incidentally discovered in the workup of acute or chronic pancreatitis. When it affects the hepatobiliary system, it develops as inflammatory fibrosclerosing cholangitis, which can mimic other hepatobiliary diseases such as primary sclerosing cholangitis. Herein, we present a case of type 1 IgG4 autoimmune cholangitis in the absence of pancreatitis. Our case is particularly unique because type 1 is the most common type associated with autoimmune pancreatitis; however, our patient had type 1 without any evidence of pancreatic involvement. Additionally, like most cases of isolated IgG4 autoimmune cholangitis, our patient was refractory to standard therapy. This case highlights the clinical significance, rarity and severity of isolated IgG4 autoimmune cholangitis.
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http://dx.doi.org/10.7759/cureus.22754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8970977PMC
March 2022

A Rare Case of Methicillin-Resistant Staphylococcus aureus (MRSA) Enterocolitis Treated With Oral Vancomycin.

Cureus 2021 Dec 3;13(12):e20143. Epub 2021 Dec 3.

Internal Medicine, St. Joseph's Regional Medical Center, Paterson, USA.

Historically, methicillin-resistant Staphylococcus aureus (MRSA) was thought to be the primary pathogen in pseudomembranous enterocolitis associated with antibiotic use or recent abdominal surgery; however, was later identified as another more common pathogen. Since the eclipse of the workup of hospital-acquired diarrhea now utilizes nucleic acid amplification rather than stool cultures and longer includes the investigation of other less common pathogens. Consequently, the diagnosis of MRSA enterocolitis has faded. It is imperative to consider more sinister pathogens not routinely covered in laboratory testing as MRSA enterocolitis infections have been known to progress to severe systemic infections and thus the delay or misdiagnosis can result in inappropriate treatment, prolonged hospitalizations, sepsis and/or death. Herein we present a case of a patient who presented with laboratory diagnosed MRSA enterocolitis in the absence of recent abdominal surgery or antibiotic use and was successfully treated with oral vancomycin.
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http://dx.doi.org/10.7759/cureus.20143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8723774PMC
December 2021

A Case of Multifactorial Viral Myocarditis.

Cureus 2021 Oct 21;13(10):e18950. Epub 2021 Oct 21.

Internal Medicine, St. Joseph's University Medical Center, Paterson, USA.

We present a case of viral myocarditis in the setting of Coxsackievirus and coronavirus disease 2019 (COVID-19) infection. This case is unique as there were two underlying active infections that could have caused the patient's myocarditis. Though both viruses have been shown to cause myocarditis, it was difficult to differentiate the exact etiology in this particular case. The unique nature of this case presents the opportunity to explore whether further diagnostic workup is warranted.
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http://dx.doi.org/10.7759/cureus.18950DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8604421PMC
October 2021

Hemophagocytic lymphohistiocytosis presenting as acute coronary syndrome.

Autops Case Rep 2021 6;11:e2021285. Epub 2021 May 6.

St. Joseph's University Medical Center, Hematology and Oncology Department, Paterson, NJ, USA.

Acquired Hemophagocytic Lymphohistiocytosis is a rare and deadly syndrome resulting from an overactive immune system, with uncontrolled activation of macrophages and lymphocytes, hypercytokinemia, and systemic inflammatory response. A 75-year-old male presented with typical anginal pain and was diagnosed with the acute coronary syndrome, which required a percutaneous transluminal coronary angioplasty. Instead of resolving the symptoms, the patient began to exhibit pyrexia and worsening altered sensorium with progressing renal failure, anemia, thrombocytopenia and respiratory failure. This constellation of symptoms caused the patient to require mechanical ventilation and hemodialysis. Upon laboratory analysis, hyperferritinemia provided an indication to the diagnosis of acquired hemophagocytic lymphohistiocytosis. After the initiation of dexamethasone, the patient made a significant recovery and was discharged from the hospital.
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http://dx.doi.org/10.4322/acr.2021.285DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8214879PMC
May 2021

Encapsulating peritoneal sclerosis in liver transplant.

Autops Case Rep 2021 6;11:e2021272. Epub 2021 May 6.

St. Joseph's University Medical Center, Department of Gastroenterology and Hepatology, Paterson, NJ, USA.

Encapsulating peritoneal sclerosis occurs due to chronic irritation of the peritoneal surface resulting in inflammation and fibrosis. Encapsulating peritoneal sclerosis usually occurs in patients requiring peritoneal dialysis (PD); however, it may also occur in liver transplant patients. The fibrosis in encapsulating peritoneal sclerosis could be severe enough to cause small bowel obstruction (SBO). Herein, we report a case of encapsulating peritoneal sclerosis secondary to liver transplantation that presented with SBO. The patient was started on Tamoxifen for encapsulating peritoneal sclerosis and evaluated at follow-up without any other intestinal obstruction episodes. This case demonstrates that encapsulating peritoneal sclerosis can occur as a liver transplant complication and present with small bowel obstruction.
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http://dx.doi.org/10.4322/acr.2021.272DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8214905PMC
May 2021

Salmonella aortitis successfully treated with antibiotics without surgery.

J Community Hosp Intern Med Perspect 2021 10;11(3):361-365. Epub 2021 May 10.

Gastroenterology Department, St. Joseph's University Medical Center, Paterson, NJ, USA.

Aortitis is an inflammation of the aorta that is linked to large vessel vasculitis and other rheumatologic cases. Less often, an infectious etiology of aortitis is diagnosed. Aortitis is associated with high mortality and morbidity and requires a high index of suspicion. Here we present a rare case of aortitis secondary to Salmonella Septicemia treated with six weeks of antibiotics in the hospital without and remained asymptomatic and inflammatory markers normalized at 2 weeks follow up (ESR, CRP, and WBCs).
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http://dx.doi.org/10.1080/20009666.2021.1896430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8118501PMC
May 2021

An Unusual Presentation of Influenza-Induced Myositis.

Cureus 2021 Feb 7;13(2):e13196. Epub 2021 Feb 7.

Internal Medicine, St. Joseph's Regional Medical Center, Paterson, USA.

Post-influenza myositis is considered a distinct clinical entity and is associated with muscle pain and elevated muscle enzymes during convalescence. Although the exact mechanism of muscle injury in acute viral myositis is unknown, there are possible mechanisms proposed in the literature. The progression of viral myositis to rhabdomyolysis, although uncommon, can be life-threatening and has been reported with many viruses, most commonly influenza. At our institution, a case of severe influenza-induced myositis prompted us to conduct a literature search focusing on the incidence, pathophysiology, typical presentation, and proper diagnosis of this rare condition.
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http://dx.doi.org/10.7759/cureus.13196DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7943049PMC
February 2021

Epidemiological, Clinical, Microbiological, and Risk Factors of Pyogenic Liver Abscess: An 18-years Retrospective Single-Center Analysis.

J Community Hosp Intern Med Perspect 2021 Jan 26;11(1):42-45. Epub 2021 Jan 26.

Gastroenterology Department, St. Joseph's University Medical Center, Paterson, NJ, USA.

A pyogenic liver abscess (PLA) is the most frequently observed subtype of liver abscess in the western world. The disease has been subjected to a remarkable change. We aimed to investigate the recent trend in pyogenic liver abscess's epidemiology, clinical, microbiological, and risk factors features. A retrospective analysis of medical records was done for the patients diagnosed with PLA from January 2000 to June 2018. The institutional review board approved the study. We identified 113 patients with PLA, 60% were males, with a mean age of 54 ± 20 years, and 58 ± 19 years old for males and females, respectively (p = 0.298), with an increasing annual incidence in 2012-2013, and 2016-2017 (Figure 1). Fever and right upper quadrant abdominal pain were the most common symptoms (65%, 55%, respectively). Forty percent of the patients had Biliary tract diseases like cholecystitis or biliary intervention as cholecystectomy or ERCP, and 20% had diabetes mellitus (Table 1). The abscess culture was obtained in 96 cases, 37 cases were negative (39%), 27 cases showed polymicrobial growth (28%) and 15 cases showed Escherichia coli (16%) (Figure 2). The abscess cultures were mostly negative in the first 5 years, then changed to Streptococcus anginosus, and polymicrobial growth in the last four years. PLA is more common in males with a recent increase in incidence. Culture negative PLA was observed in patients who were empirically treated with antibiotics. Polymicrobial was the most common identifiable organism with a change in the microbiological trend every 5 years.
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http://dx.doi.org/10.1080/20009666.2020.1831745DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7850341PMC
January 2021

Patients' reasons for missing scheduled clinic appointments and their solutions at a major urban-based academic medical center.

J Community Hosp Intern Med Perspect 2020 Sep 3;10(5):426-430. Epub 2020 Sep 3.

Internal Medicine Department, Saint Joseph's University Medical Center, Paterson, NJ, USA.

Objective: Patients that do not show up for scheduled clinic appointments affect the quality of healthcare provided. This study aimed to recognize the reasons behind missing scheduled appointments and understand possible solutions from the patient's perspective.

Method: We included 100 patients that attended the outpatient Medicine clinic in January 2020. Selection criteria were based on missing one or more of the scheduled clinic appointments in the last year. The participants answered a questionnaire to clarify the reasons for missing a scheduled clinic appointment and offer suggestions for a solution. The recruiter, in turn, answered several demographical questions.

Results: The study showed a statistically significant difference between the no-show rate in females at 60% compared to males at 40%  = 0.0023). The no show rate was not significantly affected by the day of the week, time of appointment, or the weather. Forgetting about the appointment was the most common cause (36 subjects). Work-related issues were reported in 17 participants, making it the 2 most common cause. Not notified about the appointment, Lack of transportation, childcare-related issues, along with other reasons, were less likely reported (Table 2). 11 out of 36 (30%) subjects suggested a reminder text message in their preferred language; meanwhile, 4 others suggested a weekend clinic.

Conclusion: The patients should be aware of different appointment reminders options and have the freedom to choose a suitable reminder. Patients should be educated about the importance of calling to cancel the appointment since some of the reasons for no show are unpreventable.
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http://dx.doi.org/10.1080/20009666.2020.1796903DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671744PMC
September 2020

A case of unusual presentation of acute esophageal necrosis with pneumonia.

Int J Health Sci (Qassim) 2020 Nov-Dec;14(6):66-68

Department of Internal Medicine, St. Joseph's University Medical Center, New Jersey, United States.

Acute esophageal necrosis (AEN) is a rare and often fatal pathology of unclear etiology affecting the distal two-thirds of the esophagus. Typically, elderly patients with multiple comorbidities present with signs of upper gastrointestinal (GI) hemorrhage. On endoscopy, the mucosa is black due to ischemic necrosis, resulting in the commonly used term "black esophagus." We present a rare case of a 61-year-old male presenting with shortness of breath and hematemesis diagnosed as AEN through endoscopy. This case illustrates the importance of considering AEN as part of differential diagnoses in a rising elderly population with multiple comorbidities that present with upper GI hemorrhage. Treatment should be aimed at maintaining hemodynamic stability with high-dose proton pump inhibitors.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7644451PMC
November 2020

Perivesicular Abscess Drainage with Lumen-Apposing Self-Expanding Metal Stents.

Middle East J Dig Dis 2020 Jul;12(3):206-210

Department of Medicine, St. Joseph's University Medical Center, Paterson NJ, USA.

Abdominal and pelvic abscesses can occur due to a number of reasons, the most common being surgery. They are associated with significant morbidity and mortality. The treatment approach for these types of collections is often the initiation of broad-spectrum antibiotics, accompanied by drainage. Multiple diagnostic and therapeutic modalities have been described, including; percutaneous, transvaginal, endoscopic, and surgicaldrainage. Due to the complexity of pelvic anatomy, minimally invasive approaches such as percutaneous drainage are usually difficult. Pelvic abscesses have been historically drained through surgery. Endoscopic ultrasound (EUS)-guided interventions have emerged as an alternative for the management of difficult abdominal and pelvic abscesses. Endoscopic interventions have classically included diagnostic and therapeutic aspiration, utilizing drainage catheters with or without placement of plastic stents. More recently, the use of lumen apposing self-expanding metal stents has become a treatment option for deep pelvic abscesses. Lumen opposing metal stents (LAMS) have a saddle-shaped design with two large-diameter flanges on both ends of the stent to anchor the stent edges within the respective lumens as well asa central waist that allows for communication between the two lumens. LAMS were originally designed for transmural pancreatic fluid collection drainage; however,they have been successfully implemented for numerous other off-label uses, including the drainage of pelvic and abdominal abscesses. We present the case of a 34-year-old womanwho presented with a septated abscess located between the urinary bladder and the rectum, which was successfully and definitively drained with LAMS.
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http://dx.doi.org/10.34172/mejdd.2020.183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7548090PMC
July 2020

Acute esophageal necrosis masquerading acute coronary syndrome.

Autops Case Rep 2020 Jan-Mar;10(1):e2019136. Epub 2020 Jan 21.

Saint Joseph University, Saint Joseph's University Hospital. Paterson, New Jersey, United States of America.

Acute esophageal necrosis (AEN) also known as "black esophagus" or "acute necrotizing esophagus" is a rare entity characterized by striking endoscopic findings of circumferential black coloring of the esophagus. AEN most frequently seen in the distal esophagus and can extend proximally along the entire esophagus. Characteristically, the circumferential black mucosa stops abruptly at the EGJ. AEN tends to present as acute upper gastrointestinal bleeding, though other symptoms including dysphagia and epigastric pain have been described. The etiology of AEN is multifactorial including a combination of ischemic insult, mucosal barrier defect, and a backflow injury of gastric secretions. Described is a case of AEN in a patient with history of uncontrolled diabetes who presented with an atypical chest pain mimicking acute coronary syndrome with negative subsequent cardiovascular workup.
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http://dx.doi.org/10.4322/acr.2019.136DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6984815PMC
January 2020

Re-Educating Residents About Non-Invasive Colorectal Cancer Screening: An Approach to Improving Colon Cancer Screening Compliance.

Gastroenterology Res 2019 Dec 21;12(6):312-314. Epub 2019 Nov 21.

Department of Gastroenterology, St. Joseph's University Medical Center, Paterson, NJ, USA.

Background: Colorectal cancer is the third leading cause of cancer death; therefore early detection by screening is beneficial. Residents at a clinic in NJ, USA were not offering other forms of colon cancer screening when patients refused colonoscopy, which lead to the creation of the quality improvement project.

Methods: Residents practicing at the clinic were given an anonymous survey determining which method of colon cancer screening they used and which alternative method they offered when patients refused the original method. The residents were educated about all methods of colon cancer screening and the residents were resurveyed.

Results: A total of 64% of residents offered less invasive testing when colonoscopy was refused. Six months after education, 95% of residents offered less invasive testing when colonoscopy was refused.

Conclusions: Early detection and removal of polyps by colonoscopy reduce the risk of cancer development. Colonoscopy is the gold standard for colon cancer screening; however other less invasive modalities are approved. This quality improvement project lead to offering the fecal immunochemical test or fecal occult blood test once patients refused colonoscopy at the clinic, increasing the number of patients receiving colorectal cancer screening, and thus providing better medical care.
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http://dx.doi.org/10.14740/gr1205DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6879031PMC
December 2019

Bivalirudin Versus Heparin During Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction.

Cardiol Res 2019 Oct 4;10(5):278-284. Epub 2019 Oct 4.

St Joseph's Health, New York Medical College, Paterson, NJ, USA.

Background: The aim of the study was to compare the efficacy and safety of bivalirudin versus unfractionated heparin (UFH) in patients with acute myocardial infarction who undergo percutaneous coronary intervention (PCI). Earlier trials comparing bivalirudin and UFH during PCI demonstrated that bivalirudin caused less bleeding with more stent thrombosis. Since then, adjunct antiplatelet strategies have evolved. Improved upstream platelet inhibition with potent P2Y12 inhibitors decreased the need for routine glycoprotein IIb/IIIa inhibitor (GPI), resulting in similar outcomes among UFH and bivalirudin. Therefore, the role of bivalirudin in modern PCI practices is questionable.

Methods: We utilized Cochrane Review Manager (RevMan) 5.3 to perform a meta-analysis of seven randomized controlled trials (RCTs) with 22,844 patients to compare bivalirudin to UFH in patients with acute myocardial infarction requiring revascularization.

Results: There was no difference between bivalirudin and UFH regarding major adverse cardiac events (MACE), risk ratio (RR) 0.99, 95% confidence interval (CI) 0.87 - 1.12; P = 0.83) or cardiovascular mortality (RR 0.87, 95% CI 0.71 - 1.07; P = 0.18). Bivalirudin increased acute stent thrombosis (RR 2.77, 95% CI 1.49 - 5.13; P = 0.001), which was only significant among ST-elevation myocardial infarction (STEMI) only trials. Bivalirudin caused less major bleeding (RR 0.66, 95% CI 0.49 - 0.90; P = 0.007), which was negated when GPI was used provisionally (RR 0.93, 95% CI 0.64 - 1.33; P = 0.67).

Conclusions: Among patients with acute myocardial infarction who underwent PCI, bivalirudin and UFH demonstrated similar MACE and cardiovascular mortality. Bivalirudin increased acute stent thrombosis, which was more remarkable among STEMI. Bivalirudin decreased major bleeding, but this benefit was negated when GPI was used provisionally.
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http://dx.doi.org/10.14740/cr921DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6785291PMC
October 2019

Chronic Pancreatitis Leading to Pancreatogenic Diabetes Presenting in Diabetic Ketoacidosis: A Rare Entity.

Gastroenterology Res 2019 Aug 25;12(4):208-210. Epub 2019 Aug 25.

Department of Gastroenterology, St. Joseph's University Medical Center, Paterson, NJ, USA.

Diabetes mellitus type 3c (DM3c) is an uncommon cause of diabetes due to pancreatic pathology. Its prevalence reaches about 5-10% among all diabetics in the Western world, largely due to chronic pancreatitis. DM3c occurs due to the destruction of the endocrine islet cells. Glucagon and insulin levels are both decreased due to the destruction of alpha and beta cells, respectively. This makes the development of diabetic ketoacidosis (DKA) a rare process in patients with DM3c because of the destruction of glucagon, which facilitates ketone production. We report a case of DM3c presenting with DKA. The patient presented with a history of chronic pancreatitis and was on pancreatic enzyme replacement therapy. Prior records revealed that HbA1c levels were normal. Prior computed tomography evidence revealed diffuse pancreatic calcifications. The patient was admitted for DKA, presenting with hyperglycemia, blood glucose of 703 mg/dL, bicarbonate of 16 mmol/L, ketones in the urine and acetone in the blood. The patient's anion gap corrected for albumin was 27. The patient was admitted to the medical intensive care unit where he was treated with intravenous (IV) insulin and IV hydration. Once the anion gap closed, the patient was transitioned to long-acting insulin. HbA1c level on admission was elevated, autoimmune causes of diabetes were sent and were negative, ruling out late onset type 1 diabetes. This shows that although it is a rare phenomenon, diabetics with DM3c can present in DKA.
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http://dx.doi.org/10.14740/gr1203DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6731042PMC
August 2019

Dual-Energy CT Texture Analysis With Machine Learning for the Evaluation and Characterization of Cervical Lymphadenopathy.

Comput Struct Biotechnol J 2019 16;17:1009-1015. Epub 2019 Jul 16.

Department of Radiology, McGill University, Rm C5 118, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada.

Purpose: To determine whether machine learning assisted-texture analysis of multi-energy virtual monochromatic image (VMI) datasets from dual-energy CT (DECT) can be used to differentiate metastatic head and neck squamous cell carcinoma (HNSCC) lymph nodes from lymphoma, inflammatory, or normal lymph nodes.

Materials And Methods: A retrospective evaluation of 412 cervical nodes from 5 different patient groups (50 patients in total) having undergone DECT of the neck between 2013 and 2015 was performed: (1) HNSCC with pathology proven metastatic adenopathy, (2) HNSCC with pathology proven benign nodes (controls for (1)), (3) lymphoma, (4) inflammatory, and (5) normal nodes (controls for (3) and (4)). Texture analysis was performed with TexRAD® software using two independent sets of contours to assess the impact of inter-rater variation. Two machine learning algorithms (Random Forests (RF) and Gradient Boosting Machine (GBM)) were used with independent training and testing sets and determination of accuracy, sensitivity, specificity, PPV, NPV, and AUC.

Results: In the independent testing (prediction) sets, the accuracy for distinguishing different groups of pathologic nodes or normal nodes ranged between 80 and 95%. The models generated using texture data extracted from the independent contour sets had substantial to almost perfect agreement. The accuracy, sensitivity, specificity, PPV, and NPV for correctly classifying a lymph node as malignant (i.e. metastatic HNSCC or lymphoma) versus benign were 92%, 91%, 93%, 95%, 87%, respectively.

Conclusion: Machine learning assisted-DECT texture analysis can help distinguish different nodal pathology and normal nodes with a high accuracy.
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http://dx.doi.org/10.1016/j.csbj.2019.07.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6682309PMC
July 2019

Acute Appendicitis Masquerading Distal Intestinal Obstruction Syndrome in Adult Cystic Fibrosis.

Case Rep Gastrointest Med 2018 26;2018:8475060. Epub 2018 Sep 26.

Department of Gastroenterology, St. Joseph's University Medical Center-New York Medical College, USA.

Overshadowed by Sino-pulmonary infections, Cystic Fibrosis (CF) commonly affects gastrointestinal organs because of secretory and motility dysfunction. Infrequently, these changes result in Distal Intestinal Obstruction Syndrome (DIOS), an increasingly diagnosed gastrointestinal entity in adult Cystic Fibrosis patients. We present a case 22-year-old male who presented to our hospital with right lower quadrant abdominal pain with suspicion of acute appendicitis and was subsequently diagnosed as DIOS. Our case highlights the importance of DIOS as one of the differential diagnosis of right lower quadrant abdominal pain in a patient with a CF, especially for physicians working at community hospitals which may not have a Cystic Fibrosis care program available.
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http://dx.doi.org/10.1155/2018/8475060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6178186PMC
September 2018

Diabetic ketoalkalosis: misnomer or undiagnosed variant of diabetic ketoacidosis.

BMJ Case Rep 2018 Oct 2;2018. Epub 2018 Oct 2.

Department of Internal Medicine, St Joseph's University Medical Center, Paterson, New Jersey, USA.

Usually, hyperglycaemia crisis presents with acidotic pH, but ketoalkalosis is a rare and unheard entity presenting in diabetic ketoacidosis. We describe three unique cases where the patients present with hyperglycaemia >250 mg/dL, normal or alkalotic pH, and bicarbonate >20 meq/L, which does not meet criteria for diabetic ketoacidosis. However, once these patients were supplemented with intravenous fluids, diagnosis of diabetic ketoacidosis was evident in laboratory analysis. These case series provide a learning opportunity in diagnosing and management of this rare phenomenon.
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http://dx.doi.org/10.1136/bcr-2018-226092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6169724PMC
October 2018

A Case of Diabetic Ketoacidosis Presenting with Hypernatremia, Hyperosmolarity, and Altered Sensorium.

Case Rep Endocrinol 2018 16;2018:4806598. Epub 2018 Jul 16.

Department of Internal Medicine, St. Joseph's University Medical Center-New York Medical College, USA.

Diabetic Ketoacidosis commonly presents with hyponatremia, but hypernatremia is a rare entity. We report a unique case of a 50-year-old woman admitted with altered sensorium with blood glucose 979 milligrams/deciliter, serum osmolarity 363 mOsm/kilograms, and serum sodium 144 milliequivalents/liter. Patient was given initial bolus of isotonic saline and continued on half isotonic saline for correction of hypernatremia along with insulin infusion therapy. Patient was successfully treated with intravenous fluids, insulin infusion, and the altered sensorium was resolved without any sequelae. This case illustrates a teaching point in the use of intravenous fluids for the treatment of Diabetic Ketoacidosis with hypernatremia.
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http://dx.doi.org/10.1155/2018/4806598DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6077649PMC
July 2018
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