Genesys Regional Medical Center

A 66 year old African American female was referred for screening colonoscopy. Her medical history was significant for left breast cancer diagnosed age 47, for which she underwent treatment. She had recurrence in 2016 and was placed on chemotherapy, with complete response seen on PET scan. The patient's bowel prep was poor. In the ascending colon, there was erythema and mucosal edema with tissue friability and what appeared to be a mass vs extrinsic compression [Figure A]. Biopsies were taken and pathology revealed antibodies against estrogen receptor. The pathologic diagnosis was metastatic carcinoma within the lamina propria, consistent with metastatic breast carcinoma [Figure B,C]. Metastatic breast cancer to the large bowel is rare, with majority of cases noted in case reports. Approximately 3% of breast cancer cases had colon metastasis. In another report, 17 cases of breast cancer with colorectal metastasis were reported over a 15 year period. Those cases presented at an average of 53 months after primary treatment and had a median survival time of 16 months. While rare, metastatic breast cancer to the colon does occur. A high index of suspicion should be maintained during colonoscopy in the context of a history of breast cancer.1664_A Figure 1 No Caption available.1664_B Figure 2 No Caption available.1664_C Figure 3 No Caption available.

Introduction: Normal saline can lead to worsening of existing metabolic acidosis (due to hypochloremia acidosis) caused by hypovolemic shock as seen in acute UGIB.Comparatively, in a randomized trial, Plasma-Lyte has been shown to develop less hypercholeremia with subsequent decrease in incidence of metabolic acidosis. It is important to note the role of metabolic acidosis as it contributes to renal failure and is an independent risk factor for mortality in the ICU. The purpose of this research study is to determine the effect of Plasma-Lyte vs 0.9% saline as resuscitative fluid in patients with acute UGIB. Methods: This is a retrospective, multi-center (three institutions: Level I and II) study with 232 patients (Age > 18) admitted to ICU from July 1, 2015 to November 30, 2016 with acute UGIB were identified. Patients' with Chronic Kidney Disease (GFR< 30ml/min) were excluded. Total n=16 (Rockall Score mean = 3.5), Plasma-Lyte Group (8 of 232 patients; limited use due to cost), 0.9% saline (Random selection of 8 of 224). Information regarding pre-existing co-morbidities; peptic ulcer disease, diabetes, hypertension, cirrhosis, anticoagulation therapy, endoscopy time (< 24hrs) and location was collected. Results: There was no statistically significant difference in the demographic and clinical characteristics of patients including baseline Creatinine and Chloride level (p>0.05). There was no statistically significant difference (within 24 hours) in level of creatinine change or development of acute kidney Injury (per Rifle Criteria), pH, total amount of fluids and blood product transfusion, need for hemodialysis(HD) or Continuous Renal Replacement Therapy (CRRT), Intensive care length of stay or in-hospital mortality. 75% (6/8) in 0.9% group vs 50% (4/8) in plasmalyte group had a diagnostic and therapeutic EGD. 33% (2/6) in 0.9% group vs 100% (4/4) in plasmalyte group had EGD within 24 hours. 83.3% (5/6) in 0.9% group vs 50% (3/6) in plasmalyte group had EGD performed in endoscopy unit. Conclusion: Early hemodynamic stability and intervention decreases post-procedural mortality along with intra-procedure cardiopulmonary complications. Our study did not have enough patients who received Plasma-Lyte as it is not a routinely used resuscitation fluid due to cost and limited availability in certain institutions. This analysis can serve as a pilot study for prospective analysis to determine type of resuscitation fluid used in acute upper gastrointestinal bleed.

BackgroundCongenitally corrected transposition of the great arteries (ccTGA) is a rare anomaly comprising a minimal portion of congenital heart disease cases. Some patients are not identified until adulthood. A minority of these patients maintain normal functional status into the seventh decade and generally only when no other anomalies exist. We describe a case of ccTGA, dextrocardia, and situs inversus in the oldest patient diagnosed with these congenital abnormalities to date.Case presentationAn 83 year old female with known dextrocardia presented with dyspnea and was diagnosed with ccTGA, situs inversus, and new onset heart failure.ConclusionsThe factors that lead to a delayed presentation of systemic right ventricular failure in ccTGA remain ill-defined. Common adult acquired secondary causes of heart failure, such as hypertension and coronary artery disease, likely play a role in patients with congenital heart disease. Aggressive screening and management of these co-existing diseases may improve overall outcomes in adult patients with congenital heart disease.

Cryoablation is a well-established technique to treat fibroadenomas. Pilot studies suggest this could be an effective non-surgical treatment for breast cancer. American College of Surgeons Oncology Group Z1072 is a phase II trial exploring the effectiveness of cryoablation in the treatment of breast cancers. The primary endpoint of Z1072 was the rate of complete tumor ablation, defined as no remaining invasive breast cancer (IBC) or ductal carcinoma in situ (DCIS) on pathologic examination of the targeted lesion. A secondary objective was to evaluate the negative predictive value of magnetic resonance imaging (MRI) to determine residual IBC or DCIS. Eligible patients included those with unifocal invasive ductal breast cancer ≤2cm, with <25% intraductal component and tumor enhancement on MRI. A total of 19 centers contributed 99 patients, of which 86 patients (87 breast cancers) were evaluable for data analysis. Final pathology results, regardless of whether residual IBC/DCIS was in the targeted ablation zone or elsewhere in the breast, showed successful ablation in 66/87 (75.9%) cancers. The 90% confidence interval for the estimate of successful cryoablation was 67.1-83.2, with the one-sided lower-sided 90% CI of 69.0. The negative predictive value of MRI was 81.2% (90% CI 71.4-88.8). When multifocal disease outside of the targeted cryoablation zone was not defined as an ablation failure, 80/87 (92%) of the treated cancers had a successful cryoablation. Further studies with modifications on the Z1072 protocol could be considered to evaluate the role for cryoablation as a non-surgical treatment of early-stage breast cancer.

Introduction: Choledochoduodenal fistula (CDF) is one of the least common types of biliary enteric fistula. The most common causes of CDF are iatrogenic causes, gallstone disease and peptic ulcer disease. CDF secondary to cancer appears to be an exceedingly rare condition. We report a cholangiocarcinoma causing a CDF and highlight the importance of combining endoscopic findings with CT findings to make the diagnosis as well as the importance of reviewing both axial and coronal CT images. Case: A 57-year-old female with no significant medical history presents to the hospital with a 30-pound unintentional weight loss, mid-epigastric abdominal pain, worsening fatigue and anorexia. A CT was performed in the ED. Initially, only axial images were reviewed and demonstrated a large left liver lobe mass, pneumobilia and antral and duodenal thickening. Because of the nature of her symptoms and abnormal CT, an upper endoscopy was performed and demonstrated what appeared to be a fairly large duodenal bulb fistula. A review of the original CT scan's coronal sections clearly demonstrated a fistualizing tract from the duodenum to the left lobe of the liver as well what appeared to be extension of the tumor into the perihilar region. A CA-19-9 was 1000. The patient was referred to a tertiary care center with significant cholangiocarcinoma experience. Biopsy of the mass was consistent with cholangiocarcinoma. The patient was referred to oncology for further management: palliative chemotherapy versus hospice. Discussion: The differential diagnosis of choledochoduodenal fistula (CDF) includes iatrogenic causes, gallstone disease, and peptic ulcer disease. CDF secondary to cancers appear to be an extremely rare finding with only about ten cases reported in the literature. Here, we report another cancer causing a CDF-in this case a cholangiocarcinoma. This case highlights two key clinical points: the importance of combining endoscopy and radiologic imaging in making this rare diagnosis and the importance of reviewing both coronal and axial CT images in abdominal pathology cases. In our case, the findings on EGD led to further review of the original CT scan. The fistula that was difficult to appreciate in CT axial views was clearly appreciated in CT coronal views highlighting the importance of looking at both views.