Faculty Bibliography

Pharmacomechanical therapy and catheter-directed thrombolysis have been shown to be very effective in the treatment of venous thromboembolism; however, there is much less data regarding inferior vena cava thrombi. Tumor thrombi pose an even greater clinical challenge as anti-coagulation and thrombolysis are not effective. We present the case of a 61-year-old male who presented with an inferior vena cava thrombus emanating from an accessory right hepatic vein, treated with aspiration thrombectomy.

BACKGROUND Immune thrombocytopenic purpura (ITP) is primarily caused by antibody-mediated destruction of platelets. Alterations in immune homeostasis can induce loss of peripheral tolerance and promote the development of self-reactive antibodies. Primary ITP is the diagnosis of exclusion made after the extensive work-up rules out other possible causes of thrombocytopenia. The association between the ITP and other autoimmune disorders is well-established. In recent years, increasing attention has been directed toward the association between celiac disease (CD) and ITP. CASE REPORT A 27-year-old man with a history of primary ITP presented with an occasional nosebleed, 1 episode of rectal bleeding, and easy bruising. The patient was later found to have high titers of TTG-IGA and endomysial IGA levels consistent with CD. Our patient not only failed to improve with the gluten-free diet, but also failed multiple lines of treatment including steroids, IVIG, rituximab, eltrombopag, and even a non-traditional treatment for ITP (azathioprine and plasma exchange). The patient's CD-related antibody titers remained elevated. CONCLUSIONS It is possible that in certain cases the alteration of immune response caused by CD with a concurrent elevation of CD-related antibodies can make ITP refractory to all medical management. Whether or not this refractoriness to treatment is related to the persistently elevated antibody titers of CD or unknown genetic relationship between ITP and CD remains not entirely clear and warrants further molecular, immunologic, and genetic analysis.

Pyogenic liver abscesses (PLAs) secondary to bacterial etiologies are most often seen in developing countries and are less common in North America. The predominant etiology is infection occurring in the setting of direct extension of hepatobiliary or intestinal infection. The most common pathogen isolated from a PLA in the United States is Escherichia coli, whereas Streptococcus viridans is a rare entity in the developed world. Herein we report a rare case of a complicated isolated PLA in a patient without any known comorbidities which lead to hepatectomy. The patient was born and raised in the United States with no recent travel history. The patient was found to have 10 cm isolated multicystic mass on imaging confirmed later as vancomycin-resistant Streptococcus viridans PLA. The patient was treated with multiple intravenous antibiotics and underwent multiple ultrasound-guided percutaneous abscess drainages by interventional radiology, but all unsuccessful. The patient underwent right posterior liver lobectomy, thereafter making a quick recovery and was discharged. Our case underlines the significance of considering liver abscess as a differential even in previously healthy individuals with no known prior comorbid conditions, as prompt recognition is imperative in preventing morbidity and mortality.

INTRODUCTION/BACKGROUND:Gastrointestinal (GI) symptoms are increasingly being recognized in coronavirus disease 2019 (COVID-19). It is unclear if the presence of GI symptoms is associated with poor outcomes in COVID-19. We aim to assess if GI symptoms could be used for prognostication in hospitalized patients with COVID-19. METHODS:We retrospectively analyzed patients admitted to a tertiary medical center in Brooklyn, NY, from March 18, 2020, to March 31, 2020, with COVID-19. The patients' medical charts were reviewed for the presence of GI symptoms at admission, including nausea, vomiting, diarrhea, and abdominal pain. COVID-19 patients with GI symptoms (cases) were compared with COVID-19 patients without GI symptoms (control). RESULTS:A total of 150 hospitalized COVID-19 patients were included, of which 31 (20.6%) patients had at least 1 or more of the GI symptoms (cases). They were compared with the 119 COVID-19 patients without GI symptoms (controls). The average age among cases was 57.6 years (SD 17.2) and control was 63.3 years (SD 14.6). No statistically significant difference was noted in comorbidities and laboratory findings. The primary outcome was mortality, which did not differ between cases and controls (41.9 vs. 37.8%, p = 0.68). No statistically significant differences were noted in secondary outcomes, including the length of stay (LOS, 7.8 vs. 7.9 days, p = 0.87) and need for mechanical ventilation (29 vs. 26.9%, p = 0.82). DISCUSSION/CONCLUSIONS:In our study, the presence of GI manifestations in COVID-19 at the time of admission was not associated with increased mortality, LOS, or mechanical ventilation.

BACKGROUND:The clinical importance of hypovascular liver lesions in cirrhotic patients awaiting liver transplantation (LT) has not been fully investigated. The objective of this study was to characterize the clinicopathologic features and management of these tumors and to assess their impact on post-LT outcomes. METHODS:We performed a retrospective review of cirrhotic patients with lesions suspicious for hypovascular hepatocellular carcinoma (HCC) who underwent LT at a single institution from 2011- 2017. RESULTS:We identified 22 pre-LT patients with radiologic diagnosis of a lesion(s) suspicious for hypovascular HCC. There were 28 hypovascular lesions within the 22 patient cohort; 9 lesions (32%) converted to hypervascular HCC before LT and 19 lesions remained hypovascular at LT. 88% of hypovascular lesions were HCC on explant pathology. Compared to patients with hyper-vascular HCC lesions, hypovascular HCC lesions underwent less preoperative tumor ablation (58% vs 89%; P < .01). Hypovascular HCC were more likely to be well-differentiated (67% vs 11%; P < .01), but there were no differences in the microvascular invasion, tumor recurrence, or survival post-LT. CONCLUSIONS:Hypovascular HCC has similar clinical outcomes and needs for transplantation as hypervascular HCC. The high prevalence of HCC within suspicious hypovascular lesions supports a similar monitoring and locoregional therapy strategy as for hypervascular HCC.

Splenic artery aneurysms are rare with an incidence of less than 0.8%. Evidence to support an endovascular management strategy over open surgical repair for SAA is limited. We used the Nationwide Inpatient Sample to compare open to endovascular SAA repair by assessing postoperative outcomes, length of hospital stay, and mortality. Multivariate logistic regression analysis was done to determine predictors of postoperative complications. There were 2316 admissions with a diagnosis code for SAA [347 (14.9%) endovascular repair and 112 (4.8%) open surgery]. There was a statistically significant lower rate of cardiac (2.3% vs 6.9%, P = 0.05) and pulmonary (8.9% vs 16.1%, P = 0.05) complications for the endovascular repair group. The risk of surgical site infection was also lower (0.6% vs 5.1%, P = 0.01) in the endovascular group. Median in-hospital LOS was greater for open repairs (6 vs. 4 days, P = 0.01). There were no statistically significant differences across procedures for renal complications (8.9%, P = 0.88) or in-hospital mortality (3%, P = 0.99). Regression analysis established procedure type to be independent predictor of postoperative complications. Endovascular repair of SAA is therefore associated with a lower complication rate and less resource utilization but no difference in mortality peri-operatively. This may justify an endovascular first treatment strategy in the management of SAA.