Lemmel syndrome, a rare condition, is characterized by biliary obstruction caused by a periampullary diverticulum (a pouch-like outgrowth of the duodenum near the ampulla of Vater). In our case, a 76-year-old male patient presented with epigastric pain and exhibited a cholestatic pattern on liver function tests. Imaging revealed dilated pancreatic and common bile ducts due to compression by a periampullary diverticulum (double duct sign: simultaneous dilation of the common bile duct and pancreatic duct). Upper endoscopy showed one medium-sized periampullary diverticulum. This case emphasizes the diagnostic process and the importance of considering Lemmel syndrome in differential diagnosis in elderly patients with biliary obstruction. We discuss the prevalence, diagnostic considerations, including imaging modalities, and treatment options, emphasizing the need for further research.

Background/Aims: Nonagenarians will purportedly account for 10% of the United States population by 2050. However, no studies have assessed the outcomes of nonvariceal upper gastrointestinal bleeding (NVUGIB) in this age group. Methods: The National Inpatient Sample database between 2016 and 2020 was used to compare the clinical outcomes of NVUGIB in nonagenarians and octogenarians and evaluate predictors of mortality and the use of esophagogastroduodenoscopy (EGD). Results: Nonagenarians had higher in -hospital mortality than that of octogenarians (4% vs. 3%, p <0.001). EGD utilization (30% vs. 48%, p <0.001) and blood transfusion (27% vs. 40%, p <0.001) was significantly lower in nonagenarians. Multivariate logistic regression analysis revealed that nonagenarians with NVUGIB had higher odds of mortality (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.3-1.7) and lower odds of EGD utilization (OR, 0.86; 95% CI, 0.83-0.89) than those of octogenarians. Conclusions: Nonagenarians admitted with NVUGIB have a higher mortality risk than that of octogenarians. EGD is used significant- ly in managing NVUGIB among nonagenarians; however, its utilization is comparatively lower than in octogenarians. More studies are needed to assess predictors of poor outcomes and the indications of EGD in this growing population.

The development of biliary cast syndrome (BCS) is very rare, mostly documented in patients with liver transplantation. The etiology of BCS is unknown; however, risk factors include post-liver transplant bile duct injury, ischemia, infection, fasting, parenteral feeding, and increased bile viscosity and gallbladder dysmotility. We present the case of a 41-year-old man who developed BCS secondary to a prolonged intensive care unit course without a liver transplant. This case highlights the importance of monitoring patients with protracted intensive care unit course and abnormal aminotransferases to recognize and timely manage cholangiopathy and BCS-related complications.

Background Serum Pepsinogen (PG) and Helicobacter pylori (Hp) have potential as biomarkers to identify persons at high risk for gastric cancer (GC) in low incidence populations. We explored the use of these biomarkers in a diverse US population. Methods Single institution study using serum samples from 32 newly diagnosed GC (before treatment) and 60 non-cancer participants. ELISA-based PG-I, PG-II, Hp IgG, and Hp virulence seromarker (CagA, VacA) tests were conducted to examine differences between GC and non-GC participants. Results Median age was 58 (IQR 48-68); 56% were females; 30.1% were white, 14.8% black, 28.7% Hispanic, 6.1% Asian and 18.2% other/unknown race/ethnicity. Median values of Hp (47.9 vs 12.6U/mL, p=0.003) and pepsinogen ratio (PGR=PGI/PGII) (4.0 vs 7.5, p= 0.003) differed between GC and non-GC. Performance of pepsinogen tests using “standard” cut-offs (PGI<70ng/mL and PGR<3) were highly specific (91.7%), but not sensitive (34.4%), while Hp IgG test using “standard” cut-off (>30U/mL) was sensitive (78.8%), but less specific (41.2%). Optimized cut-off values identified in our population using Youden’s Index were PGR<5.2 and Hp>17.5 U/ml. Using a combination of these values resulted in a significant increase in test sensitivity (87.9%) with lower specificity (50.8%). Conclusion The combination of pepsinogens and Hp show promise as biomarkers of GC risk in a racially and ethnically diverse US population. Optimal biomarker cut-off points for US populations may differ from those established in East Asia. By adjusting cut-offs there is potential to design GC risk stratification tools tailored specifically for the diverse population within the US. Synopsis Pepsinogen and H. pylori show promise as biomarkers of GC risk in a racially and ethnically diverse US population. Optimal biomarker cut-off points for diverse populations in the US may differ from those previously established in East Asia.

Background/Aims: The pancreatic pseudocyst (PP) is a type of fluid collection that typically develops as a delayed complication of acute pancreatitis. Drainage is indicated for symptomatic patients and/or associated complications, such as infection and bleeding. Drainage modalities include percutaneous, endoscopic, laparoscopic, and open drainage. This study aimed to assess trends in the utilization of different drainage modalities for treating PP from 2016 to 2020. The trends in mortality, mean length of hospital stay, and mean hospitalization costs were also assessed. Methods: The National Inpatient Sample database was used to obtain data. The variables were generated using International Classification of Diseases-10 diagnostic and procedural codes. Results: Endoscopic drainage was the most commonly used drainage modality in 2018-2020, with an increasing trend over time (385 procedures in 2018 to 515 in 2020; p=0.003). This is associated with a decrease in the use of other drainage modalities. A decrease in the hospitalization cost for PP requiring drainage was also noted (29,318 United States dollar [USD] in 2016 to 18,087 USD in 2020, p<0.001). Conclusions: Endoscopic drainage is becoming the most commonly used modality for the treatment of PP in hospitals located in the US. This new trend is associated with decreasing hospitalization costs.

Biliary strictures or narrowing of a portion of the biliary tree can have benign and malignant etiologies. One third of these will originate from iatrogenic injury and these are typically managed endoscopically. We present the case of a 76-year-old man with history of laparoscopic cholecystectomy ten years prior, who presented with one week of jaundice, dark urine, and pruritus. Along with non-invasive biliary imaging, he underwent cholangioscopy during endoscopic retrograde cholangiopancreatography revealing inflammatory-appearing stenosis of the common hepatic duct with embedded suture material. The stenotic area was biopsied using mini forceps and subsequently dilated with a balloon dilator. A plastic biliary stent was placed with improvement in the patient’s hepatic function, with final cytology and pathology being negative for malignancy. Cholangioscopy facilitated detailed visual inspection of strictures and biopsies under direct visualization. The visual impression increased the sensitivity of the biopsy and assisted in ruling out malignancy from the most critical portion of the stricture. While timing of cholangioscopy remains to be determined, its use is a valuable tool in the diagnosis of indeterminate biliary strictures.

Introduction: In the United States, hepatitis B virus (HBV)-associated hepatocellular carcinoma (HCC) is predominantly seen in patients from Sub-Saharian Africa and Eastern Asia where HBV infection is prevalent. Because of delayed diagnosis and resource-intensive management required to treat advanced disease, the prognosis of HCC is often very poor, even in otherwise healthy patients. Here, we present the case of a patient with advanced HBV-related HCC and aim to analyze the factors that led to this presentation in order to identify potential areas of intervention and develop strategies to prevent similar outcomes. Case Description/Methods: In 2019, a 52 year-old man from Ghana without any known medical history, initially presented to our hospital with complaint of dizziness. At the time, he was diagnosed with concomitant HIV and acute HBV infection, and discharged with infectious disease (ID) clinic follow-up. Antiviral therapy including TAF was started and Liver US was performed which showed coarse heterogeneous hepatic echotexture. He was enrolled in a retention and adherence program to assist with insurance, medication procurement, and appointment scheduling. After being successfully discharged from RAP in September 2020, the patient’s insurance coverage was lost for 7 consecutive months during which he was unable to procure antiviral medications or attend regular follow-up. With the involvement of social and financial services, in late December 2022, the patient’s insurance was re-instated and he was linked to ID clinic to re-establish care. However, in April 2023, he presented to the ER for severe right upper quadrant abdominal pain. Further imaging was performed and biopsy-proven advanced HBV-related HCC was diagnosed. He was discharged with close follow-up with oncology and is currently receiving durvalumab and tremelimumab in oncology clinic. Discussion: Overall this case highlights several hurdles and gaps that hamper care for immigrant patients in the United States. Lack of longitudinal follow-up and cancer surveillance screening is ultimately responsible for advanced disease presentations requiring resource-intensive therapies and leading to dismal outcomes. Immigrants with HBV/HIV infections remain at high risk for HCC and face unique challenges that require a comprehensive and multidisciplinary approach to improve outcomes. Further natural history studies of HCC in HIV-HBV coinfection within these populations are needed to better understand disease progression and develop targeted interventions (Figure 1).Figure 1.: Image A shows an ultrasound on the initial presentation in 2019, coarse echotexture of the hepatic parenchyma can be appreciated, no lesions were seen. Image B is the patient's ultrasound from a subsequent encounter in 2023. Numerous lesions can be seen. The patient did not undergo any imaging in between. Images C and D are cross-sections from a CT scan performed during his encounter in 2023. Image C: Innumerable liver lesions can be seen (Portal venous phase). Image D: multiple liver lesions with ascites (portal venous phase, hepatic window). An image-guided paracentesis was performed revealing 700 mL of old blood. Imaging findings along with ascitic fluid findings suggested that the patient had likely sustained a rupture of a subcapsular liver mass, resulting in intraperitoneal bleeding.