Residents’ Day 2022

On May 13th, Berks County Medical Society held its first Residents’ Day and Memorial Lecture after a two-year hiatus. This year’s lecture and presentations were held virtually but the content and quality of posters and presentations was excellent. It is our hope that this program will be held live next year. In the meantime, congratulations to these winning posters!

Cardiac Amyloidosis: A Diagnostic Dilemma and The Role of a Novel Electrocardiogram Criterion

Muhammad Asad Hanif1 , Tuoyo Omasan Mene-Afejuku2 , Olivera Chandler2, Julian Diaz-Fraga2 1. Department of Medicine, Tower Health, Reading Hospital, West Reading, PA, USA 2. Department of Cardiology, Tower Health, Reading Hospital, West Reading, PA, USA

INTRODUCTION

! Symptoms and signs of cardiac amyloidosis are nonspecific which makes diagnosis a challenge.

! An electrocardiogram (EKG) criterion of total QRS score divided by average left ventricular wall thickness can be used to aid in diagnosis in men with a bundle branch block as described by Sharma et al [1].

! We present a case of cardiac amyloidosis to stress upon the utility of this novel EKG criterion.

Figure 1. Electrocardiogram

Figure 2. Transthoracic Echocardiogram CASE DESCRIPTION

! A 70-year-old male with significant cardiac history presented to the emergency department after a syncopal episode.

! The episode was preceded by lightheadedness, shortness of breath and fatigue.

! Vital signs were normal.

! Physical exam revealed an elevated JVP, bibasilar lung crackles and bilateral lower extremity edema.

! He had a mild troponin elevation and an elevated BNP.

! EKG showed normal sinus rhythm, left axis deviation, and a left bundle branch block (figure 1).

! CTA chest was indicative of fluid overload.

! Transthoracic echocardiogram (TTE) revealed a normal ejection fraction, moderate to severe concentric left ventricular hypertrophy, dilated left atrium and a low stroke volume (figure 2).

! Patient was diuresed aggressively but continued to feel dyspneic and fatigued.

! Cardiac MRI was performed which was highly suggestive of amyloidosis (figure 3).

! Serum lambda free light chains were elevated, and a bone marrow biopsy was positive for plasma cell myeloma and amyloid deposition (figure 4).

! A diagnosis of cardiac amyloid light chain amyloidosis was made, and chemotherapy initiated.

! Patient was subsequently discharged to rehab where he suffered a cardiac arrest eight days after discharge and passed away.

REFERENCES

1. Sharma S, Labib SB, Shah SP. Electrocardiogram Criteria to Diagnose Cardiac Amyloidosis in Men With a Bundle Branch Block. The American Journal of Cardiology. 2021 May 1;146:89-94. DISCUSSION

! In retrospect, we found out that our patient’s score on the

EKG criterion described by Sharma et al. [1] for patients with a bundle branch block was indicative of cardiac amyloidosis. ! The criterion uses the total QRS score, calculated as the sum of the total QRS amplitude in all 12 EKG leads, divided by the average left ventricular wall thickness on TTE. ! A score of less than 92.5 is 100% sensitive and 83.3% specific for cardiac amyloidosis. ! Our patient had a total QRS score of 138 and an average left ventricular wall thickness of 1.65cm on TTE. ! His ratio comes out to be 83.6 which points towards a diagnosis of amyloid cardiomyopathy. ! Hence, this score may be utilized in patients with a bundle branch block who have evidence of significant ventricular hypertrophy on TTE and refractory heart failure or syncope to screen for cardiac amyloidosis.

Figure 3. Cardiac MRI showing diffuse heterogeneous enhancement overlying the entire subendocardial circumference extending into at least 50% of the myocardial thickness (white arrows).

Figure 4. Congo red stain of the bone marrow biopsy showing amyloid deposits in the vessel walls (black arrow).

Liver Resection as Definitive Management for Infected Embolization Coils after Pseudoaneurysm Embolization for Grade IV Liver Injury

Elise F. Heidorn, M.D.1, Filip Moshkovsky, D.O.1, Gary Xiao, M.D.2 & David Sacks, M.D.3 Tower Health, Reading Hospital, West Reading, PA 1. Department of Surgery 2. Department of Hepatopancreatobiliary Surgery 3. Department of Interventional Radiology

BACKGROUND Liver injuries after blunt abdominal trauma are very common. According to the National Trauma Database (NTDB), 22.2% of patients who suffer blunt trauma will have a liver injury. Nonoperative approaches to liver injuries, such as arterial coil embolization, are now standard of care for many patients. However, the long-term complications associated with coil embolization can be challenging to manage.

CASE REPORT A 29-year-old male with a history of an ATV accident resulted in a grade IV liver laceration requiring IR embolization of the right hepatic artery. Three weeks post-procedure, he developed a pseudoaneurysm requiring direct percutaneous transhepatic embolization. Approximately a year later, the patient presented after experiencing intermittent fevers, fatigue and a recurring chest wall wound with purulent drainage. Workup revealed this was a fistulous tract at the site of an old percutaneous drain which was draining an encapsulated liver abscess at the site of his prior liver injury. Initially, more conservative management was attempted with local wound exploration, fistula excision and antibiotics. A multidisciplinary discussion was held between Trauma Surgery, Thoracic Surgery, Interventional Radiology and Hepatobiliary Surgery to discuss the best option for definitive treatment. The patient subsequently underwent surgical management with a partial liver resection, fistula tract excision and diaphragm repair. Intra-operatively, an abscess cavity was discovered at the confluence of segments V, VI, VII & VIII containing coils. Additionally, intraoperative ultrasound was performed to identify structures. A B

C D

Figure 1: (A) Right chest wall wound (B) X-ray demonstrating embolization coils. (C) Abscess cavity. (D) Segment of resected liver with coils.

DISCUSSION The management of blunt liver trauma is based on patient hemodynamic stability and grade of injury. Per NTDB, approximately 83% are managed non-operatively1. While studies show that angioembolization of liver injuries improves survival, they also show that these patients have an increased number of complications, including hospital length of stay, sepsis, acute respiratory distress syndrome (ARDS) and time on the ventilator2. Additionally, the complications associated with non-operative management, as seen in our patient, can lead to the need for further interventions. These complications can be complex and challenging to manage. One study cited an 11% complication rate after angioembolization3. These complications included liver necrosis, gallbladder necrosis, bile leak and abscess3 .

Managing complications after these procedures can be very challenging and require a multidisciplinary approach to provide the patient with the best outcome. Our patient developed a pseudoaneurysm after initial embolization of his liver injury, which required percutaneous transhepatic direct embolization. The subsequent hepatic infection in this area required further drainage, leading to a fistulous tract and chronically draining wound in our patient. In this case, we present a definitive management strategy for these complex patients.

REFERENCES

1. Tinkoff G, Esposito T, Reed J, et al. American Association for the Surgery of Trauma Organ

Injury Scale I: Spleen, Liver and Kidney Validation Based on the National Trauma Data

Bank. J Am Coll Surg. 2008; 207: 646-655. 2. Sivrikoz E, Teixeira P, Resnick S, et al. Angiointervention: an independent predictor of survival in high-grade blunt liver injuries. Am J Surg. 2015; 209: 742-746. 3. Misselbeck TS, Teicher EJ, Cipolle MD, Pasquale MD, Shah, KT, Dangleben DA, Badellino

MM. Hepatic angioembolization in trauma patients: indications and complications. J

Trauma. 2009 Oct;67(4):769-773.

SPONTANEOUS INTRAMURAL SMALL BOWEL HEMATOMA - CASE REPORT

Sigrid Williamson, M.D., Aishwarya Suresh B.A., Adrian Ong, M.D.

Department of Surgery, Division of Trauma and Critical Care, Reading Hospital, Tower Health System Learning Objectives

• Nontraumatic SISBH should be considered in patients with coagulopathy who present with small bowel obstruction and hematochezia. • CT imaging is effective in diagnosis of SISBH. • Initial management is conservative. Surgical intervention reserved for signs of perforation. • Early recognition of SISBH is important; • symptoms may mirror pathologies requiring surgical intervention. • Anticoagulants can be stopped or reversed as soon as possible • Resolution of SISBH typically occurs within 4-7 days with conservative management alone.3,6 Case Report

History of Present Illness: A 67 year old male with a history of multiple myeloma treated with chemoradiation presented to the ED with two days of constipation, hematochezia, epigastric pain, and nausea. Most recent chemotherapy session was four days prior to onset of symptoms. Patient was not on anticoagulants. Surgical History: Unknown bowel surgery in childhood, ventral hernia repair x3, cholecystectomy, appendectomy. Physical Exam: Abdominal Distention, right lower quadrant tenderness, no signs of peritonitis. Large midline and mid-transverse abdominal scars Labs: White Blood Cell Count 1000/µL, Hemoglobin 7.4g/dL, Platelets 4000/µL. Imaging: CT abdomen showed partial SBO and masslike hyperintense segment of ileum with circumferential wall thickening and an intraluminal foci of active extravasation.

Results: Patient conservatively managed with correction of electrolyte abnormalities, bowel rest, and Nasogastric tube decompression. He received 2 units of packed red blood cells, 2 units of platelets, and filgrastim to stimulate white blood cell proliferation. Hospital Day 3: non-bloody bowel movements. Oral diet was reintroduced Hospital Day 4: repeat CT with resolution of the small bowel lesion. Hospital Day 5: discharged ! Nontraumatic SISBH is related to anticoagulant therapy, greatest association with Warfarin toxicity.1-5 ! Risk factors: Anticoagulant therapy, hematologic malignancies, coagulopathies, chemotherapy, and vasculitides.

1-5 ! Presentation: Non-specific including abdominal pain, nausea, emesis, signs of

GI bleed or obstruction, peritonitis, or hemorrhagic shock.4,5 ! Imaging: CT showing circumferential long segment bowel wall thickening, intramural hyperdensity, luminal narrowing. Hyperdensity limited to the intramural region on imaging can help distinguish from neoplasm.7 ! Pathophysiology: Likely due to slow bleeding of small submucosal vessels of the bowel wall causing intramural osmotic gradient, promoting further hematoma expansion.7 ! Management: No clear guidelines established. Conservative management recommended including discontinuation of anticoagulation, reversal of hypercoagulable state, bowel rest and decompression, fluid restriction, transfusion of blood product.1,3,6 ! Surgical intervention is reserved for patients presenting with peritonitis, ischemia, perforation, or refractory symptoms.3 ! Symptoms typically resolve within 4-7 days with this conservative management.3,6

CT Abdomen showing long segment area of circumferential wall thickening and a small amount of active extravasation (blue arrow). There is resultant partial small bowel obstruction proximal to this area (red arrow). Discussion

References

1. Abbas, M. A., Collins, J. M., Olden, K. W., & Kelly, K. A. (2002). Spontaneous intramural small-bowel hematoma: clinical presentation and longterm outcome. Archives of surgery (Chicago, Ill. : 1960), 137(3), 306–310. https://doi.org/10.1001/archsurg.137.3.306 2. Kang, E. A., Han, S. J., Chun, J., Lee, H. J., Chung, H., Im, J. P., Kim, S. G., Kim, J. S., Yoon, H., Shin, C. M., Park, Y. S., Kim, N., Lee, D. H., & Jung, H. C. (2019). Clinical features and outcomes in spontaneous intramural small bowel hematoma: Cohort study and literature review. Intestinal research, 17(1), 135–143. https://doi.org/10.5217/ir.2018.00085 3. Abdel Samie, A., & Theilmann, L. (2012). Detection and management of spontaneous intramural small bowel hematoma secondary to anticoagulant therapy. Expert review of gastroenterology & hepatology, 6(5), 553–559. https://doi.org/10.1586/egh.12.33 4. Kones, O., Dural, A. C., Gonenc, M., Karabulut, M., Akarsu, C., Gok, I., Bozkurt, M. A., Ilhan, M., & Alıs, H. (2013). Intramural hematomas of the gastrointestinal system: a 5-year single center experience. Journal of the Korean Surgical Society, 85(2), 58–62. https://doi.org/10.4174/jkss.2013.85.2.58 5. Acar, N., Acar, T., Gungor, F., Kamer, E., Karasu, S., Karaisli, S., & Dilek, O. N. (2019). A Rare Complication of Anticoagulant Therapy: Intramural Hematoma of the Small Bowel. Archives of Iranian medicine, 22(11), 653–658. 6. Yoldaş, T., Erol, V., Çalışkan, C., Akgün, E., & Korkut, M. (2013). Spontaneous intestinal intramural hematoma: What to do and not to do. Ulusal cerrahi dergisi, 29(2), 72–75. https://doi.org/10.5152/UCD.2013.41 7. Abbas, M. A., Collins, J. M., & Olden, K. W. (2002). Spontaneous intramural small-bowel hematoma: imaging findings and outcome. AJR. American journal of roentgenology, 179(6), 1389–1394. https://doi.org/10.2214/ajr.179.6.1791389