Abstracts S589

acute pancreatitis was confirmed with a lipase of 4670 U/L and CT abdomen showing pancreatic inflam-
mation. Other labs were within normal limits. A right upper quadrant ultrasound was consistent with
cholecystectomy. Upon further questioning, the patient noted taking L-Arginine supplement 1000 mg
daily for the past 3 weeks as a treatment for erectile dysfunction. A brief literature search yielded the
use of L-Arginine in mice to induce acute necrotizing pancreatitis. The patient improved with standard
management of acute pancreatitis. Upon discharge, the patient was instructed to discontinue L-Arginine
and has since not had a recurrent episode of acute pancreatitis.
L-Arginine is sold in the United States as a dietary supplement. It is alleged to improve erectile dysfunc-
tion, male fertility, and athletic performance. However, L-arginine has been used, albeit at higher doses,
as a major model to induce acute pancreatitis in rats for animal studies. The exact mechanism of L-argi-
nine induced pancreatitis is unknown, but previous studies have postulated that L-arginine may increase
nitric oxide affects in the pancreas. Although the levels used to experimentally induce pancreatitis in
rats, approximately 500 mg per 100 g animal weight, is much greater than the amount most supplements
recommend, 1-3 g/day, there is one prior documentation in medical literature reporting an adolescent
male who experienced acute pancreatitis after ingesting L-arginine 500 mg daily for five months with the
aims of increasing muscle mass. Though our patient had only been using L-arginine for about 3 weeks, it
is reasonable to consider L-arginine supplementation as a possible cause for his episode of acute pancre-
atitis. This case serves to highlight the broad differential for acute pancreatitis etiology and to consider
drug-induced etiology especially if a patient was started on medications or supplements whose effects on
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human physiology have yet to be fully elucidated.

[1318B] Figure 2.

1320
Septic Shock from Cholecystitis in an Intrahepatic Gallbladder
Rachana Koya, DO1, Lindsay Zielinski, DO2, Kinesh Changela, MD3, Yitzchak Moshenyat, MD4. 1. New
York University Lutheran Medical Center, New Hyde Park, NY; 2. New York University Langone Medical
Center, Brooklyn, NY; 3. Brooklyn Hospital Center, Brooklyn, NY; 4. New York University Lutheran
Medical Center, Brooklyn, NY.

Introduction: Intrahepatic gallbladders, a rare anatomical variant, usually have impaired functional-
ity and do not empty completely. This stasis leads to the formation of gallstones which in turn leads to
an increased risk of developing associated complications with increased morbidity and mortality. We
illustrate this point with a case of a male with a history of partial cholecystectomy who presented with
sepsis from cholecystitis within an intrahepatic gallbladder. Case Report: A 31-year-old male presented
with complaints of right upper quadrant abdominal pain, nausea and vomiting. His past medical his-
tory included cholelithiasis with elective open partial cholecystectomy a few months prior for biliary
cholic. His postoperative course had been complicated by stump leakage requiring an ERCP with stent
placement. On this admission, the patient presented with hypotension and tachycardia, elevated WBC
count of 12.6 K/mL, total bilirubin of 1.4, and direct bilirubin 0.56. Blood cultures were positive for
gram-negative bacilli. CT scan was significant for a fluid collection in the gallbladder fossa (Figure 1).
MRCP revealed an intrahepatic gallbladder with dark signal representing possible calculi (Figure 2).
The patient was admitted to SICU on IV antibiotics and vasopressors. The patient had 15cc of purulence

[1318C] Figure 3.

passed in a retrograde fashion alongside of the EID (parallel cannulation method). We present a case
of a 69 year old female who presented with acute cholangitis secondary to choledocholithiasis. ERCP
was attempted, but was aborted after ampulla was not identified due to two large duodenal diverticula
[Fig 3]. Interventional radiology was consulted and PTC with placement of EID was performed. Repeat
ERCP consisted of multiple unsuccessful attempts to cannulate the common bile duct (CBD) alongside
of the EID [Fig 4]. The interventional radiology consult was placed. EID was exchanged for a Bernstein
catheter [Fig 5], and a guidewire was then inserted through the duodenoscope directly into the Bernstein
catheter and externalized. The Bernstein catheter was then retracted into the right intrahepatic duct,
the CBD was accessed with straight cannula, the guidewire was removed and a cholangiogram was per-
formed revealing multiple filling defects. The Bernstein catheter was removed, the straight catheter was
exchanged for sphincterotome, and a traditional ERCP with sphincterotomy, stone extraction and biliary
stent insertion was performed. To our knowledge this is the first case reported in the United States of
the modified rendezvous procedure. Traditional technique is cumbersome, time consuming and carries
high risk of procedure complications, such as loss of wire and pancreatitis. We propose that our method
should replace the traditional approach in all Rendezvous cases.

1319
An Interesting Case of Acute Pancreatitis
Thomas Murphy, MD, Douglas Katein-Taylor, MD, Bruce Scott, MD. Wright State University Boonshoft
School of Medicine, Dayton, OH.

The patient is a 32 -year-old male with no significant medical history who presented with nausea and
epigastric pain for the past day. He had a previous cholecystectomy secondary to biliary colic and denied
recent abdominal trauma, scorpion exposure, viral illness, tobacco, or alcohol use. He denied medi-
[1320A] Figure 1.
cations. Vitals were normal and physical examination showed epigastric tenderness. The diagnosis of

© 2016 by the American College of Gastroenterology The American Journal of GASTROENTEROLOGY

S590 Abstracts

cation. Immunohistochemical studies, demonstrated strong staining of the tumor with CD10, vimentin,
progesterone receptor, nuclear and cytoplasmic B-catenin, CD56, cyclin D-1, NSE. No staining is noted
with cytokeratin AE1/AE3 and chromogranin. This staining pattern and the morphology are consistent
with a Hamoudi tumor. Hamoudi tumor also known as solid pseudopapillary tumor of the pancreas is a
benign pancreatic tumor, they are extremely rare and thought to account for 1-2% of exocrine pancreatic
tumors, they have a good prognosis after resection, usually occurs in non-Caucasian women in their 2nd
and 3rd decade and occasionally present with a gradually enlarging abdominal mass or vague abdominal
pain. The median size at diagnosis is 8 cm. This case is of interest because this particular type of neoplasm
is typically found in women and, in our case, our patient is a Caucasian male that does not follow the age
or usual presentation of the disease.

1322
Unusual Case of Metastatic Pancreatic Lesions from Renal Cell Carcinoma
Moiz Ahmed, MD, Abhishek D. Polavarapu, MBBS, Hafiz Khan, MBBS, Sherif Andrawes, MD, Liliane
Deeb, MD. Staten Island University Hospital, Staten Island, NY.

Isolated metastasis to the pancreas from renal cell carcinoma (RCC) is extremely unusual accounting
for 1-2% of pancreatic tumors. Patients may be asymptomatic and it can be difficult to distinguish RCC
metastasis from a primary ductal adenocarcinoma or a neuroendocrine tumor of the pancreas. The aver-
[1320B] Figure 2. age time to presentation for pancreatic metastasis from RCC is 9.2 years after initial resection, which
highlights the importance of long-term post-nephrectomy surveillance. We report a rare patient with
RCC who developed isolated metastases to pancreas 20 years after radical nephrectomy. Case: 65 year
old female with history of RCC limited to the capsule had radical nephrectomy 20 years ago. Subsequent
periodic surveillance abdominal scans were unremarkable. A year prior to this presentation, computed
drained by interventional radiology. GI was then consulted for an ERCP. The prior stent was removed,
tomography (CT) of abdomen revealed 2 hypodense lesions in head and body of pancreas, 2.9 x 2.5 cm
sphincterotomy performed, a cholangiogram did not reveal any bile leaks or filling defects in the com-
(fig1) and 1.9 x 1.8cm respectively, suspicious of intraductal papillary mucinous neoplasm (IPMN). PET
mon bile duct, and a new stent was placed. The patient’s vital signs improved and he no longer required
scan was unremarkable. A year later the same hypodense lesions were found to be hyperdense (fig 2),
vasopressors within 24 hours after the ERCP. Discussion: Intrahepatic gallbladders are predisposed to
suggesting metastases. An EUS (fig 3) guided biopsy of these lesions disclosed clear cell-RCC. Patient
develop cholelithiasis, which presents a significant cause of morbidity. A delay in diagnosis leads to inap-
was started on Sunitinib as she declined resection. Discussion: Metastatic tumors to the pancreas are
propriate management and increases in morbidity and mortality. In our case, the patient likely required
uncommon. RCC is one of the few tumors known to metastasize to the pancreas. Isolated solid organ
earlier stent placement because the entirety of the gallbladder was not removed during his initial surgery.
metastasis of RCC to the pancreas occurs via blood or lymphatics and is infrequent in the absence of
The remaining portion of the gallbladder remained at risk of developing further cholelithiasis due to its
widely disseminated disease. The lesion is found during the initial staging work-up for treatment of the
anatomical position if the original gallstone was not removed during the initial cholecystectomy. Intra-
primary tumor, or discovered via routine follow-up imaging after the primary tumor has been treated,
hepatic gallbladders should be identified early as they have a higher propensity for developing gallstones,
which can lead to other complications such as cholecystitis, cholangitis, perforation, abscess formation
and even death.

1321
Pancreatic Tumor a Rare Subtype
Barakat Aburajab Altamimi, MD. University of New Mexico, Albuquerque, NM.

47-year-old gentleman admitted to the hospital after being electrocuted and suffering full-thickness
burns for 30% of his body surface area including face, neck and upper torso was found during the latter
course of his hospitalization to have obstructive jaundice on the basis of elevated LFT. On exam vital
signs were normal except for heart rate of 110, physical showed dressing over patient face and upper
extremities with a benign abdominal exam. His LFT showed an AST / ALT of 154/244, total bilirubin of
4.8, direct bilirubin of 4.0, ALP of 614, albumin 2.1, and total protein of 6.7. His initial admission LFT
showed that his AST /ALT was 100/110, total bilirubin 0.8, ALP 84 albumin 3.3 and total protein 6.5.
ERCP was done and noted a distal common bile duct stricture with choledocholithiasis. A plastic stent
was placed with the plan for him to return in 6 weeks for biliary stent removal. An EUS was also done
at the same time and demonstrated that the filling defect was likely secondary to a complex mass with
calcification compressing the distal bile duct. FNA with cytologic analysis were positive for a neoplasm.
Recommendation was provided to do Pancreaticoduodenectomy. This was done and a tumor was found
in the ampulla measuring 2.6*1. 9cm.The tumor demonstrated a largely solid and nested growth pat-
tern. The tumor cells were round to oval with nuclear grooves, indistinct nucleoli and pale eosinophilic
cytoplasm with some vacuolization. The tumor was interspersed with areas of hyalinization with calcifi- [1322A] Figure 1.

[1321A] Figure 1.

The American Journal of GASTROENTEROLOGY VOLUME 111 | SUPPLEMENT 1 | OCTOBER 2016 www.nature.com/ajg