Auburn Research Day 2022

Cl i n i ca l Case Repor t | Med i ca l St udent Case Review of Nesidioblastosis: Pancreaticodudenoectomy, Subtotal Gastrectomy, and Cholecystectomy

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Dr. Thomas Mahan, MD; Christopher Cacciatore, OMS II 2 AdventHealth, Winter Park, FL (1); Edward Via College of Osteopathic Medicine-Auburn Campus (2)

Nesidioblastosis in adults is an extremely rare condition that causes hyperinsulinemic hypoglycemia, it comprises only 0.5% to 7.0% of all hyperinsulinemic cases. This case study examines a 46-year- old female that had recurrent nesidioblastosis of the pancreas, causing non-insulinoma hyperinsulinemic hypoglycemia. After initial treatment with a distal pancreatectomy, the patient continued to have hypoglycemic episodes. Therefore, it was decided to perform a pancreaticoduodenectomy, subtotal gastrectomy, and cholecystectomy. The patient’s post-operative course was without complications until she developed colonic ischemia along the transverse and splenic flexure of the colon. This was likely due to the suboptimal blood flow to the watershed area as well as the hypotension from renal dialysis that led to necrosis of the bowel. The patient underwent a resection of the involved segment and an end-to-end colostomy. She was then discharged home until organs were available for transplant. An interesting aspect of the patient’s medical history was that she had a previous Roux-en-Y gastric bypass procedure. Although rare, there have been some case reports and studies that highlight

the possible association between Roux-en-Y gastric bypass and nesidioblastosis. In an initial investigation into the association, six patients (post Roux-en-Y) who expressed clinical symptoms of postprandial hypoglycemia were observed. Five out of six of the patients presented with islet cell hypertrophy which signified nesidioblastosis. In addition, another study took 36 patients who underwent a partial pancreatectomy for nesidioblastosis from 1994- 2007, it was found that 27 of the patients had a previous Roux-en-Y gastric bypass procedure. These studies present a possible correlation between the Roux-en-Y and developing nesidioblastosis. Although not a definitive cause, it is hypothesized that hormonal changes and pre-surgery homeostasis play a role in the development of nesidioblastosis. This association is important for further evaluation so providers can educate their patients with the most up-to-date information and possible complications that may arise from a Roux-en-Y gastric bypass procedure.

Cl i n i ca l Case Repor t | Med i ca l St udent Identification and Management of a Periappendiceal Abscess and Elevated Fecal Calprotectin in the Pediatric Emergency Room

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Kevin Bryan (1); Collin R. Vargas (2) Fort Walton Beach Medical Center (1);Edward Via College of Osteopathic Medicine- Auburn Campus (2)

Background: Acute appendicitis is a common surgical diagnosis in children. The complication of periappendiceal abscess is already problematic, this combined with a family history of Crohn’s Disease (CD) can pose a challenge for management. We present a case of a 10-year-old-girl who presented with intermittent lower abdominal pain, fever, and a recent elevated fecal calprotectin significant for Crohn’s disease. Method: Detailed review of a multitude of cases, articles, complications, and outcomes Results: Distinguishing appendiceal CD and appendicitis in the setting of CD is difficult as long-term follow up may be required. Symptoms of appendiceal CD typically include a prolonged history of intermittent lower abdominal pain and diarrhea (Han 2014). These symptoms typically present in a chronic manner compared to acute appendicitis. Our patient had clinical symptoms of appendicitis for roughly two months in duration with gastroenterology referral. An elevated fecal calprotectin with intermittent abdominal pain, fevers, and diarrhea gives the impression of appendiceal CD. These results are speculative without access to medical records or pathology reports after transferring the patient to another facility for further management.

Conclusions: Thorough family and patient GI history is necessary in the identification and management of periappendiceal abscesses. Intermittent abdominal pain with recurrent fevers should be evaluated further in the pediatric population.

25 2022 Via Research Recognit ion Day