Louisiana Research Day Program Book 2025

Case Studies: Section 2

Case Studies: Section 2

FNU Arti, MD 1 ; Rahul Robaish Kumar, MD 2 ; Dirgha Patel, MD 3 ; Harikrishna Bandla, MD 4 ; Henry H Hinkle, MD 5 1-5 St. Francis Medical Center Internal Medicine Graduate Medical Education, Monroe Louisiana 103 DELAYED CHOLEDOCHOLITHIASIS AND BILIARY OBSTRUCTION EIGHT YEARS AFTER CHOLECYSTECTOMY IN A PATIENT WITH CHOLEDOCHODUODENOSTOMY: A RARE AND COMPLEX CASE

Ram Kumar, MD; Hamama Javaid, MD; Navin Ramlal, MD; Benjamin Morehead, MD Department of Medicine, St. Francis Medical Centre, Monroe, LA 104 SEVERE LACTIC ACIDOSIS CAUSED BY PROPYLENE GLYCOL POISONING IN THE SETTING OF EXCESSIVE FIREBALL WHISKEY INGESTION

Background: Although bile duct stones can occur post-cholecystectomy, they are most prevalent within the first three years following the procedure. Greater than three years following cholecystectomy however, migration of surgical clips is considered the most common mechanism for choledocholithiasis, with development of stones being much rarer. The exact mechanism for delayed stone formation and common bile duct (CBD) obstruction remains unknown. Possible explanations do include primary hepatic lithiasis and retrograde accumulation of debris in the CBD, especially after sphincterotomy, which could potentially act as a nidus for stone formation. Here, we present a case of an elderly male who developed a large, distal CBD stone eight years after cholecystectomy, in the context of a previous choledochoduodenostomy. An 84 year old male with a history of a gallbladder polyp post cholecystectomy eight years prior and duodenal diverticulum (choledochoduodenostomy) four years prior, presented with generalized abdominal pain localized primarily to the epigastrium. His pain was accompanied by severe nausea, vomiting, pruritus, jaundice and weight loss. Physical examination revealed scleral icterus,

jaundice and generalized abdominal tenderness. Initial laboratory results indicated elevated liver enzymes consistent with a cholestatic pattern. Further evaluation with abdominal CT imaging showed dilation of the intrahepatic bile ducts with an obstruction at the distal CBD. An ERCP confirmed choledocholithiasis. While balloon and basket techniques were able to remove most of this material, two large stones remained. It was determined that due to patient’s altered anatomy, a sphincterotomy was not feasible and a double-pigtail stent was instead placed for long-term drainage to encourage stone breakdown. Following these procedures, patient showed significant improvement with the resolution of his hyperbilirubinemia on laboratory test. Repeat ERCP was attempted but again failed to remove the larger stones, necessitating referral to a specialized facility where ERCP with cholangioscopy and hydraulic lithotripsy was performed with successful extraction of a 2 cm stone. This case describes the rare occurrence of choledocholithiasis eight years following cholecystectomy in a patient with altered biliary anatomy due to choledochoduodenostomy, highlighting the complexities involved in treating such cases.

Case Description: An 18-year-old female patient with medical history significant for Bulimia Nervosa was brought to the ED by her parents after being found unresponsive and face down in her bedroom next to an empty bottle of Fireball Cinnamon Whiskey. History was provided by her parents who reported that patient had come home after hanging out with her friends and had immediately gone to her room to get ready for the dinner. After approximately an hour, they went to check on her and she was found unresponsive. Although her initial vital signs were stable, she underwent emergent intubation due to inability to protect her airway. She was unable to participate in a meaningful physical examination and was unresponsiveness to both verbal and tactile stimuli thereafter. Her initial labs were significant for elevated lactic acid levels, high anion gap metabolic acidosis and a serum alcohol level in the 300s (N<10). Initial imaging including CT head and chest x-ray were unremarkable. Patient was admitted to ICU on mechanical ventilation and supportive treatment including IV fluids. She responded well to these measures, with normalization of her lactic acid levels and improvement in her mental status. Following

successful extubation, patient admitted to consumption of significantly large amounts of Fireball Cinnamon Whiskey prior to this event. She was then discharged back home with resources for rehab and counseling. Discussion: Fireball Cinnamon Whiskey is a Canadian made whiskey drink that contains propylene glycol as a sweetener. Although, many cases of severe lactic acidosis due to unintentional overdose of medications containing this compound have been reported, there has been no official data or studies exploring the potential effects of excessive propylene glycol consumption in the setting of alcohol intoxication. More research is needed in this area to elucidate the effects of propylene glycol content in alcohol, such as Fireball Cinnamon Whiskey and any associated adverse effects including acute kidney injury, hypotension, cardiac arrythmias and most importantly CNS depression leading to life threatening airway compromise.

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119 2025 Research Recognition Day