Poster Finalists

Analytical and Cohort Studies

Significance: Pancreatic cancer is a lethal disease with poor outcomes and increased mortality rate. To date, no study has been conducted in the Philippines to evaluate the survival predictors among Filipino patients with pancreatic cancer.

Methodology: This study is a single center hospital-based retrospective cohort which aimed to determine the incidence, clinical profile and predictors of survival among patients with pancreatic cancer seen at The Medical City Hospital from 2018 to 2022. The study design is a hospital-based observational case-control in which cases were retrospectively determined. Raw data was entered into SPSS (IBM) version 23. The Kaplan–Meier with log-rank test was used to compare the distribution of the baseline variables. The Cox regression univariate analysis with p < .10 was used to evaluate the effect of variables on patients' survival. The Cox proportional hazard model was used for multivariate analysis. 82 83 848586 Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. Significance was defined as the P-value of less than 0.05.

Results: 200 cases were reviewed. The mean age was 65.1 years (SD = 88 12.1), with 90% aged 50 years and older, with a male- female ratio of 1:2. Most patients presented with advanced and metastatic disease at stage 4 (79%) upon diagnosis. The median survival time was 10 months, while the 1-, 2-, and 3-year survival rate were estimated to be 44%, 26%, and 20% respectively. Based on univariate analysis, patients with normal total bilirubin and without concomitant pulmonary comorbidities, demonstrated a superior survival outcome compared to those with abnormal bilirubin level and those with concomitant pulmonary comorbidities. Meanwhile, Cox multivariate analysis results showed that concomitant pulmonary comorbidity was significantly correlated with the reduced survival rate (HR = 1.87, 95% CI: 1.11 to 18 3.15, p-value = 0.018). An elevated total bilirubin did not significantly correlate with a reduced survival rate (HR = 1.46, 95% CI: 0.96 to 2.20, p-value = 0.075).

Conclusion: Having a concomitant pulmonary comorbidity could increase the vulnerability to pulmonary infection or respiratory failure, which are the leading causes of death in patients with pancreatic cancer. Levels of serum total bilirubin could be a possible predictor of survival among pancreatic cancer patients but further studies are needed to generalize this finding.

Significance: Hepatocellular carcinoma (HCC) is the most common primary liver cancer. This study compares complication rates between radiofrequency ablation (RFA) and microwave ablation (MWA) in HCC patients and identifies factors predictive of complications.

Methodology: Consecutive patients from 2007-2023 who underwent RFA or MWA were included. Major complications include death, seeding, and any complication that warranted prolonged hospital stay or instrumentation to be done. The rest were considered minor complications.

Results: Among RFA patients, 17/319 (5.3%) experienced major complications, compared to 4/92 (4.3%) in the MWA group (p=0.706). Minor complications occurred in 24/319 RFA patients (7.5%) and 8/92 MWA patients (8.7%) (p=0.712). A bigger tumor size was significantly associated with an increased likelihood of both major (p=0.049) and minor complications (p=0.020). Patients receiving antibiotic prophylaxis had a higher rate of minor complications (60% vs 32.5%; p=0.003). The most common minor complication overall was fever (2.7%), followed by pleural effusion (2.2%). For major complications, abscess formation was the most frequent (2.2%), followed by tumor seeding and organ damage (1%). On multivariate analysis, only total ablation time emerged as a predictor of major complications (OR=0.968;95%CI=0.948-0.989;p=0.003). No independent predictors of minor complications were identified.

Conclusion: Both RFA and MWA had low major and minor complication rates. The fact that total ablation time was an independent predictor of major complications emphasizes the need for careful consideration of procedural duration to minimize risks.

Significance: Acute variceal bleeding (AVB) is a life-threatening complication of liver cirrhosis with a 6-week mortality rate of 20%. The 2024 AASLD guidelines recommend evidence-based interventions, including use of vasoactive agents, prophylactic antibiotics, nonselective beta-blockers (NSBBs), timely endoscopy and variceal band ligation, to improve patient outcomes. Evidence on the impact of full guideline adherence in our setting is limited, hence, our study evaluates whether full adherence to these guidelines enhances survival in cirrhotic patients with acute variceal bleeding.

Methodology: A retrospective cohort study was conducted at St. Luke’s Medical Center-Global City (2018–2023) involving 105 cirrhotic patients with AVB. Adherence was evaluated based on five CPG quality metrics: prophylactic antibiotics, use of somatostatin analogues, timely endoscopy (within 12 hours), endoscopic hemostasis, and NSBB administration. The primary outcome was 6-week mortality, with secondary outcomes included early infection, rebleeding rates, acute-on-chronic liver failure (ACLF), and 1-year mortality.

Results: A total of 105 patients were included in the study, with baseline characteristics similar between the full adherence versus suboptimal adherence groups. Full adherence was associated with a significant reduction in 6-week mortality (10.6% vs. 25.9%; OR = 0.34, 95% CI: 0.11–1.0, p = 0.0493), lower early infection rates (23.4% vs. 32.8%), and ACLF events (6.4% vs. 8.6%). While 1-year mortality was lower (23.4% vs. 36.2%), it was not statistically significant (p = 0.1584). Advanced liver disease (Child-Pugh C or MELD-Na ≥15) remained a predictor of poor outcomes despite full adherence to CPG quality metrics.

Conclusion: Full adherence to CPG quality metrics significantly reduces 6-week mortality and complications in AVB, this serve as a benchmark for improving quality care in cirrhotic patients.

Significance: The only validated indication for fecal immunochemical test (FIT) is colorectal cancer (CRC) screening. No local studies have explored FIT practice trends. We examined FIT utilization, focusing on its indications and impact on clinical management and outcomes.

Methodology: This retrospective cohort study involved chart reviews of adult patients who underwent FIT from January 1 to December 31, 2023. Logistic regression analysis was used to determine the association of FIT positivity with gastroenterology referrals, endoscopic procedures, and findings.

Results: A total of 701 patients were analyzed, with 516 (73.6%) from outpatient clinics and 317 (60.47%) for CRC screening. Inappropriate FIT requests were common, with 204/516 (39%) outpatient and 180/185 (97%) inpatient tests ordered outside evidence-based indications; outpatient tests had a significantly lower rate of inappropriate requests (Z-score-4.39,p<0.05). Among inpatients, 162/185 (87.57%) were for anemia, while only 5 (2.7%) were for CRC screening. Of the positive FITs for anemia, only 10/237 patients (4.22%) had a potential gastrointestinal cause identified. Notably, 63% (85/136) of FIT-positive inpatients were not referred to gastroenterology. None underwent annual serial FIT after a negative result. While FIT positivity correlated with increased gastroenterology referrals (OR 13.84, 95%CI 8.92,21.48, p<0.001) and subsequent endoscopy (OR 6.60, 95%CI 4.09,10.66, p<0.001) in outpatients, it did not significantly relate to inpatient endoscopy. Importantly, majority of inpatients who underwent FIT were critically ill.

Conclusion: FIT was often ordered in clinically inappropriate settings and did not consistently translate to effective clinical management or follow-up endoscopy particularly among inpatients, confirming limited clinical utility in this setting.

Significance: Acute Pancreatitis is a common inflammatory disease of the pancreas. Neutrophil-to-lymphocyte ratio (NLR) and Platelet-to-lymphocyte ratio (PLR) are emerging parameters of inflammatory reaction and has correlation with disease severity and mortality among diseases. This study aimed to determine the NLR and PLR of patients admitted in a tertiary hospital in Cebu for Acute Pancreatitis and its relation to the course, severity, and outcome of the disease.

Methodology: This was a retrospective, analytical, cohort study performed in Cebu Doctors’ University Hospital, a tertiary private hospital in Cebu City, Philippines. A chart review of patients admitted between January 2019 to December 2023 which included 188 patients. The NLR and the PLR were calculated as the ratio of neutrophil count to lymphocyte count and as the ratio of platelet count to lymphocyte count, respectively. Admitting laboratory results, demographics, etiology of pancreatitis, comorbidities, duration of hospital stay, and outcome measure (including development of shock, ICU admission, and all-cause mortality) were noted from chart review.

Results: Neither NLR nor PLR showed a statistically significant association with shock, ICU admission, or in-hospital mortality in patients with acute pancreatitis, as none of the p-values reached the significance threshold of 0.05. This suggests that while there are slight trends, neither NLR nor PLR is a reliable predictor for these severe outcomes in this sample.

Descriptive and Cross-Sectional Studies

Significance: This study aims to determine the prevalence of drug induced liver injury in anti-tuberculosis treatment among patients treated at a tertiary hospital and identify treatment response based on the liver biochemical test.

Methodology: This is a single-center, retrospective cohort study which included 44 Filipino patients admitted and treated with Anti-Koch Treatment. Descriptive statistics was used to summarize the demographic, biochemical, and clinical characteristics. One-way ANOVA and Kruskal Wallis test was used to analyze significant differences in the measurement of the patient’s biochemical test.

Results: The incidence of drug induced liver injury from treatment of Anti-Koch treatment was documented to be 4.5% in the span of 5 years. There is a slight predominance of male and with hypertension as the more prevalent comorbidity in the study population. Treatment with Glycyrrhizic Acid + Glycine + L-Cysteine Hydrochloride in a statistically significant reduction in bilirubin(p-value 0.02) compared to other treatments and showed a trend to improving AST/ALT, however changes were not statistically significant. Mortalities among patients consisted predominantly due tmico acute respiratory failure as complication of community or hospital acquired pneumonia, there were no documented mortality due to DILI.

Conclusion: Drug induced liver injury from anti-koch treatment is a well-documented adverse event. The liver enzymes showed decline through withholding of offending drug and prescribing hepatoprotectant. These findings provide valuable insights into the epidemiology and outcomes of DILI, emphasizing the need for enhanced preventive strategies and management particularly in patients with significant comorbidities and those at risk of severe respiratory complications

Significance: Acute cholangitis is associated with a high mortality rate, ranging from 9.6% to 37%. Effective management relies on timely biliary drainage and appropriate antimicrobial therapy. The choice for empiric antibiotic treatment is heavily dependent on local antimicrobial susceptibility profiles. At present, there are not published data on the local antibiogram that is a critical component of effective therapy. This study aims to identify the microbial profiles and susceptibility patterns in patients with acute cholangitis while also analyzing the impact of culture-guided treatment on patient outcomes.

Methodology: We conducted a retrospective cross-sectional study, reviewing medical records of adults (aged 19 and above) diagnosed with acute cholangitis at a tertiary university hospital in the Philippines from Jan 2022- Dec 2024. A total enumeration was performed including all patients with confirmed cholangitis based on Tokyo guidelines who underwent endoscopic retrograde pancreatography for biliary drainage.

Results: A total of 268 patients were included in the study. The most common organisms in bile cultures were Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Resistance patterns revealed that 26% of isolates were multidrug resistant (MDR), particularly among Klebsiella pneumoniae. Notably, patients infected with MDR agents and those without bile cultures taken during biliary drainage experienced longer hospital stays. Although culture-guided treatment correlated with lower mortality rates, this difference was not statistically significant.

Conclusion: This study emphasizes the role of culture-guided therapy and the urgent need to establish a local antibiogram to inform empiric treatment strategies for acute cholangitis.

Significance: Chronic kidney disease (CKD) is an independent risk factor that affects mortality among cirrhotic patients with ascitic fluid infections. The aim of this study is to determine the outcomes between spontaneous bacterial peritonitis (SBP) and culture-negative neutrocytic ascites (CNNA) among patients with CKD on hemodialysis.

Methodology: Between January 2011 to January 2024, 308 patients with liver cirrhosis and CKD who had SBP and CNNA were evaluated. All patients underwent abdominal paracentesis and the ascitic fluid was processed for cell count and culture. Clinical and laboratory parameters of these patients were recorded at index admission to determine if there is difference on the 7-day, 14-day, and 30-day outcomes (discharged, prolonged admission, and mortality).

Results: Out of 308 patients included in the study, 201 patients (65.3%) were SBP and 107 patients (34.7%) were CNNA. Baseline characteristics, incidence of hepatic encephalopathy, and variceal bleeding did not differ between the two groups. Gram-negative bacteria accounted for 97.02% of the identified pathogens. Using logistic regression analysis, decreased platelet count, increased blood polymorphonuclear, and increased ascitic polymorphonuclear cells are independent predictor factors for culture positive SBP. In this study, patients with CKD on hemodialysis and liver cirrhosis who had SBP and CNNA had 62.69% and 88.78%, overall mortality respectively.

Conclusion: Patients with liver cirrhosis and chronic kidney disease on hemodialysis who had SBP and CNNA have similar seven-day, 14-day, and 30-day mortality rates. The dual burden of kidney and liver impairment leads to overall worsened outcomes.

Significance: The role of colonoscopy in the preoperative evaluation of suspected ovarian cancer is not well-defined. While it is routinely performed in some institutions, there are currently no established guidelines on preoperative colonoscopy in patients with gynecologic malignancies. While colonoscopy can identify synchronous cancers and other non-neoplastic lesions, there are no published local data in terms of its diagnostic yield. This study aims to evaluate the role of preoperative colonoscopy in patients suspected of having ovarian cancer.

Methodology: This retrospective cross-sectional study reviewed medical records of adults (aged 19 and above) with suspected ovarian cancer who underwent colonoscopy at a tertiary university hospital from January 2021 to December 2023. Data collected included demographics, gastrointestinal symptoms, tumor markers, and colonoscopy findings. Descriptive statistics and appropriate tables and graphs were used to summarize the data.

Results: A total of 186 patients were analyzed. The most common findings were extrinsic compression, colonic polyps, diverticulosis, and hemorrhoids. Only 4% of colonoscopies revealed masses, 2% of which are primary colonic neoplasm on biopsy. Colonoscopies performed for suspected ovarian malignancy had a lower cecal intubation rate with lower Boston Bowel Preparation Scores than published standards.

Conclusion: While the primary indication for colonoscopy is to rule out colorectal extension of ovarian tumors, only 1% of procedures were consistent with a tumor extension. These findings suggest a need to reevaluate current practices regarding the routine use of colonoscopy in this patient population.

Significance: The rising incidence of colorectal adenomas, precursors to colorectal cancer, in individuals under 45 years old necessitates targeted screening strategies. This study aimed to identify risk factors associated with colorectal adenomas in this age group to enhance early detection and intervention.

Methodology: A retrospective case-control study conducted at Chinese General Hospital from January 2019 to July 2024. Patients aged <45 years with complete medical records. Cases were patients with histopathologically confirmed adenomas, and controls were patients without adenomas matched 1:1.

Results: The study included 106 patients. Family history of colorectal cancer was significantly associated with colorectal adenomas (Adjusted OR: 3.14, 95% CI: 1.29–9.81, p = 0.014). Other factors, including BMI, smoking, alcohol intake, hypertension, and diabetes, showed no significant associations after adjustment. A trend of higher prevalence in overweight individuals was noted but was not statistically significant.

Conclusion: Family history of colorectal cancer is a critical risk factor for colorectal adenomas in individuals under 45 years. Screening programs should prioritize this population to improve early detection and reduce cancer progression. Future research should explore the role of genetic predisposition and other modifiable risk factors in younger populations.

Meta-Analysis

Significance: Non-alcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD) are major liver pathologies, both characterized by abnormal fat accumulation in the liver, which can progress to cirrhosis or hepatocellular carcinoma. Emerging evidence suggests that a parental history of liver disease may increase the risk of fatty liver disease in offspring, implicating both genetic and environmental factors. This meta-analysis aims to assess the impact of parental NAFLD and ALD on the risk of developing fatty liver disease in their children.

Methodology: A comprehensive search of literature was conducted through multiple electronic databases and grey literature sources until December 2023. Three cohort studies were included in the analysis, and RevMan 5.4 was used for statistical computation.

Results: The cohort studies by Long, Park, and Jepsen demonstrated that offspring of patients with NAFLD or ALD had nearly a two-fold increased risk of developing fatty liver disease. The I² value of 57% indicated moderate heterogeneity, prompting a subgroup analysis of the two studies on NAFLD alone, which yielded an I² of 0% (p=0.001). The pooled odds ratio was 2.25 (95% CI 1.63 to 3.10), which was statistically significant, indicating that a family history of NAFLD significantly increases the risk of fatty liver disease in offspring.

Conclusion: This study highlights a significant association between parental NAFLD (especially) and ALD with increased risk of fatty liver disease in offspring. These findings emphasize the need for early screening and preventive measures for families with a history of liver disease.

Forest Plot 1. Offspring with a parental history of NAFLD or ALD are at increased risk for developing fatty liver disease

Forest Plot 2. Offspring with a parental history of NAFLD are at increased risk for developing fatty liver disease

Significance: Endoscopic retrograde cholangiopancreatography (ERCP) is the standard treatment for obstructive jaundice, with a 90% success rate. However, common bile duct cannulation fails in up to 10% of cases. The standard salvage technique for difficult cannulation is precut sphincterotomy, while the endoscopic ultrasound-guided rendezvous (EUS-RV) technique is a newer alternative. EUS-RV involves puncturing the bile duct using EUS guidance and maneuvering the guidewire across the papilla before cannulation, whereas precut sphincterotomy entails a deliberate incision to facilitate cannulation. Despite their clinical use, the comparative effectiveness of these methods remains unclear. This meta-analysis evaluates and compares the outcomes of EUS-RV and precut sphincterotomy as salvage techniques for biliary access.

Methodology: A search of major electronic databases and grey literature up to August 2024 identified randomized controlled trials and cohort studies. Three studies (Dhir 2012, Choudhury 2021, Ko and Su 2024) were included in the analysis, with RevMan 5.4 used for statistical computation.

Results: The success rates for EUS-RV and precut sphincterotomy were compared. The pooled odds ratio was 1.71 (95% CI 0.71–4.11), which was not statistically significant, indicating no difference between the two methods. The I² value of 0% (p=0.37) suggests no heterogeneity. Two studies (Choudhury 2021 and Ko and Su 2024) found that the techniques were complementary, with successful crossover cannulation.

Conclusion: Both EUS-RV and precut sphincterotomy are effective salvage techniques for biliary access, with no significant difference in success rates. The choice between them can depend on patient needs and the endoscopist’s expertise.

Forest Plot 1. The success rates as salvage technique for biliary access of EUS-RV versus Precut Sphincterotomy showed no significant difference

Significance: Good bowel preparation is one of the key indicators of a high quality colonoscopy. While polyethylene glycol (PEG) is the established standard for bowel cleansing, its requirement for large volumes and associated poor tolerability can hinder patient compliance. Lactulose, a non-absorbable disaccharide laxative, has emerged as a promising alternative due to its palatability and favorable safety profile. This study aims to compare lactulose with PEG as a bowel preparation agent for colonoscopy.

Methodology: A literature search for randomized controlled trials comparing lactulose versus PEG among adult patients who underwent bowel preparation for colonoscopy. The primary outcome of interest was the quality of bowel preparation using validated scales. Secondary outcomes were polyp detection rate, tolerability, and adverse effects. Three independent reviewers were involved in study selection, data collection, and risk of bias assessment.

Results: A total of 3 studies were included in the quantitative analysis. Pooled analysis revealed that the lactulose group had higher bowel preparation scores compared to PEG with a standardized mean difference of 0.56 (p=0.01). Polyp detection rates were higher in the lactulose group, although not statistically significant (odds ratio 1.73, p=0.06). Adverse effects were reported across all studies, with nausea and vomiting being the most common.

Conclusion: Lactulose appears to be a safe and effective alternative to PEG for bowel preparation prior to colonoscopy as it offers improved cleansing efficacy and comparable polyp detection rates. These findings suggest that lactulose could be considered a viable option in settings where PEG is less accessible or tolerated.

Significance: Managing obesity that does not respond to lifestyle change or pharmacotherapy poses significant challenges, especially in determining the best intervention. The situation emphasizes the challenge of maintaining weight loss over time and the importance of using comprehensive strategies to effectively address obesity. In the recent years, bariatric surgery, such as gastric bypass and sleeve gastroplasty, offers significant weight loss and metabolic advantages, especially for those with severe obesity or obesity-related health conditions.

Methodology: A meta-analysis was performed using 4 studies which directly compared the effectiveness of endoscopic gastric balloon (EGB) placement versus endoscopic sleeve Gastroplasty (ESG) for management of obesity. Electronic databases such as The Cochrane Library, Pubmed, Google Scholar, and Science Direct were searched for relevant studies on May 01 2024 using the search strategy: (gastric balloon placement) AND (sleeve Gastroplasty) AND (obesity). Random effects meta-analysis was performed to compute for mean difference and risk ratio to pool individual study data.

Results: The pooled mean difference showed that ESG is associated with higher %TBWL than EGB at 1 month (MD=-2.3, 95%CI=-4.1 to -0.6, p=0.009) and at 12 months (MD=-7.6, 95%CI=-10.8 to -4.5, p<0.00001). No significant difference was observed in the 6 months period (MD=-2.3, 95%CI=-5.3 to 0.7) and in terms of adverse events (RR=1.6, 95%CI= 0.2 to 12.8). Conclusion: We observed a higher benefit of ESG for weight loss compared to EGB among obese individuals. Both interventions are equally safe and not associated with serious adverse events.

Significance: Contrast-induced acute kidney injury represents a significant concern with liver cirrhosis, who may possess unique risk factors for developing contrast-induced nephropathy (CIN). Studies reporting the nephrotoxic potential of contrast agents in this population are limited. We aim to determine if the use of contrast agents for imaging procedures among patients with cirrhosis is associated with the development of CIN.

Methodology: A comprehensive search for databases of randomized controlled trials (RCTs) and observational studies comparing contrast-enhanced imaging versus non-contrast studies for CIN among adult patients with cirrhosis was done. PubMed, EMBASE, Cochrane library, and ClinicalTrials.gov were searched using relevant terms including cirrhosis, CIN or contrast associated acute kidney injury (AKI) until October 2023. Data extraction was performed using a standardized data form, and any discrepancies were resolved by consensus among the authors. Data were pooled and analyzed using Review Manager Software version 5.4 as a systematic review and meta-analysis.

Results: A total of nine studies were included in the systematic review, with reported incidence of CIN ranging from 2.5-5%. Two prospective (n=385) and two retrospective (n=604) observational studies were included in the meta-analysis. The contrast group was associated with an increased risk for CIN, OR 2.52, 95% CI, 1.52-4.16. Risk factors predisposing patients with cirrhosis to CIN include ascites and presence of infection (OR 2.796, 95% C: 1.109–7.052; OR 22.18, 95% CI 2.87-171.22, p=0.003 respectively).

Conclusion: Available evidence suggests that cirrhotic patients exposed to contrast agents face a heightened risk of AKI, necessitating careful monitoring during contrast-enhanced imaging procedures.

Case-Reports

Significance: Malignant peritoneal mesothelioma (MPM) is a rare and aggressive neoplasm that is frequently associated with asbestos exposure. Diagnostic pitfalls are encountered in this disease entity particularly in differentiating it from tuberculous peritonitis (TBP), which is more common in developing countries. We report a first case of MPM and rifampicin-resistant TBP coexisting in a patient without any history of environmental exposure or tuberculosis, with an unusual presentation of high serum-ascites albumin gradient (SAAG).

Clinical Presentation: A 58-year-old hypertensive male presented with a progressively enlarging abdomen and significant weight loss over three months. He had no history of hospitalizations, prior tuberculosis, or notable environmental exposure. Physical examination revealed abdominal distension with shifting dullness. Laboratory tests showed normal liver and renal function, negative viral hepatitis serology, and negative sputum AFB testing. Imaging studies revealed massive ascites and peritoneal nodular thickening.

Management: Paracentesis was performed, yielding a high SAAG and elevated protein levels. Endoscopic evaluations are unremarkable. Diagnostic laparoscopy revealed histopathologically-confirmed MPM concurrent with rifampicin-resistant TBP on Xpert MTB/RIF Assay, necessitating a multidisciplinary approach to treatment.

Recommendation: It is paramount to do a thorough work-up for patients presenting with ascites, as etiologies like malignancy and infection may present with similar findings and may co-exist, as in this case. This report highlights the need for early and appropriate work-up and management.

Significance: Aberrant right subclavian artery (ARSA) is a rare congenital anomaly of the aortic arch, found in 0.2–2.5% of the population. While often asymptomatic, ARSA can cause compressive symptoms such as dysphagia or dyspnea, and rarely, upper gastrointestinal bleeding due to esophageal erosions. Prolonged nasogastric tube (NGT) placement can lead to pressure necrosis and an ARSA-esophageal fistula, a life-threatening complication that may present with gastrointestinal bleeding.

Clinical Presentation: A 94-year-old female with atrial fibrillation on Apixaban, tracheostomy, and NGT presented with bloody tracheal secretions, melena, and bloody NGT output.

Management: Imaging revealed an ARSA adjacent to the trachea and esophagus. Esophagogastroduodenoscopy (EGD) showed a linear ulcer with indurated borders and a non-bleeding, pulsating vessel 18 cm from the incisors. Initial treatment with hemospray was attempted but led to subsequent hematemesis and tracheostomy bleeding, requiring vasopressors for hemodynamic stability. Repeat EGD and CT angiography confirmed contrast extravasation into the esophagus from an ARSA. Definitive management involved inserting a covered vascular stent, which effectively controlled bleeding. Follow-up EGD two weeks later showed ulcer healing and a visible, non-bleeding vessel.

Recommendations: Endoscopic placement of a Sengstaken-Blakemore tube can provide temporary hemostasis in ARSA-esophageal fistula cases. Definitive management includes open repair, thoracic endovascular aortic repair (TEVAR), or hybrid procedures. Endovascular stenting, as demonstrated, offers a minimally invasive and effective solution. This case highlights the utility of a covered vascular stent in managing ARSA-esophageal fistula and emphasizes the importance of early intervention to prevent fatal complications.

Significance: Gastrointestinal amyloidosis is a rare form of amyloidosis with the exact prevalence being unknown. The significance of this report is to present a case of a localized form of Gastrointestinal amyloidosis, the less commonly observed subset.

Clinical Presentation: This is a case of a 56 year old female, who was a known case of sigmoid amyloidosis back in 2018; incidentally diagnosed upon annual checkup, who now presented with beginning gastrointestinal obstruction.

Management: Patient was admitted and a CT scan done showed circumferential wall thickening of the sigmoid colon with non-obstructive bowel gas pattern. Flexible sigmoidoscopy was then done showing a rectal mass at the 10 cm level and a polypoid mass lesion about 13 cm in length. Rectal biopsy showed amyloid deposits and a laparoscopic sigmoidectomy was done succeedingly. Sigmoid biopsy and IHC stains showed amyloid deposits with Lambda-Light chain predominant atypical plasmacytosis. Serum protein electrophoresis (SPE) and Total Protein (TP) and serum immunofixation both showed no monocloncal gammopathy. Serum Free Light Chain panel showed findings suspicious for very low level monotypic serum free Lambda light chians based on the Free Light Ratio (FLC) of 0.40. Cardiac PYP-scan was done and noted to have negative results. Patient was then discharged and followed up after 1 week with repeat SPE+TP and Immunofixation wherein both still showed negative for monoclonal gammopathy.

Conclusion: The etiology of amyloidosis in this case is likely of the AL type as IHCs showed Lambda light chain predominant atypical plasmacytosis. Resection of the involved organ is the mainstay treatment of Localized AL-Amyloidosis, with gastrointestinal amyloidosis having an excellent 5-year disease free progression rate.

Significance: Secondary aortoenteric fistula (SAEF) is a fistulous communication between the duodenum and the aorta. SAEF is a rare yet lethal complication of abdominal aortic reconstruction which arises months to years after aortic surgery. Herald bleeding refers to a bleeding episode associated with abdominal pain that occurs before a severe hemorrhage. This is a case of SAEF in a young male who presented with massive hematochezia.

Clinical Presentation: A 32-year-old male with past medical history of abdominal aortic aneurysm repair presented with herald bleeding of 3 weeks’ duration. Gastroscopy and Colonoscopy showed unremarkable results. Blood pressure was 100/60 mmHg with cardiac rate of 110 bpm. Physical examination revealed generalized pallor and epigastric tenderness without any peritoneal signs. Laboratory analysis showed hemoglobin of 7.9 mg/dL, platelets of 251,000 /μL, and INR of 1.26.

Results: Tagged RBC scan was negative. Antegrade Push Enteroscopy showed a SAEF with eroding graft at segment D3-D4. Mesenteric Angiogram showed the D3 segment adherent to the infrarenal abdominal aorta at the level of the proximal anastomosis. Exploratory laparotomy revealed the secondary aortoduodenal fistula at D3 segment with multiple pockets of necrotic tissue and densely adherent to the native aorta and graft. The patient underwent repair of SAEF and post-operative course was complicated by sepsis and DIC and eventually went into arrest on his fourth week.

Recommendations: This is the first case of SAEF documented at our institution, and possibly within the nation as well. It is an extremely rare condition with an estimated annual incidence of 0.036–1.6%. Every patient presenting with UGIB with a history of aortic graft surgery should be presumed to have an aortoenteric fistula until proven otherwise. A high index of suspicion is key to its diagnosis and management. All patients should undergo endoscopy as soon as possible as prompt surgical intervention is the key to survival among these patients.

Significance: Early ampullary cancers present with good prognosis. Pancreaticoduodenectomy has been standard treatment for ampullary cancers, but postoperative complications rate remains high. Therefore, raises a discussion on the role of local ampullectomy for early ampullary cancers.

Clinical Presentation: A case of a 72-year-old male, known hypertensive and coronary artery disease (s/p PTCAx1) who presented with 1 week history of jaundice and tea-colored urine. On review of systems, patient also had unintentional weight loss of 10kg within 1 month. On evaluation, patient was noted to have generalized jaundice and icteric sclerae. Abdomen was soft, nondistended and nontender without palmar erythema and spider angiomata. CA 19-9 was noted to be 324x elevated (value: >12000). MRI and MRCP of abdomen revealed presence of a 1.6 cm periampullary soft tissue thickening, with moderate to severe upstream dilatation of the intrahepatic and extrahepatic ducts, and in the pancreatic duct. No liver metastasis and lymphadenopathies were noted. Snare ampullectomy performed via hot snare using Endo Cut Q alternate with soft coagulation. Ampullary mass retrieved measuring 2cm x 1cm x 1.5cm and sent for histopathology. Histopathology revealed ampullary adenocarcinoma. Monthly follow-up showed no recurrence of jaundice and decreasing bilirubin levels. Currently, patient is being treated with adjuvant chemotherapy.

Conclusion: In conclusion, it is noteworthy that to date, there has been only one documented case report on ampullectomy in the Philippines, published back in 2003. Ampullectomy is associated with lower surgical morbidity and should therefore remain in the armamentarium when comorbidity precludes major surgery.