Mukund

But as you guys have astutely pointed out, this was a difficult study to interpret because of his question mark cirrhosis, which complicates the study.

And two, because he couldn't tolerate the study and it ended early.

When I received this patient on the floors after two days of investigation around cholecystitis, the question really was, are we going to do a procedure to decompress the gallbladder?

And we knew at some point that he had ascites and that made the procedure more difficult because surgery actually had evaluated him in the emergency department and did not think that he was a surgical candidate, that it was unsafe to operate on him.

Then interventional GI was consulted and they were like,

I don't think that this guy should get a percoli.

I think if you really want to decompress the gallbladder, you should use an axial stent, which is a transgastric or transduodenal endoscopically deployed stent that goes through some of the biliary tree to decompress the gallbladder into the intestinal tract.

When I inherited this patient, that's kind of where the conversation was, is this is probably cirrhosis with portal hypertensive ascites and probably cholecystitis that was driving his sickness.

And what we need to do is decompress the gallbladder.

So I think why this case was so exciting for me to present to you is that when I tapped him and the fluid was frankly hemorrhagic and bilious, I was like, wow, this completely changes the diagnostic trajectory of this patient's case.

Now we start to worry about cancer.

We start to worry about peritoneal hemorrhage.

We start to worry about ruptured gallbladder.

You know, I think while the initial malignancy workup was negative with negative tumor markers, CT scan not showing peritoneal carcinomatosis or HCC and cytology initially returning negative as well after some time.

I don't think we could still rule out cancer in this guy.

And this was one of the diagnostic arcs that we were still engaging with when he ultimately transitioned to hospice.

An MRI of the abdomen would have been more sensitive, especially for small peritoneal adhesions.

That was going to be our next step, as well as a repeat of the cytology, because one run of cytology in the peritoneal fluid is really not that sensitive either.

Initially, I think the other thing that was interesting was that his ascites fluid had a very high LDH.

And so we were also invoking the possibility of a lymphomatous process.