Ascending cholangitis is a bacterial infection of the extra-hepatic biliary system and presents as a life-threatening systemic condition. Increased bacterial loads and biliary obstruction favor bacterial translocation into the vascular and lymphatic systems. Common organisms isolated are Escherichia Coli , Klebsiella , Enterococcus species, and Enterobacter species . Methicillin-resistant Staphylococcus aureus (MRSA) is a rare isolate in ascending cholangitis. We present a case of a 24-year-old patient with cystic fibrosis who presented with epigastric abdominal pain, low-grade fever, jaundice, dark urine, and nausea for two days. Initial workup revealed elevated liver enzymes, hyperbilirubinemia, leukocytosis, and an ultrasound which showed common bile duct dilation to 14 mm with choledocholithiasis. He underwent endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction and bile fluid culture. Cultures grew out MRSA and the patient was treated with appropriate antibiotic therapy. The mainstay of therapy for ascending cholangitis is adequate hydration, antibiotics, and biliary decompression. Early recognition of the offending organism is critical in guiding therapy. Current guidelines focus on the empiric treatment of Gram-negative and anaerobic bacteria. Clinicians should be aware of the possibility of less common pathogens (such as MRSA), especially in a patient who is decompensating despite antibiotic therapy.

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necrosis with necrotic adipocyte ghosts and basophilic material, consistent with pancreatic panniculitis. C) Endoscopic ultrasound identification of pancreatic head mass measuring 50mm x 60mm. D) Pancreatic mass aspirate. Cell block, H&E Stain. The pancreatic mass aspirate demonstrates a highly cellular pleomorphic sarcoma with frequent bizarre mitotic figures and anaplastic cytology, consistent with an undifferentiated pleomorphic sarcoma.

INTRODUCTION: A presacral abscess is one of the most difficult abscesses to be drained. It is very challenging to drain it through the transabdominal route due to overlying pelvic structures. We present a patient with sizeable presacral abscess secondary to acute appendicitis that was drained transrectal under an endoscopic-ultrasound (EUS) guidance with stent placement. CASE DESCRIPTION/METHODS: A 23-year old male presented with worsening pelvic pain, fever, and chills for four weeks. He denies any change in the bowel movement, dysuria, recent trauma, or bladder or bowel incontinence. Past medical history was unremarkable and had no surgeries. Vital signs were normal except for the temperature of 101.2 F. Abdomen was soft, non-tender, with audible bowel sound. The rectal and genital exam was normal. Labs revealed Hgb 11.2 g/dl, WBC 17.9k/mm3, platelets 545k/mm3, creatinine 0.7 mg/dl, CRP 18.8 mg/dl, negative HIV, and negative urine and blood cultures. CT scan of the abdomen and pelvis revealed large presacral abscess and possibly ruptured acute appendicitis. Magnetic resonance enterography (MRE) showed 9.6 × 2.6 × 6.1 cm presacral abscess with acute ruptured appendicitis (Figure 1). Interventional Radiologist was consulted for drainage, but abscess was not amenable to be drained percutaneously. Despite being on intravenous antibiotics, the patient continued to be spiking febrile and having persistent pelvic pain. So, rectal endoscopic ultrasound (EUS) was performed and showed 5 cm × 3.5 cm abscess in the pre-rectal space (Figure 2). Aspiration was done with the 19-gauge needle using a transrectal approach. A 7Fr x 5 cm double pigtail plastic stent and a 10Fr x 5 cm double pigtail plastic stent were placed into the abscess (Figure 3). Good drainage from the stent was visualized into the rectum. Patient’s symptoms improved. Fluid cultures remained negative, Leukocytosis resolved, and he was discharged in a stable condition. He will follow up with a repeated CT pelvis in 2 weeks to assess for resolution of abscess and interval appendectomy. DISCUSSION: The presacral abscess is a complication with difficult management in the course of acute appendicitis. It is challenging to drain with the transabdominal route because of the overlying pelvic structures. EUS-guided transrectal drainage is safer and effective in these cases. The clinician should be aware of this treatment modality and considered as the first-line option.