Biliary-cutaneous fistulae can occur after hepatic surgery or trauma.When the fistulous portion of the biliary system does not communicate with the rest of the biliary tree, chemical sclerosis can be attempted. Case ReportA 57-year-old woman had a sigmoid colectomy with primary anastomosis for a moderately well-differentiated adenocarcinoma. Metastatic lesions were observed in the right lobe of the liver during surgery. Abdominal CT after surgery showed the right lobe lesions and an absence of lesions in the left lobe. With no extrahepatic metastatic disease after 5 months of chemotherapy, a right hepatic lobectomy was performed. The postoperative course was complicated by fever. A sonogram made 1 1 days after surgery showed a fluid collection in the right upper quadrant; culture of the aspirated fluid showed it was sterile. Four weeks after surgery, The patient had persistent drainage of approximately 30 ml of bilious fluid per day through the percutaneous catheter. Several sinograms were obtained during the subsequent 4 months, each of which showed closure of the abscess cavity but continued communication of the catheter tract with the isolated bile duct. Endoscopic retrograde cholangiography confirmed the absence of a connection between the major part of the biliary system and the isolated fistulous biliary radicle (Fig. 1A). Because of the persistence of biliary drainage (30 mI/day) despite prolonged conservative management, sclerosis of the isolated biliary segment was begun in an attempt to stop the drainage.For the sclerosis, a solution of 1 g of tetracycline in 10 ml of normal saline was prepared. A 7-French balloon occlusion catheter was placed in the fistula with its tip near the isolated segment of the biliary tree (Fig. 1B). After 20 mm, this was aspirated and a second aliquot was injected; this was repeated after another 20 mm. At 1 hr, the balloon was deflated, and the balloon catheter was exchanged for a drainage catheter. The procedure was uncomplicated, although the patient experienced moderate to severe pain with the injection of each aliquot of tetracycline. She complained of mild pain and nausea for a few hours after the procedure. The patient was observed in the hospital for 24 hr. She had no adverse clinical sequelae. Drainage from the fistula ceased for 3 days but then resumed at a reduced rate of 10 mI/day.Recurrent malignant disease was discovered on CT, its workup temporarily delaying additional scierotherapy. Three weeks after the first tetracycline treatment, a second sclerosis was performed by using the same procedure. A sinogram obtained before this second treatment revealed continued patency of the isolated bile duct.Fistula output again stopped for 3 days before resuming at 5 ml/ day. The output then gradually diminished over 5 weeks to less than 1 mI/day. The patient had chemotherapy, which temporarily delayed Downloaded from www.ajronline.org by 34.210.69.67 on 05/12/18 from IP address 34.210.69.67.

Background: Patients with vasculitis, a set of rare diseases, encounter delays in obtaining an accurate diagnosis which can lead to substantial morbidity and increased mortality. This study sought to describe the diagnostic journey of patients with vasculitis and identify factors associated with time to diagnosis. Methods: Patients with vasculitis enrolled in an online registry completed a two-stage study: Stage 1: Survey of open-ended questions about patients' diagnostic journeys and perceived factors associated with rapid or delayed diagnosis; Stage 2: Survey with speci c questions based on data from Stage 1 and additional investigator-identi ed factors. Results: patients with vasculitis participated in Stage 1; 456 patients participated in Stage 2. 85% of patients were seen by a healthcare provider within 3 months of the onset of symptoms. The median time to diagnosis of vasculitis was 7 months. 313/456 (73%) of patients were misdiagnosed initially. 40% of diagnoses were made in a hospital setting; 2% of diagnoses were made at a specialized vasculitis center. 60% of patients had at least 1 visit to an emergency room prior to diagnosis. Unemployment, time to travel to a medical center > 1 hour, initial misdiagnosis, and delays in seeing a specialist were all associated with longer times to diagnosis. 373/456 (82%) of patients reported that a delayed diagnosis had negative consequences on their health. Conclusion: Patients with vasculitis encounter substantial delays in achieving an accurate diagnosis and these delays are associated with negative health consequences. Both patient-related factors and healthcare-related factors are associated with diagnostic delays. January 10, 2018). Consent for publication: Not applicable Availability of data and material: All data generated during and/or analyzed during the current study are not publicly available because the data includes participants' personal health information (e.g. diagnosis, age) but are available from the corresponding author on reasonable request.

Background: Patients with vasculitis, a set of rare diseases, encounter delays in obtaining an accurate diagnosis which can lead to substantial morbidity and increased mortality. This study sought to describe the diagnostic journey of patients with vasculitis and identify factors associated with time to diagnosis. Methods: Patients with vasculitis enrolled in an online registry completed a two-stage study: Stage 1: Survey of open-ended questions about patients’ diagnostic journeys and perceived factors associated with rapid or delayed diagnosis; Stage 2: Survey with specific questions based on data from Stage 1 and additional investigator-identified factors. Results: 375 patients with vasculitis participated in Stage 1; 456 patients participated in Stage 2. 85% of patients were seen by a healthcare provider within 3 months of the onset of symptoms. The median time to diagnosis of vasculitis was 7 months. 313/456 (73%) of patients were misdiagnosed initially. 40% of diagnoses were made in a hospital setting; 2% of diagnoses were made at a specialized vasculitis center. 60% of patients had at least 1 visit to an emergency room prior to diagnosis. Unemployment, time to travel to a medical center > 1 hour, initial misdiagnosis, and delays in seeing a specialist were all associated with longer times to diagnosis. 373/456 (82%) of patients reported that a delayed diagnosis had negative consequences on their health.Conclusion: Patients with vasculitis encounter substantial delays in achieving an accurate diagnosis and these delays are associated with negative health consequences. Both patient-related factors and healthcare-related factors are associated with diagnostic delays.