Background and Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a high risk for morbidity, mortality, and hospital readmission. Data regarding those risks in the United States is scarce. We assessed post-ERCP 30-day readmission rates, their etiologies, and impact on the health care system using national data. Methods: Using the National Readmission Database 2016, we identified patients who underwent inpatient ERCP from January 2016 to December 2016 using ICD-10-CM procedure codes. The primary endpoint was all-cause 30-day readmission rate. Etiologies of readmission were identified by tallying primary diagnosis. Multivariable logistic regression with complex survey design was used to identify independent risk factors associated with readmission. Results: A total of 130,145 patients underwent ERCP, 16,278 (12.5%) were readmitted within 30 days, with an associated cost of 268 million dollars. Nearly 40% of readmissions occurred within 7 days, and 47.9% were related to gastrointestinal etiologies. Male gender, increased comorbidities, cirrhosis, Medicare insurance, and pancreatitis or pancreatitis-related indications for ERCP were readmission risk factors. Performance of cholecystectomy on index hospitalization decreased odds of readmission by 50% (adjusted odds ratio: 0.48, 95% confidence interval: 0.45-0.52, P<0.0001). While academic and nonacademic centers had similar readmission rates, high ERCP volume centers had higher rates compared with low-volume centers (adjusted odds ratio:1.10, P=0.008). Conclusion: All-cause 30-day readmission rates after inpatient ERCPs are high, mostly occur shortly postdischarge, and impose a heavy health care system burden. Large, multicenter prospective studies assessing the impact of center procedure volume on complications and readmission rates are needed.

Amyand's hernia is an extremely rare condition in which the appendix is positioned in the inguinal hernia sac. Acute appendicitis is much less common in this situation, especially in the elderly population, and few reports are found in the literature. Whether the presence of the appendix within the inguinal sac increases the chance of developing appendicitis or the relationship is coincidental is unclear. Majority of cases reported are in the male pediatric population. The varying surgical approaches are entirely case-specific without much standardization. Perioperative planning remains difficult in all cases as this condition is exceedingly rare, especially outside of the pediatric population. We present such a case with the hope that we increase awareness about this uncommon condition, in which preoperative diagnosis and planning remains difficult.

Acute acalculous cholecystitis (AAC) represents gallbladder inflammation without evidence of gallstones. This typically results from gallbladder stasis and/or ischemia, which then causes a local inflammatory response within the wall. The condition is typically multifactorial and seen in critically ill patients, with associated risk factors that include trauma, burns, infections, total parenteral nutrition, and surgery. We present the case of a patient with acute-on-chronic hepatitis C infection leading to AAC.

Tumor markers and paraneoplastic hormones are key investigative tools utilized for diagnosis, prognosis and at times response to treatment in patients with suspicion or diagnosis of malignancy. In the setting of hepatocellular carcinoma, the use of alpha fetoprotein for preclinical detection, prognosis and response to treatment has been readily utilized for over 40 years. In combination with ultrasonography, alpha fetoprotein is also used for surveillance. Serum AFP levels >400 ng/mL in a high-risk patient are nearly diagnostic of HCC, with a specificity of >95 percent. Other tumor markers which have been found to be associated with hepatocellular carcinoma include des-gamma-carboxy prothrombin and lens culinaris agglutininreactive AFP (AFP-L3), but very few cases report parathyroid hormone related peptide to be associated with this malignancy specifically. We present a rare relationship between hepatocellular carcinoma and parathyroid hormone related peptide in the setting of extreme elevation of alpha fetoprotein at a level above 500,000 ng/mL.

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