Most of the malignant pancreatic lesions are primary pancreatic tumors with only a small percentage due to metastases. Pancreatic malignancies often present with symptoms such as jaundice and weight loss. Less commonly, new-onset diabetes mellitus has been seen in the setting of pancreatic adenocarcinomas. Although colon cancer commonly presents with metastatic disease, it typically spreads to the liver, lung, and peritoneum. We present a rare case of colon cancer metastatic to the pancreas presenting as diabetic ketoacidosis.

Introduction: Errors in communication during handoffs are a significant source of medical error and put patients at risk. The I-PASS system was designed to systematically communicate information to the oncoming healthcare provider and has been shown to decrease the risk of communication errors. The objective of this observational quality improvement study was to determine whether the addition of a partially automated, electronic handoff tool would further decrease errors in communication during transitions of care for inpatient medical teams. Methods: We created an electronic tool to incorporate user-generated patient information in the I-PASS format with automatically compiled data derived from the electronic medical record. Numbers of errors in the printed handoff document were recorded before and after intervention. Results: The first implementation cycle demonstrated an absolute risk reduction for written errors of 45.6% (95% confidence interval [CI] 39.2–51.2%) and a number needed to treat (NNT) of three patients. The second cycle showed an absolute risk reduction of 53.3% (95% CI 39.8–63.9%; NNT 2). Aggregate data showed an absolute risk reduction of 46.6% (95% CI 41.0–51.7%, NNT 3). Conclusions: Improving the routine task of patient handoff through the thoughtful application of technology can yield benefits in terms of decreasing documentation errors and streamlining workflow before patient handoff.

The use of biologic therapies continues to become more prevalent in the treatment of inflammatory bowel disease, particularly for more severe disease. Although generally safe and effective, specific biologic classes such as tumor necrosis factor inhibitor (anti-TNF) medications are known to increase the risk of certain cancers. Glioblastoma multiforme (GBM) is an aggressive brain tumor which tends to arise sporadically but may be associated with anti-TNF therapies. Here, we present a case of a 69-year-old male with Crohn’s disease who developed GBM while on adalimumab therapy. This case report highlights the potential rare association between GBM and anti-TNF therapy and further discusses the difficulty of managing active Crohn’s disease with concomitant GBM, specifically the difficulty encountered in managing a disease flare.

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INTRODUCTION: New onset diabetes mellitus (DM) in the setting of a pancreatic mass has been described, primarily with adenocarcinomas, due to the secretion of diabetogenic substances. DM related to pancreatic metastases is rarely seen. We present a case of colon cancer metastatic to the pancreas presenting as diabetic ketoacidosis (DKA). CASE DESCRIPTION/METHODS: A 69-year-old male with a 70 pack-year tobacco history and hypertension presented to the emergency department with fatigue, weight loss, and abdominal pain. Laboratory tests demonstrated a white blood cell count of 11.8 109/L, a hemoglobin of 8.0 g/dL, sodium of 125 mmol/L, carbon dioxide of 18 mmol/L, and a glucose of 656 mg/dL with positive serum ketones indicating diabetic ketoacidosis. He was admitted to the hospital and treated with insulin and IV crystalloids. A chest x-ray showed multiple lung nodules. A CT scan of the chest, abdomen, and pelvis revealed bilateral lung masses, an uncinate process pancreatic mass, multiple hypodense liver lesions, and thickening of the sigmoid colon. Bronchoscopy was performed and cytology revealed metastatic adenocarcinoma with suspected source of colonic, hepatobiliary, or upper gastrointestinal source. EUS/FNA was performed on the pancreatic mass and demonstrated poorly differentiated carcinoma of unclear primary source. Flexible sigmoidoscopy discovered a friable mass in the sigmoid colon. Biopsies were taken revealing adenocarcinoma on the background of high grade dysplasia consistent with a primary colon cancer. Given the widely metastatic nature of his disease he was offered FOLFOX + Bevacizumab as well as a palliative care referral. DISCUSSION: The majority of malignant pancreatic lesions are primary pancreatic tumors, with a small percentage due to metastases. The most common tumor to metastasize to the pancreas is renal cell carcinoma. Few cases of metastatic colon cancer to the pancreas have been reported. DKA as a first presentation of pancreatic adenocarcinoma is a very rare phenomenon with more typical presenting symptoms including abdominal pain, nausea and jaundice. Our case features two rare findings; metastatic colon cancer to the pancreas and DKA as the initial presentation of a pancreatic mass. This highlights the need to consider uncommon metastatic lesions in cases of symptomatic pancreatic masses.