Diabetes mellitus type 3c (DM3c) is an uncommon cause of diabetes due to pancreatic pathology. Its prevalence reaches about 5-10% among all diabetics in the Western world, largely due to chronic pancreatitis. DM3c occurs due to the destruction of the endocrine islet cells. Glucagon and insulin levels are both decreased due to the destruction of alpha and beta cells, respectively. This makes the development of diabetic ketoacidosis (DKA) a rare process in patients with DM3c because of the destruction of glucagon, which facilitates ketone production. We report a case of DM3c presenting with DKA. The patient presented with a history of chronic pancreatitis and was on pancreatic enzyme replacement therapy. Prior records revealed that HbA1c levels were normal. Prior computed tomography evidence revealed diffuse pancreatic calcifications. The patient was admitted for DKA, presenting with hyperglycemia, blood glucose of 703 mg/dL, bicarbonate of 16 mmol/L, ketones in the urine and acetone in the blood. The patient’s anion gap corrected for albumin was 27. The patient was admitted to the medical intensive care unit where he was treated with intravenous (IV) insulin and IV hydration. Once the anion gap closed, the patient was transitioned to long-acting insulin. HbA1c level on admission was elevated, autoimmune causes of diabetes were sent and were negative, ruling out late onset type 1 diabetes. This shows that although it is a rare phenomenon, diabetics with DM3c can present in DKA.

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BackgroundColorectal cancer is the third leading cause of cancer death; therefore early detection by screening is beneficial. Residents at a clinic in NJ, USA were not offering other forms of colon cancer screening when patients refused colonoscopy, which lead to the creation of the quality improvement project.MethodsResidents practicing at the clinic were given an anonymous survey determining which method of colon cancer screening they used and which alternative method they offered when patients refused the original method. The residents were educated about all methods of colon cancer screening and the residents were resurveyed.ResultsA total of 64% of residents offered less invasive testing when colonoscopy was refused. Six months after education, 95% of residents offered less invasive testing when colonoscopy was refused.ConclusionsEarly detection and removal of polyps by colonoscopy reduce the risk of cancer development. Colonoscopy is the gold standard for colon cancer screening; however other less invasive modalities are approved. This quality improvement project lead to offering the fecal immunochemical test or fecal occult blood test once patients refused colonoscopy at the clinic, increasing the number of patients receiving colorectal cancer screening, and thus providing better medical care.

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Introduction: Sclerosing cholangitis is a diffuse inflammation and fibrosis that progressively leads to stenosis and destruction of the bile ducts. It includes 3 types: primary sclerosing cholangitis (PSC), secondary cholangitis, and IgG4 sclerosing cholangitis (IgG4-SC). Usually they all present with cholestatic symptoms like pruritus and abdominal pain along with elevated ALP and GGT as well as bilirubin, however IgG4-SC has better outcomes, treatment response to steroids and less recurrence. We hereby presenting a case of IgG4-SC presenting as cholangiocarcinoma. Case Description/Methods: An 80 year-old male with a past medical history of bladder cancer was referred to the gastroenterology for EUS after blood work showed (ALT 320, AST 297, Bilirubin 1.4, GGT 2032), and CT abdomen with IV contrast revealed intra and extrahepatic biliary dilatation with an abrupt cutoff in mid CBD, suspicious for either a primary CBD mass or pancreatic mass (Figure). EUS showed an irregular mass in the CBD wall, suspicious for cholangiocarcinoma (Figure). The ERCP showed malignant appearing stricture of the extrahepatic bile duct consistent with cholangiocarcinoma, Bismuth 2 vs early 3B (Figure). Exploratory laparotomy was done and portal node biopsy came back benign; for which a repeat ERCP/Spyglass with direct visualization cholangioscopy, was done and showed diffusely dilated main bile duct with sludge and pus, single diffuse stenosis in right hepatic duct sludge with lining malignant appearing abnormal mucosa (nodularity and dilated vessels). IgG4 was elevated (931) consistent with IgG4 cholangitis (Figure). Biopsy and cytology brush showed no signs of dysplasia or neoplasia. Patient was then started on prednisone for a month and scheduled to repeat ERCP/Spyglass after. Discussion: IgG4-RD is a fibrous-inflammatory process related to immunomodulation, therefore IgG4-SC often co-presents with auto-immune pancreatitis, dacryoadenitis and sialadenitis. IgG4-SC is extremely challenging, as it's frequently misdiagnosed on imaging as a pseudotumor, and can progress to liver cirrhosis if left untreated, however it comes with great response to steroids. In 2021, Mendoza criteria (tortuous vessels, irregular nodulations, raised intraductal lesions, irregular surface, and friability) was published and found to be accurate to differentiate malignant and benign causes of biliary stricture, with overall diagnostic accuracy of 77%. Our case didn't meet the 5 criterias of Mendoza, which is consistent with IgG4-SC.