Methods
This quality improvement project was conducted during a scheduled internal medicine resident didactic session. The intervention consisted of a 30-minute educational lecture focused on MASLD, its clinical significance, and the use of the Fibrosis-4 (FIB-4) score for risk stratification in the outpatient setting.
Prior to the session, residents completed a pre-lecture questionnaire assessing baseline knowledge and confidence in identifying MASLD and using the FIB-4 score. Following the lecture, the same questionnaire was administered to evaluate changes in knowledge and competency.
Questionnaire responses were anonymized and analyzed to compare pre- and post-intervention scores. The primary outcome was the improvement in residents’ understanding of MASLD and appropriate application of the FIB-4 score to guide referrals for further hepatology evaluation or advanced imaging.
Introduction
Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common chronic liver disease and is often underrecognized in primary care. The Fibrosis-4 (FIB-4) score is a validated, non-invasive tool that helps identify patients at risk for advanced fibrosis who may benefit from further hepatology evaluation.
This quality improvement (QI) project aims to increase internal medicine (IM) residents’ knowledge of MASLD and competency in using the FIB-4 score in the outpatient setting.
Enhancing Resident Competency in MASLD and FIB-4 Score Use Through a QI Project
Celise Ferreira, MD; Reema Salim, MD; Ayesha Shahzad, MD
Internal Medicine Residency, Saint Agnes Medical Center, Fresno, CA
Saint Agnes Medical Center, Fresno, CA
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Results cont
Results
Results are pending completion of the educational intervention. Pre- and post-lecture questionnaire responses will be analyzed to assess changes in residents’ knowledge and confidence in using the FIB-4 score for MASLD risk stratification and appropriate referral decision-making in the outpatient setting.
References
2. Kanwal, F., Shubrook, J. H., Adams, L. A., et al. (2021). Clinical care pathway for the risk stratification and management of patients with nonalcoholic fatty liver disease.
Gastroenterology, 161(5), 1657–1669.
3. Siddiqui MS, Yamada G, Vuppalanchi R, et al. Diagnostic accuracy of noninvasive fibrosis models to detect change in fibrosis stage. Clin Gastroenterol Hepatol 2019;17:1877–1885.e5.
4. McPherson S, Stewart SF, Henderson E, et al. Simple non-invasive fibrosis scoring systems can reliably exclude advanced fibrosis in patients with non-alcoholic fatty liver disease. Gut 2010;59:1265–1269
Discussion
A prior chart review showed that among 90 clinic patients, 19% had a FIB-4 score >2.6, but only 24% of those were appropriately referred to hepatology. Additionally, 5 patients with low-risk scores were referred unnecessarily, revealing gaps in both recognition and appropriate use of the FIB-4 score.
This QI project addressed those gaps by educating residents on MASLD and FIB-4 interpretation. Our intervention aimed to improve clinical decision-making, promote appropriate referrals, and support more consistent, evidence-based care in the outpatient setting.
Results graphic here
Case Presentation
A 74-year-old female with a history of CKD, HFpEF, valvular disease, HTN, HLD, hypothyroidism, and an outpatient-treated leg ulcer presented after syncopal episode preceded by dizziness and weakness.
In the ED, she was hypotensive, HR 102, with WBC 28.5. She received IV fluids and Ancef for presumed cellulitis. EKG normal sinus rhythm, and chest x-ray showed no acute findings. Admitted for further workup, she later developed severe, non-radiating epigastric pain relieved by pantoprazole. CT A/P revealed extrahepatic biliary dilation (1.4 cm) and duodenal thickening. Blood cultures grew gram-negative rods, and Cefepime was started. On day 4, she developed new-onset Afib with RVR, hypotension, anemia, and hypoxia. She received 2 units PRBCs and plasma. MRCP showed CBD dilation (10 mm), gallbladder distention, free fluid, duodenal/gastric thickening, and lung consolidations (Figure 1). ERCP identified a bleeding duodenal ulcer with suspected CDF; the ulcer was cauterized, and a biliary stent placed (Figure 2). NSAID deemed likely cause. Antibiotics escalated to Zosyn, and treated with pantoprazole and hydrocortisone.
Due to persistent hypoxia, she was intubated, transferred to ICU for septic shock. Meropenem was started, with improvement allowing extubation the next day.
TPN initiated for poor oral intake.
Introduction
A choledochoduodenal fistula (CDF) is an abnormal connection between the common bile duct and duodenum, also referred to as a biliary-enteric fistula [1,2]. These fistulas are rare, with limited case reports since first being described in 1840. The use of advanced hepatobiliary imaging such as ERCP and MRCP has improved their detection [3].
When an Ulcer Crosses the Line: A Rare Case of Biliary-Duodenal Fistula
Celise Nardes Ferreira MD, Hamna Javed MD, Ajaypreet Singh MD, Nicholas Reyes, MD, Parisa Rezapoor MD
Internal Medicine Residency, Saint Agnes Medical Center, Fresno, CA
Saint Agnes Medical Center, Fresno, CA
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Discussion
This case highlights gram-negative bacteremia and septic shock secondary to a bleeding NSAID-induced duodenal ulcer complicated by CDF; A rare outcome of PUD. Though PUD is common, CDF is rare and may cause sepsis, cholangitis, and biliary obstruction [4,5].
The patient’s nonspecific symptoms initially masked the GI pathology. Imaging and ERCP were key in diagnosing the CDF and managing bleeding. Clinicians should maintain high suspicion for GI sources in elderly patients with sepsis and NSAID use [6]. ERCP remains the diagnostic and therapeutic gold standard [7].
Case Presentation cont.
Repeat CT showed improved duodenal thickening, early ileus, choledochoduodenal fistula, CBD stenosis with patent stent, intrahepatic pneumobilia, and free fluid. WBC rose to 31.5; Ceftriaxone was stopped, and she was continued on Meropenem with plans for Levaquin on discharge. Despite improvement, she continued to require ICU-level care.
References
Conclusion
This case emphasizes thorough diagnostic evaluation in elderly patients with vague symptoms. Early recognition and multidisciplinary management of CDF are essential to prevent severe complications like septic shock.
Methods
Introduction
When an Ulcer Crosses the Line: A Rare Case of Biliary-Duodenal Fistula
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Saint Agnes Medical Center, Fresno, CA
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