Elective Robotic Splenectomy for Wandering Spleen‐Associated Pancreatitis: A Novel Case Report

A 32-year-old man visited our emergency department complaining of severe left upper quadrant abdominal pain. He had history of alcoholic acute pancreatitis complicated with multiple peripancreatic pseudocysts and splenic vein thrombosis with splenic artery pseudoaneurysm and obliteration of the pseudoaneurysm was done by transarterial coil embolization 6 months ago. An abdominal computerized tomography scan at admission showed decreased perfusion at lower pole of spleen with focal splenic infarct, fluid collection at adjacent areas of pancreatic tail and stomach, and pseudocyst at pancreatic tail (Fig. 1). The patient received conservative treatment. On the 16th day of hospitalization, sudden onset of severe abdominal pain developed. His blood pressure declined to 80/50 mmHg, and remained to be persistently below 90 mmHg despite intravenous fluid therapy and use of inotropics. An emergent abdominal computed tomography scan revealed hemoperitoneum with active bleeding around splenic hilum and pancreatic tail (Fig. 2). An emergency surgery was performed and pin point bleeding from lateral wall of spleen was noted. Splenectomy with clipping of short gastric and splenic vessels was done. The patient was discharged without complication on the 10th postoperative day. Figure 1. Abdominal computed tomography scan at admission. Decreased splenic perfusion and focal splenic infarct (arrow) were noted. Figure 2. Abdominal computed tomography scan at the time of hemoperitoneum. Active bleeding around the spleen (arrow) and hemoperitoneum had developed. Pseudoaneurysm of the splenic artery, infarction, and rupture of the spleen are uncommon complications of acute or chronic pancreatitis. In our case, splenic vein thrombosis and adhesion around the pancreas and spleen due to previous severe acute pancreatitis as well as decreased splenic perfusion due to embolization may have contributed to development of splenic infarction with rupture. Treatment of a ruptured spleen depends primarily on hemodynamic stability of the patient, followed by extent of spleen injury and degree of hemoperitoneum. In our case, the patient underwent surgery due to hemodynamic instability. We report a case of splenic infarction and subsequent splenic rupture, treated by open splenectomy, following transcatheter embolization of an asymptomatic splenic artery pseudoaneurysm associated with acute pancreatitis.

Introduction: Abdominal pain is one of the most encountered problems in paediatrics, which baffles the experienced paediatrician, disturbs the parents, and adversely affects the quality of life of a child. This study was planned to find the prevalence, clinical spectrum, and etiological profile of recurrent abdominal pain in western Uttar Pradesh, India. Methods: An observational descriptive study was conducted from 0ctober 2019 to October 2020 at a tertiary care hospital. All children attending the Paediatric OPD between the age group of four to 16 years, suffering from recurrent abdominal pain were included in the study. Detailed history and examination of each patient were recorded on predesigned pretested performa. Results: The prevalence of recurrent abdominal pain (RAP) was found 0.34%, and approximately 2/3rd of RAP cases were from the adolescent age group (11 - 16 years). A strong association between a non-vegetarian diet and junk food was found with RAP (P < 0.05). A significant correlation was found between school absenteeism and RAP (P = 0.0027). It was observed that approximately 61% of the cases experienced pain for an average of one to two episodes per week and one to three hours per episode. We observed that localization of pain in the majority of cases was diffuse 30 / 75 (40%), and 67% of the children were found to have an organic cause of RAP (P = 0.0041). IBS and functional dyspepsia were contributing major causes of non-organic RAP. Conclusions: RAP has significant prevalence among children. Junk food and non-vegetarian diet was significantly associated with RAP. Major causes of non-organic RAP were IBS and functional dyspepsia. Dietary modification and personal hygiene may play a significant role as a preventive measure for RAP.

Background: Both primary pancreatic lymphoma (PPL) and primary splenic lymphoma (PSL) represent rare entities. PPL typically arises in the head of the pancreas but may arise in other locations also. PSL usually presents with nonspecific symptoms, including left upper quadrant pain, weight loss, and fever. This report describes a patient with a large left upper quadrant mass, which initially was believed to be a primary pancreatic mass, but which on final pathology appeared to be consistent with a PSL.Presentation: The patient is a 64-year-old woman who initially presented with symptoms of left upper quadrant abdominal pain and distension; she subsequently was found to have an 18 cm heterogeneous mass arising from the pancreatic tail. She underwent a distal pancreatectomy with splenectomy. Final pathology confirmed a diffuse large B cell lymphoma arising from the splenic parenchyma.Conclusions: Both PPL and PSL are rare causes of left upper quadrant masses. In this case, we describe a large lymphoma that appeared to arise from the tail of the pancreas, but on final pathology was found to be splenic in origin. Differentiating these two clinical entities is important for prognostication and treatment. A multimodal approach with surgical resection followed by chemotherapy is preferred.

Introduction: Pancreatic pseudocysts are common occurrences after episodes of acute pancreatitis. Up to 20% of pseudocysts are extra-pancreatic throughout the abdomen including intrahepatic. There are only a few cases of hepatic pseudocysts reported in the literature. We report this unique case with both pancreatic and intrahepatic pseudocysts occurring at the same time in a patient with pancreatitis. Case Description/Methods: A 56-year-old White woman with history of alcoholism and chronic pancreatitis, presented with epigastric and left upper quadrant abdominal pain radiating to the left shoulder. Examination revealed tenderness in the epigastric and left upper quadrant of the abdomen. Labs showed an elevated lipase of 217 IU/L (13-60), normal total bilirubin and transaminases, hemoglobin of 9.1 g/dL(11.5-15), and slight leukocytosis 12.6 K/uL (3.7-10.4). She was admitted 3 times in the last 4 months. Prior computerized tomography (CT) scan showed pseudocysts in the head and tail of the pancreas. CT scan this admission showed a decreased size of pseudocyst in the pancreatic head from 2.5 cm to 2.2 cm and pancreatic tail from 4.2 cm to 3.7 cm (Figure). It also showed 2 subcapsular fluid collections in the left lobe of the liver measuring 9X5X2cm and 9X7X3 cm. Percutaneous drainage of the hepatic cysts with the placement of a drainage catheter was performed by interventional radiology. 50 mL of bilious appearing fluid was drained with negative gram stain and cultures with an elevated fluid amylase level of 1,765 U/L. The patient’s pain improved and a subsequent CT a few weeks after discharge showed a decrease in the size of the hepatic cysts. Discussion: This is the first documented case of combined pancreatic and intrahepatic pseudocyst formation. Elevated amylase level in the hepatic fluid analysis confirmed the diagnosis of a hepatic pseudocyst. The interesting fact is that the size of the pancreatic pseudocyst decreased as the hepatic pseudocyst increased because of fluid tracking likely in the pre-renal space or along the hepato-gastric ligament. The diagnosis of hepatic pseudocyst needs to be considered in a patient with new hepatic fluid collection with a recent history of pancreatitis and pancreatic pseudocyst.Figure 1.: A – Axial CT showing previous pancreatic pseudocyst prior to admission B – Axial CT showing new hepatic pseudocyst adjacent to falciform ligament during admission C – Axial CT showing drain in hepatic pseudocyst.

Background Abdominal pain defined as any type of pain or discomfort that occurs in any area from the lower chest to the groin. Abdominal pain is symptom of a wide variety of mild to serious diseases, disorders, conditions. Abdominal pain can result from infection, malignancy, inflammation, obstruction and other abnormal processes. Aim of the Work To define the causes of recurrent abdominal pain among a sample of school age children. Subjects and Methods This cross sectional study was carried out to evaluate those children who presented to the Pediatric Outpatient Clinic, Children Hospital, Ain Shams University because of recurrent abdominal pain they were diagnosed in the pediatric Gastroenterology unit between June 2016 and July 2017. History taking included full analysis of abdominal pain, associated gastrointestinal symptoms and associated systemic manifestations. Examination included anthropometric measurements, general and local abdominal examination. Routine investigations included complete blood counts, urine analysis and culture, microscopic stool examination and pelviabdominal US. Other specific investigations were selected according to clinical manifestations to reach an organic cause. After reaching the definitive diagnosis, patients were classified into 2 groups organic causes and functional abdominal pain. Results During the study period, 100 children presented with recurrent abdominal pain. Results revealed that only 28% of the recurrent abdominal pain causes were attributed to organic factors; the most commonly encountered organic causes of recurrent abdominal pain were urinary tract infection (12%) while 72% of children presented with functional recurrent abdominal pain. The most common causes of function recurrent abdominal pain in our study was irritable bowel syndrome. Conclusion Most of the cases of RAP among school age children are due to functional abdominal pain (72%).

INTRODUCTION: Splenic injury is a rare complication of colonoscopy, with about 100 reported cases worldwide. Identification of splenic injury following colonoscopy is challenging given its non-specific presentation and low incidence. This case report highlights the importance of a high index of suspicion in patients with vague abdominal symptoms post colonoscopy and the need to increase awareness for splenic injury as a possible complication of colonoscopy. CASE DESCRIPTION/METHODS: A 72-year-old female presented to the ER with left upper quadrant (LUQ) abdominal pain and weakness 8 hours after a diagnostic colonoscopy. Past medical history included DVT and multiple episodes of PE, for which she was on Coumadin. Coumadin was held prior to colonoscopy. PT and the INR on the day of the procedure were 19.0s and 2.0. Normal findings with no technical difficulties, therapeutic interventions, or biopsies taken during colonoscopy. At discharge, she remained asymptomatic, and Coumadin was resumed. On return, exam revealed normal vital signs and distended abdomen with LUQ tenderness. Labs showed: hgb = 8.1, PT = 15.3s, INR = 1.6, and aPTT = 22.3s. CT revealed peri-splenic fluid collection suspicious for hemorrhage or subcapsular hematoma with free fluid extending into the pelvis. Coumadin was discontinued, and she was managed non-operatively with serial abdominal exams and hemoglobin measurement. Hemoglobin remained stable without requiring blood transfusions. Coumadin was resumed on day 4 and hemoglobin was monitored for another 48 hours, remaining stable at 9.0 g/dl. DISCUSSION: Splenic injury is a rare complication of colonoscopy with a reported incidence of 1:6,000 to 1:100,000 colonoscopies performed. Associated symptoms are non-specific with significant variability in timing of onset, posing a diagnostic dilemma for clinicians. Most patients with splenic injury present within 24 hours post procedure. However, some may present after 10–14 days. LUQ abdominal pain is the most common symptom, although in some cases, patients may be asymptomatic. Hypotension, anemia, and elevated white blood cell count may be present as well. Anti-coagulants and anti-platelets have been shown to not increase the risk of splenic injury during colonoscopy. The most accurate test for diagnosing splenic injury is abdominal CT, with a 98 % specificity and sensitivity. Splenic hematoma represents a rare complication of colonoscopy and should be included in the differential for a patient complaining of abdominal pain following the procedure.

Pancreatic B-cell lymphoma is rare; it accounts for 0.2% to 2.0% of extranodal non-Hodgkin lymphoma, and constitutes less than 0.5% of all pancreatic malignancies. Most histologic types of the pancreatic lymphoma are diffuse large B-cell lymphoma, and follicular lymphoma is quite rare. We report here a case of pancreatic follicular lymphoma that was initially detected by acute pancreatitis. This is the first reported case of pancreatic follicular lymphoma presenting with acute pancreatitis. A 71-year-old woman had epigastric and left upper quadrant abdominal pain. Computed tomography (CT) revealed features of acute pancreatitis. After standard therapy for pancreatitis, enhanced CT showed a pancreatic tumor (50 × 35 mm) in the body of the pancreas with gradual enhancement. Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography showed a complete interruption of the pancreatic duct in the body, with mild dilation of the duct in the tail of the pancreas. Endoscopic ultrasonography revealed hypervascularity of the pancreatic tumor. The patient underwent distal pancreatectomy to remove the cause of pancreatitis and to disclose the diagnosis. Histologic examination revealed follicular lymphoma of pancreas. Despite recent improvement in clinical strategies, differential diagnosis between pancreatic lymphoma and pancreatic cancer is still difficult without histologic information. Pancreatic lymphoma should be considered as a differential diagnosis in a patient who initially presents with acute pancreatitis.

Mycophenolate mofetil (MMF), also known as Cellcept (Genentech, S. San Francisco, CA), is a commonly used immunosuppressant following solid organ transplantation. It has effectively reduced rates of rejection of transplanted organs, but this medication has been associated with a variety of gastrointestinal (GI) side effects, including abdominal pain, nausea, diarrhea, constipation, vomiting, anorexia, and dyspepsia. Here we present a case of non-healing gastric and duodenal ulcers related to MMF use following liver transplantation. A 36-year-old female with a history of familial intrahepatic cholestasis status-post an orthotopic liver transplant (1986), who was referred with complaints of chronic mid-epigastric and left upper quadrant abdominal pain. She has been maintained on long-term immunosuppressive therapy with MMF and cyclosporine, but unfortunately developed cirrhosis of her transplanted liver for which she has been getting routine variceal screening by esophagogastroduodenoscopies (EGD). Her last EGD in January 2016 revealed 6 moderately-sized esophageal varices, multiple gastric ulcers, and one clean-based duodenal ulcer. Screening for Helicobacter pylori was negative. She was subsequently placed on twice daily proton pump inhibitor (PPI) therapy and follow up EGD was performed in April 2016. This revealed persistent gastric and duodenal ulcers without evidence of healing. On subsequent clinic visit, she continued to endorse unchanged left upper quadrant and mid-epigastric abdominal pain, despite appropriate use of twice daily PPI therapy. Repeat EGD in January 2018 revealed a persistent antral gastric ulcer, as well as numerous white plaques scattered throughout the stomach (Figure 3). Biopsy of these plaques revealed active gastritis with evidence of cellular apoptosis, characteristic of mycophenolate-induced gastropathy. Repeat testing for Helicobacter pylori remained negative. Case Highlights:Mycophenolate mofetil remains a standard of post-transplant immunosuppression but has several known GI side effects. This case describes an instance of a less common side effect, MMF-induced ulcers. GI complications may improve with reduction or cessation of MMF, but this may not always be feasible in cases of transplant immunosuppression. Newer formulations of mycophenolate include an enteric coating which may reduce GI side effects and may be a good alternative for patients who experience more severe symptoms.1917_C Figure 3. Repeat visualization of gastric ulcer during EGD procedure dated January 20181917_A Figure 1. Duodenal ulcer as visualized during January 2016 EGD procedure1917_B Figure 2. Gastric ulcer as visualized during January 2016 EGD procedure

P0717 SPLENIC INFARCTION DURING INFECTIOUS MONONUCLEOSIS

Purpose: A 64-year-old white female with history of diabetes, hypertension, and multiple abdominal surgeries presented with left upper quadrant abdominal pain, associated with nausea and vomiting. Physical exam revealed left upper quadrant tenderness. Labs revealed leukocytosis at 17.6. CT abdomen was concerning for small bowel obstruction and incidentally noted bilateral renal masses which were heterogeneously enhancing, and concerning for malignancy. A 2.1-cm cystic mass in the pancreatic body was also noted. The patient's small bowel obstruction resolved with conservative management. She then underwent CT-guided, right-sided renal mass biopsy, with pathology revealing renal cell carcinoma (RCC), clear cell type. Later EUS was performed, which identified a 2.7 x 2.3 cm cystic lesion in the pancreatic body. FNA was performed which was positive for Cam 5.2, synaptophysin, and chromogranin, consistent with a well-differentiated neuroendocrine tumor (NET). Immunostaining for RCC was negative, and Ki-67 proliferation index was less than 2%. Subsequently, somatostatin receptor scintigraphy (SRS) scan was obtained, and was normal. Serum chromogranin was borderline high at 6 nmol/L and serum gastrin was normal. Patient was then referred for possible partial nephrectomy and pancreatic tumor resection. Pancreatic NETs constitute about 2% of all gastrointestinal neoplasms. Secondary primary malignancies in these patients are a known entity, and their incidence is on the rise. We report a rare case of synchronous pancreatic NET and RCC. Physicians should be aware of the rising trend of synchronous tumors. Every effort should be made to further characterize the suspected lesions, as they are not always metastatic and treatment options may vary widely.

Introduction: Recurrent abdominal pain (RAP) is one of the most common gastrointestinal complaints during childhood and most frequent presentation in paediatric clinics. RAP has been classified etiologically into two broad groups: organic and functional. Functional causes of RAP were reported to be present in 90% of cases in the past. Because of the new diagnostic tools and an improved knowledge, the prevalence of RAP has been now increasing. The current study was done to find out the etiology of RAP in Nepalese children. Materials and Methods: This was a prospective study conducted in Civil Services Hospital, Paediatric department from April 2010 to March 2011 in children aged between 4 and 15 years, attending the outpatient department. All the children with RAP, who fulfilled the Apley’s criteria were included in this study. Results: Out of 47 children with RAP, organic causes were found in 41 children while non-organic causes, in 6 children. Parasitic infestation was the commonest organic cause of RAP, followed by idiopathic chronic constipation. Other causes were culture proven urinary tract infection, antral gastritis and H. pylori infection. Conclusion: Organic disorder is still the commoner cause of RAP in our part of the world. The key step in the management of RAP is to first investigate for the organic cause based on the symptoms. DOI: http://dx.doi.org/10.3126/jnps.v33i1.7413 J Nepal Paediatr Soc. 2013;33(1):31-33

AN UNUSUAL CASE OF RECURRENT HYPERTRIGLYCERIDEMIC PANCREATITIS

BackgroundAcinar cell carcinoma of the pancreas is a rare neoplasm. Although this tumor has been well characterized histologically, the morphological patterns in Fine Needle Aspiration Cytology have not been well defined. Unlike ductal adenocarcinomas, endocrine tumors, and solid pseudopapillary tumors of the pancreas with their characteristic FNA cytological features, acinar cell carcinomas pose a particular diagnostic challenge by sharing many cytomorphologic features with endocrine tumors of the pancreas.Case presentationA 37-year-old man presented with lower chest and left upper quadrant abdominal pain. Computed tomography revealed a 7.8 × 7.3 cm irregular, partially cystic mass in the body and tail of the pancreas, and two lesions in the liver compatible with metastases. Subsequently, the patient underwent endoscopic ultrasound-guided fine needle aspiration on one of the two metastatic liver masses.FNA cytology revealed abundant, loosely cohesive clusters of malignant epithelial cells with vaguely acinar and trabecular formations. The pleomorphic nuclei had fine granular chromatin and occasionally small nucleoli. There were scant to moderate amounts of cytoplasm. Scattered, strikingly large tumor cells with giant nuclei, prominent mitoses and associated necrosis were evident. A pancreatic endocrine tumor was suspected initially, but acinar cell carcinoma of the pancreas was confirmed by immunohistochemistry, cytochemical and ultrastructural studies.ConclusionWe describe a case of pancreatic acinar cell carcinoma with unusual cytomorphologic features mimicking an endocrine tumor of pancreas, encountered in endoscopic ultrasound-guided fine needle aspiration of a metastatic liver mass and discuss the diagnostic approach for this unusual pancreatic tumor in fine needle aspiration cytology.

Primary benign splenic tumours are unique and account for < 0.007% of all tumours identified during surgery and autopsy. Splenic lymphangiomas are rarely seen in adults. Splenic lymphangiomas may be asymptomatic, or may present with upper left abdominal pain, splenomegaly, hypersplenism, or splenic rupture with haemorrhagic shock. The clinical and radiological features of these lesions are not specific. This case report serves to remind the clinician to consider the rare but important differential diagnosis of splenic lymphangioma while treating splenic lesions. We report a case of splenic lymphangioma in a 22-year-old woman who presented with left upper quadrant abdominal pain for three months. Initial investigations were unremarkable; however, computed tomography later revealed multiple splenic micro-abscesses. The patient underwent laparoscopic splenectomy, and histopathological examination revealed splenic lymphangioma. The patient was discharged on postoperative day three. One month after surgery, the abdominal pain resolved completely, with no new complaints. Splenic lymphangiomas present clinically as splenomegaly or left upper quadrant abdominal pain; prompt intervention is necessary for avoiding complications. This case report concludes that splenic lymphangiomas should be considered in the differential diagnosis of splenomegaly or left upper quadrant pain, even in adults, because they are amenable to curative treatment. Delays in surgical intervention may lead to severe complications, such as infection, rupture, and hemorrhage. Such lesions can be safely managed with laparoscopy, involving less postoperative pain and early patient discharge with excellent cosmetic outcomes.

Background: Splenic artery aneurysms most commonly present with vague epigastric or left upper quadrant abdominal pain that may radiate to the left shoulder. Chest pain associated with splenic artery aneurysm is an unusual phenomena. This case presents a rare occurrence of a splenic artery aneurysm originally presenting as atypical chest pain. Case Presentation: A 46 year old G3P2 AAF patient with family history of hypertension presented to the ER with pleuritic left chest pain, episodes of shortness of breath, and new onset hypertension. Chest x-ray and ECG were unremarkable. Pertinent labs included a hemoglobin of 10.6 and D-dimer of 4.10. CTA of the chest revealed no evidence of pulmonary embolism. Bilateral ultrasound of the lower extremities was negative for deep vein thrombosis. Following her negative workup, the patient’s symptoms were presumed to be related to allergies or asthma, although there was no symptomatic improvement with albuterol inhaler. Following discharge, the patient’s symptoms persisted and began to present as left upper quadrant abdominal pain with fullness. CT of the abdomen and pelvis with and without contrast revealed a large lobular mass in the left upper quadrant with unknown origin. Open exploratory laparoscopy surprisingly revealed a splenic artery aneurysm that had recently ruptured. The patient underwent distal pancreatectomy, splenectomy, and adrenalectomy during this operation. Conclusion: Although the presentation of a splenic artery aneurysm as chest pain is rare, evaluation for this pathology may be indicated in patients with new onset left chest pain, hematologic abnormalities, and negative pulmonary/cardiac workup.