CT Scan Of Abdomen Research Articles

S1423 Lipoprotein Lipase Deficiency as a Rare Cause of Acute Pancreatitis

INTRODUCTION: Hypertriglyceridemia (HTG)-induced pancreatitis comprises 1 to 14 % of all cases of acute pancreatitis. Generally, primary HTG refers to a genetic disorder that includes type 1, 4 and 5 dyslipidemia. Familial lipoprotein lipase (LPL) deficiency is a rare condition of primary HTG with autosomal recessive transmission and a prevalence of 1-2:1,000,000. This case describes a patient with acute pancreatitis attributed secondary to LPL deficiency. CASE DESCRIPTION/METHODS: A 28 year old female with a history of type 1 diabetes mellitus complicated by diabetic gastroparesis s/p gastrojejunal bypass, HTN, HTG, recurrent pancreatitis presented to ED with abdominal pain. She had numerous admissions in the past due to recurrent pancreatitis secondary to HTG , one of which was complicated by necrotizing pancreatitis and wall off necrosis for which she underwent partial pancreatectomy. The patient also has an extensive family history of early onset type 1 diabetes and HTG. Despite the use of high intensity statin, fenofibrate, diet restriction and insulin pump, triglyceride levels has been very difficult to control. On physical examination, multiple red-yellowish bumps are noted on the arms consistent with xathomas. Labs were significant for elevated triglycerides and lipase (4500 and 400 respectively). Abdomen and pelvis CT scan showed evidence suggestive of acute pancreatitis, splenic vein thrombosis and hepatosplenomegaly. Due to high suspicion, molecular genetic testing for LPL deficiency was sent and came back positive. DISCUSSION: Patients with LPL are classically found to have high serum plasma triglycerides, low HDL-cholesterol, and presence of fasting chylomicrons in the plasma due to mutation of the enzyme that is responsible for hydrolysis and removal of triglycerides from the plasma. The most feared complication of the disease is recurrent and potentially life threatening acute pancreatitis. Although this is a very rare condition, it is an important differential diagnosis to consider due to refractoriness of conventional medical therapies including statins, fibrates and reduced fat intake(less than 20 g/day). There have been some studies that suggested high dose antioxidant therapy could potentially help lower the level of triglycerides and prevent recurrent episodes of acute pancreatitis in that particular group of patients. It is also critical to make the diagnosis as soon as possible for early medical interventions during childhood and genetic counseling and testing for family members.

S2774 An Unusual Case of Duodenal Obstruction from an Unsuspected Intramural Hematoma

INTRODUCTION: Intramural duodenal hematoma (IDH) is an unusual presentation after blunt abdominal trauma. IDH rarely leads to gastric outlet obstruction (GOO), acute pancreatitis, obstructive cholestasis, and gastrointestinal hemorrhage. We report first case of delayed presentation of large IDH associated with acute pancreatitis and GOO four months after abdominal trauma. CASE DESCRIPTION/METHODS: A 53-year-old man with history of diabetes mellitus, alcohol use disorder presented with upper abdominal pain, nausea and vomiting of 2 days duration. Reports fall on to the edge of bathtub and hitting his abdomen 4 months ago. Abdominal exam revealed a non-tender palpable mass in the epigastrium. Labs were significant for elevated AST-214, ALT-63, ALP- 218, lipase-419, and CA 19-9 -377.8. A CT scan of Abdomen showed a large duodenal intramural mass without enhancement and upstream GOO, which is new compared to prior CT scan done a year ago for other reasons. An MRI of the abdomen showed a large heterogeneous duodenal filling defect, with no internal enhancement likely representing a hematoma (Figure 1). Patient underwent EGD and Endoscopic ultrasound(EUS) that showed a submucosal duodenal mass occupying the entire lumen of the duodenum (Figure 2). FNA showed many inflammatory and necrotic cells and was non-diagnostic. Patient had persistent obstruction despite one week of conservative therapy with Nasogastric decompression and TPN (Figure 3). He underwent surgical hematoma evacuation with a feeding jejunostomy tube placement and was discharged on post-operative day 7 after tolerating oral feeds, normalization of lipase and LFTs. DISCUSSION: Most cases of IDH are secondary to blunt abdominal trauma. Spontaneous IDH occurs in patients with bleeding disorders, anticoagulation therapy, vascular collagen diseases, or after invasive endoscopic procedures. IDH is more frequent among children. Due to its anatomic location and high submucosal vascularity distal duodenum is the most common site involved. Symptomatic patients present with GOO symptoms. Compression of the ampulla or pancreatobiliary ducts can cause acute pancreatitis and obstructive jaundice. Cross sectional imaging aids in diagnosis and to evaluate for complications such as perforation or retroperitoneal hemorrhage. EGD and EUS are helpful when imaging is inconclusive. Most patients improve with conservative management by 1 week. Surgical, image guided or endoscopic drainage is needed in patients who fail conservative management or develop complications.Figure 1.: A: CT scan of abdomen showing large heterogeneous filling defect ( arrow) extending from 1st to 3rd portion of duodenum, measuring at least 13 cm × 5.6 cm resulting in upstream gastric outlet obstruction, as evidenced by distended stomach and contrast not passing in to small bowel. B: MRI of abdomen- Post contrast subtraction films showing large heterogenous filling defect (arrow) with no internal enhancement, likely representing a hematoma.Figure 2.: A: ESD showing large 4-5 cm smooth, subepithelial duodenal mass involving the bulb and the duodenal sweep occupying 99% of the lumen of the duodenum. B: -Linear EUS imaging showing a 37.2 mm × 60.5 mm subepithelial lesion in the duodenal bulb. Due to local inflammation and the large size of the lesion, the layers of the duodenum could not be well defined.Figure 3.: Upper Gastrointestinal series showing filling defect in the lateral aspect of the duodenum with a narrow trail of contrast coursing in the residual medial lumen at 1 week of conservative therapy.

S2553 Endometriosis: A Rare Cause of Ascites

INTRODUCTION: Ascites is the pathological accumulation of fluid within the peritoneal cavity. These are mostly due to portal hypertension resulting from cirrhosis but there are non cirrhotic rarer causes of ascites. It is important to investigate the etiology of non-cirrhotic ascites as treatment of the underlying etiology can reverse it. CASE DESCRIPTION/METHODS: A 34-year-old female with history Cerebral Palsy presented to the clinic with 3 months of increasing abdominal distention. No associated jaundice, changes in urine color or constitutional symptoms. Examination revealed 10 cm reducible umbilical hernia along with abdominal fullness. No signs of portal hypertension or cirrhosis noted. Labs showed normal metabolic panel, blood counts and coagulation profile. Abdominal ultrasound revealed moderate to large ascites with nodular liver suggesting developing cirrhosis. She underwent paracentesis with removal of 5 liters of black-brown colored fluid showing many RBCs, 500 WBCs, Albumin of 3.5, Protein of 5.8, LDH of 978, SAAG of 0.6 and negative cytology. CT scan showed large abdominal and pelvic ascites, nodular liver and a 7 × 7 cm pelvic mass. MRI showed multiseptated pelvic collection with solid component in the right adnexal region. She underwent an exploratory laparoscopy with a right salpingo-oophorectomy and adnexal mass biopsy. Pathology showed ovarian fibroma with endometriosis. Follow up 3 months into the surgery, the patient was doing well and had no ascites. DISCUSSION: Cirrhosis is the most common cause of ascites. Ovarian fibroma and endometriosis are some of rare non cirrhotic causes as seen in this case. Ascites related to endometriosis was first described in 1954. A systematic review noted 63 cases with endometriosis related ascites between 1950 to 2010 who were mostly nulliparous women of African origin of ages 19 to 51 years. Diagnosis of endometriosis is usually delayed as it mimics gynecological malignancy and requires surgical exploration. Bilateral oopherectomy is the definite treatment. Here, right salpingo-oophorectomy was considered per patient preference. Ovarian fibromas are benign sex cord-stromal tumours seen in postmenopausal women which can present with ascites as a component of Meigs syndrome. Atypical causes such as these need to be considered especially in the young nulliparous females. Peritoneal fluid analysis and imaging may be misleading as they both can mimic malignancy, hence surgery is diagnostic. Therefore a broader differential is critical in evaluating ascites.Figure 1.: Initial CT scan of abdomen and pelvis with IV contrast showing soft tissue density structure within the anterior midline pelvis measures 6.5 × 7.5 × 7 cm.

S2881 Lupus Enteritis as the Unique Manifestation of Lupus Flare - Report of 2 Cases

INTRODUCTION: Gastrointestinal (GI) symptoms are common in patients with systemic lupus erythematous (SLE) but real GI involvement is rare. Lupus enteritis refers to either vasculitis or inflammation of the bowel wall. It is present in 0.2–5.8% of patients usually in the context of high-SLE activity. The symptoms are nonspecific and can be life-threatening especially if the treatment is delayed. We present two cases of lupus enteritis as the sole manifestation of SLE flare. CASE DESCRIPTION/METHODS: Case 1. 19-year-old female with no prior SLE diagnosis was admitted with four months of persistent diarrhea, vomiting, and epigastric pain. Workup revealed Mg 0.5 mg/dl, K 2.5 mEq/l, Hb 11.2 g/dl, CRP 1.40 mg/dl, and subnephrotic proteinuria. Infectious workup was negative. CT scan showed diffuse thickening and enhancement of the small and large bowel wall. Upper and lower endoscopy with biopsy revealed nonspecific edema and chronic inflammation. Further evaluation showed low complement levels, positive ANA ( > 1:160), anti-dsDNA ( > 300 IU/ml), SSA, SSB, anti-histone Ab, and lupus anticoagulant. IV methylprednisolone was started with marked improvement, later transitioned to hydroxychloroquine, azathioprine, and prednisone with taper dose. Case 2. 49-year-old female, SLE diagnosed in 2017, no treatment for 2 years was admitted with one month of persistent vomiting and abdominal pain. Evaluated initially with upper and lower endoscopy which revealed Barret’s esophagus. Workup revealed Na 132 mEq/L, Mg 1.6 mg/dl, lymphopenia (200 k/uL), elevated CRP (0.67 mg/dl), and subnephrotic proteinuria. Negative infectious workup. Further evaluation showed ANA ( > 1:160), Anti Smith ( > 8), anti-dsDNA (4 IU/ml), SSA ( > 8), and low complement levels. CT scan with diffuse thickening and enhancement of the small bowel and entire colon and rectum. IV methylprednisolone and a short course of IV erythromycin was started with significant improvement; later transitioned to hydroxychloroquine, azathioprine, and prednisone with taper dose. Both patients did not present recurrence of symptoms during the next 3 months. DISCUSSION: Lupus enteritis is very rare as an unique feature of SLE flare. Current knowledge is scarce. CT scan is the test of choice. It usually responds to steroids. Steroid-sparing agents are required in severe-relapsing cases. Our cases highlight the difficult diagnosis of this disease. Identifying this condition is crucial to avoid complications as bowel necrosis or perforation.Figure 1.: Contrast enhanced abdomen CT scan coronal axial views revealed “target” sign that represent circumferential thickening of the intestine wall. In this case affecting both small and large intestine.Figure 2.: Contrast enhanced abdomen CT scan showing diffuse thickening of the small and large intestine wall. "Target" sign can also be appreciated here.

S1664 Colonic Obstruction Caused by GB Stone

INTRODUCTION: Colonic gallstone ileus is one of the rare causes of intestinal obstruction. These stones usually require surgery although endoscopic removal by different methods; such as extracorporeal lithotripsy, Dormia baskets and polypectomy snares have been described. CASE DESCRIPTION/METHODS: A 69-year-old female with no significant past medical history presented with several days of lower abdominal pain, nausea, vomiting, constipation and abdominal distension. There was no h/o hematemesis, melena or jaundice. She reported no previous colonoscopy. On exam, the patient was found to be in abdominal discomfort. No icterus or pallor was present. Abdominal exam showed distension with tenderness present in the left iliac fossa. Lab results were WBC 19.6, hemoglobin 6.0, platelets 340, total bilirubin 0.9, alkaline phosphatase 84, AST 12, ALT 8, Lactate 8.6. Fecal occult blood was negative. CT abdomen showed significant edema of the proximal colon, pneumobilia with 3.7 cm lamellated calcified lesion resembling a large gallstone present in the distal sigmoid colon resulting in local mechanical obstruction. The patient was diagnosed with gallstone colonic ileus and cholecystocolonic fistula. She underwent attempted removal of stone with the help of rigid sigmoidoscopy and then flexible colonoscopy, but both failed. Finally, she underwent open laparotomy and extended sigmoid colectomy, Hartmann’s procedure and colostomy. The cholecystocolonic fistula was not disturbed. She had a good recovery and was discharged in stable condition after 5 days. At around 6 months, she underwent a biliary scan which showed that the cholecystocolonic fistula had closed spontaneously. She subsequently underwent reversal of the Hartmann procedure and cholecystectomy. Currently she is doing well with no recurrence. DISCUSSION: Large bowel ileus due to gallstone is a rare cause of obstruction. The stone reaches the colon most commonly through cholecystocolonic fistula. The impacted area is usually at a point of pathological narrowing, such as related to diverticular disease, as in our patient. The patient typically presents with abdominal distension, pneumobilia and ectopic stone all of which were present in our patient. CT abdomen is the investigation of choice. Endoscopic Dormia basket removal has been successfully used in the past by authors. But when the stone is too large, surgical removal of the stone may be necessary. The cholecystocolonic fistula also needs to be repaired at a later date which may require surgical re-exploration.Figure 1.: Colonoscopic view showing large Gall Bladder stone in Sigmoid colon.Figure 2.: CT scan abdomen showing the radio-opaque GB stone in the sigmoid colon.

S1436 Outcome of the Use of Corticosteroids for Treatment of Autoimmune Pancreatitis (AIP) in a COVID-19 Patient

INTRODUCTION: Autoimmune Pancreatitis (AIP) is a steroid-responsive disease of the pancreas. Due to poor outcomes in severe acute respiratory syndrome (SARS-CoV) and Middle East respiratory syndrome (MERS-CoV) outbreaks, the World Health Organization (WHO) advises against the use of corticosteroids in the treatment of 2019 Coronavirus Disease (COVID-19) except if steroid therapy is required for coexisting illness. We present a case of uncontrolled AIP which was treated with high dose steroids while the patient was hospitalized with COVID-19. CASE DESCRIPTION/METHODS: A 53-year-old male was hospitalized with COVID-19 and uncontrolled AIP. The patient had elevated IgG4 levels and negative work up for other etiology of pancreatitis in the past and was already taking prednisone 40 mg daily due to a recent AIP exacerbation. On physical exam, temperature of 101 F, heart rate 101 beats/minute, respiratory rate 20 breaths/minute while blood pressure was normal. Tenderness in the epigastric region was noted. Labs showed Hct 35.8%, WBC 12.32 thousand/uL, BUN 9 mg/dL, lipase 530 u/L and normal LFTs. CT abdomen showed severe necrotizing pancreatitis with infected necrosis (multiloculated collections of gas and fluid) (Image 1). Chest imaging showed bibasilar infiltrates consistent with COVID-19 pneumonia (Image 2). Patient was continued on steroids, started on meropenem, and supportive treatment for COVID-19. Due to persistent abdominal pain and inability to tolerate oral intake, the patient underwent CT-guided percutaneous drainage of the necrotic collection. Azathioprine (AZA) was added to treatment regimen due to uncontrolled AIP despite steroid therapy. Patient recovered clinically without need for oxygen supplementation or further complication from COVID-19. He was discharged from the hospital with a short antibiotic course, a prescription to continue AZA and prednisone 40 mg with plan to taper dose by 5 mg per week. He returned home to continue quarantine which he completed without problems. DISCUSSION: Despite having multiple risk factors associated with poor outcomes in COVID-19 (age greater than 45 years, male gender, comorbidity due to uncontrolled AIP and immunosupression with steroid treatment), our patient experienced complete resolution of the illness with supportive measures. Our case supports current recommendations advocating steroid therapy for co-existing diseases in patients with COVID-19.Figure 1.: Image 1. CT scan abdomen shows multiloculated ill-defined of herterogeneous consistency as well as presence of gas pockets in the pancreatic and peri-pancreatic tissues, consistent with infected pancreatic necrotic collection in (A) and (B).Figure 2.: Image 2: Bibasilar lower lung infiltrates seen on CT scan chest (A) and Chest X-ray PA view (B), consistent with COVID-19 pneumonia.

ICU admission body composition: skeletal muscle, bone, and fat effects on mortality and disability at hospital discharge\u2014a prospective, cohort study

BackgroundReduced body weight at the time of intensive care unit (ICU) admission is associated with worse survival, and a paradoxical benefit of obesity has been suggested in critical illness. However, no research has addressed the survival effects of disaggregated body constituents of dry weight such as skeletal muscle, fat, and bone density.MethodsSingle-center, prospective observational cohort study of medical ICU (MICU) patients from an academic institution in the USA. Five hundred and seven patients requiring CT scanning of chest or abdomen within the first 24 h of ICU admission were evaluated with erector spinae muscle (ESM) and subcutaneous adipose tissue (SAT) areas and with bone density determinations at the time of ICU admission, which were correlated with clinical outcomes accounting for potential confounders.ResultsLarger admission ESM area was associated with decreased odds of 6-month mortality (OR per cm2, 0.96; 95% CI, 0.94–0.97; p < 0.001) and disability at discharge (OR per cm2, 0.98; 95% CI, 0.96–0.99; p = 0.012). Higher bone density was similarly associated with lower odds of mortality (OR per 100 HU, 0.69; 95% CI, 0.49–0.96; p = 0.027) and disability at discharge (OR per 100 HU, 0.52; 95% CI, 0.37–0.74; p < 0.001). SAT area was not significantly associated with these outcomes’ measures. Multivariable modeling indicated that ESM area remained significantly associated with 6-month mortality and survival after adjusting for other covariates including preadmission comorbidities, albumin, functional independence before admission, severity scores, age, and exercise capacity.ConclusionIn our cohort, ICU admission skeletal muscle mass measured with ESM area and bone density were associated with survival and disability at discharge, although muscle area was the only component that remained significantly associated with survival after multivariable adjustments. SAT had no association with the analyzed outcome measures.

Fully automated body composition analysis in routine CT imaging using 3D semantic segmentation convolutional neural networks

ObjectivesBody tissue composition is a long-known biomarker with high diagnostic and prognostic value not only in cardiovascular, oncological, and orthopedic diseases but also in rehabilitation medicine or drug dosage. In this study, the aim was to develop a fully automated, reproducible, and quantitative 3D volumetry of body tissue composition from standard CT examinations of the abdomen in order to be able to offer such valuable biomarkers as part of routine clinical imaging.MethodsTherefore, an in-house dataset of 40 CTs for training and 10 CTs for testing were fully annotated on every fifth axial slice with five different semantic body regions: abdominal cavity, bones, muscle, subcutaneous tissue, and thoracic cavity. Multi-resolution U-Net 3D neural networks were employed for segmenting these body regions, followed by subclassifying adipose tissue and muscle using known Hounsfield unit limits.ResultsThe Sørensen Dice scores averaged over all semantic regions was 0.9553 and the intra-class correlation coefficients for subclassified tissues were above 0.99.ConclusionsOur results show that fully automated body composition analysis on routine CT imaging can provide stable biomarkers across the whole abdomen and not just on L3 slices, which is historically the reference location for analyzing body composition in the clinical routine.Key Points• Our study enables fully automated body composition analysis on routine abdomen CT scans.• The best segmentation models for semantic body region segmentation achieved an averaged Sørensen Dice score of 0.9553.• Subclassified tissue volumes achieved intra-class correlation coefficients over 0.99.

A rare hepatic mass in an Italian resident

BackgroundAmebiasis is a rare condition in developed countries but epidemiologically growing. Clinical manifestation may range from asymptomatic to invasive disease, amoebic liver abscess being the most common manifestation. We report a peculiar case of left hepatic amoebic liver abscess in a patient without a well-known source of infection and presenting with left portal vein thrombosis.Case presentationPatient, working as longshoreman, presented with complaints of remittent-intermittent fever lasting from 2 weeks. Physical examination was normal. Blood tests showed mild anemia, neutrophilic leukocytosis and elevated inflammation markers. Chest x-rays was normal. Abdominal ultrasound showed multiple hypoechoic liver masses. CT-scan of abdomen showed enlarged left liver lobe due to the presence of large abscess cavity along with thrombosis of left portal vein. The indirect hemagglutination test for the detection of antibodies to Entamoeba histolytica (Eh) was positive. Ultrasound-guided percutaneous drainage revealed “anchovy sauce” pus. Metronidazole and a follow up imaging at 3 months showed resolution of abscess cavity.ConclusionThis case shows that amoebic liver abscess is possible even in first world country patients without travel history. Left sided abscess and portal vein thrombosis are rare and hence reported.

Large Malignant Phyllodes Tumor of the Breast: Case Report of a Young Female and Review of Literature

Background: Phyllodes tumors are rare fibroepithelial neoplasm of the breast, representing 0.3 to 0.5% of all female breast neoplasms. The term ‘‘phyllodes tumor” by the World Health Organization (WHO) categorizes it into benign, borderline, and malignant tumors based on histopathological characteristics. Malignant phyllodes tumor is an uncommon but aggressive breast malignancy and accounts for approximately 25% of all phyllodes tumors.Case Presentation: A 23-year-old female patient Gravida 0 Para 0, previously healthy, with no family history of breast or ovarian cancer was referred to our institution for managing a right breast mass increasing in size over a period of 1 month associated with reddish-brown discoloration of the skin. Breast ultrasound showed an isodense oval mass measuring approximately 16x14x12cm in the right lower outer quadrant of her breast. Core biopsy and FNA done revealed a low grade phyllodes tumor. MRI of breasts showed a huge mass of the right breast occupying all quadrants, measuring 15x14.5 cm in its greatest axis with involvement of the pectoralis major muscle, with no evidence of suspicious axillary lymphadenopathy. Distant metastatic work-up with CT scan of chest abdomen and pelvis and a PET scan did not show distant metastasis. Hence, the patient underwent right total mastectomy with a final pathology compatible with malignant phyllodes tumor. She is on regular follow up and 18 months post-surgery is still disease free.Conclusion: Management of malignant phyllodes tumor remains debatable, especially when it comes to the effect of adjuvant radiotherapy and chemotherapy. From a surgical perspective, whether phyllodes tumors should be considered as epithelial breast cancers or as soft tissue sarcoma is another debate. On the other hand, although challenging, accurate identification of phyllodes tumor initially may aid in decreased recurrence.

Splenic Infarcts and Splenectomy: 5 Years of Surgical Experience

Splenic infarction is encountered rarely in clinical practice. The wide spectrum of clinical presentation makes its diagnosis elusive. It usually responds to conservative management but rarely surgical intervention is needed if it is refractory symptoms or secondary complication. We present our experience of splenectomy performed for splenic infarct which failed to respond to medical management over the last 5 years from 2015 to 2019. We performed 9 splenectomies (7 laparoscopic and 2 open). Most of these patients were young females (66.7%, 6/9). Mean age of patients in our series was 31.1 years (± 15.8 years). Fever (77.8%) and abdominal pain (66.7%) were the most common presenting symptoms. Diagnosis was made on the basis of contrast-enhanced CT scan of abdomen. Infective endocarditis (33.3%, 3/9) was the most common underlying aetiology. All of these patients initially received a trial of conservative management for a median duration of 19 days. Post-operative course was uneventful for most of these patients with a resolution of symptoms in post-operative period. There were two patients who developed surgical site infection and one who developed subdiaphragmatic collection which was drained percutaneously via a pigtail insertion. Patients were discharged after a median duration of 4 days after surgery and referred for post-splenectomy vaccination in haematology clinic. There is scarcity of literature on role of surgical intervention in symptomatic splenic infarct refractory to conservative management. How long should these patients be managed before considering them for splenectomy is a question worth exploring.

Isolated Splenic Metastasis from Ovarian Carcinoma

Isolated Splenic metastasis from ovarian cancer rarely occurs with only very few cases recorded in the literature. It can occur as a synchronous metastasis or as late as 20 years post-primary debulking surgery. A 62-year-old woman with carcinoma ovary stage IIIC was treated with primary debulking surgery in 2009, followed by six cycles of chemotherapy. In 2013, she was found to have an elevated serum CA-125 level during her regular follow-up. Imaging with CT scan abdomen showed a hyperdense lesion in splenic parenchyma of 2.1 × 2.4 cm. She underwent laparoscopic splenectomy. Histopathological examination revealed adenocarcinoma localised to the spleen, consistent with metastasis carcinoma ovary. Post-splenectomy, her CA-125 level returned to normal. Over the last 6 years, she is on regular follow-up and remains disease-free. Isolated, solitary splenic metastasis from epithelial ovarian cancer is very rare. It occurred after a DFI of 4 years and was successfully treated and is remaining disease-free without any chemotherapy for the last 7 years.

A Rare Case of Metastatic Mucinous Breast Carcinoma as a First Presentation of Colon Cancer in a Male Patient: Case Report and Review of the Literature

The majority of breast tumors are primary; however metastatic tumor to the breast from extramammary sites has an incidence of 0.5 to 3% and can be misinterpreted clinically as a primary breast tumor. We report a case of metastatic mucinous breast carcinoma as a first presentation from colon cancer in a male patient who hasn’t had any bowel symptoms. The immunohistochemical study helped in suspecting the diagnosis, which was then confirmed by CT scan abdomen and pelvis and endoscopic biopsy of the colonic lesion. Management of such patients usually by palliative chemotherapy due to the aggressive nature of the disease however, surgical intervention may be indicated in symptomatic patient or risk of tumor ulceration as in our patient.

Solid Pseudopapillary Neoplasm of the Pancreas: Clinical-Radiological-Pathological Characteristics of Four Pediatric Cases

Solid Pseudopapillary Neoplasm (SPN) of the pancreas represents 1-3 % of all exocrine pancreatic tumors and is uncommon in children. We report four pediatric patients with SPN where each patient posed a unique diagnostic and therapeutic challenge. We describe these four cases with detailed clinical-radiological-pathological correlations. All patients are female, with a median age 13.5 years. Two patients presented with abdominal pain, one with jaundice and one with an incidental pancreatic mass on abdominal CT scan. Radiological studies included abdominal ultrasound, CT scan and MRI of abdomen. Pancreaticoduodenectomy was performed in three patients and laparoscopic distal pancreatectomy in one patient. Mean tumor size was 4.5 cm (ranged from 1.9 to 11.5 cm). All SPNs were benign on histological exam. One patient developed pancreatic insufficiency post-surgery. No tumor recurrence was observed over a mean follow up period of 1 year. We conclude that diagnosis of SPN in pediatric population can be challenging due to non-specific clinical findings, and surgical removal of the tumor is usually required for definitive histologic diagnosis and treatment. Most tumors are benign and recurrence is very rare.

Situs Inversus Totalis: Operating on the Mirror Image

Situs inversus totalis is a rare congenital anomaly where the internal organs are located in the reverse position, thus forming a mirror image of the normal distribution of organs in our body, i.e. situs solitus. Laparoscopic cholecystectomy in patients with situs inversus poses a challenge for the surgeon for its anatomical variation and reverse ergonomics. Herein we report the case of a 27-year old lady who presented with pain over the left hypochondrium often radiating to left scapular region associated with flatulence and dyspepsia. Ultrasonography revealed gall stone disease with situs inversus totalis, which was subsequently confirmed with CT scan of abdomen and echocardiography. Laparoscopic cholecystectomy was performed safely with the ports placed on the left side. Patients with situs inversus may harbour other serious cardiorespiratory or intra-abdominal anomalies including anomalies of the extra-hepatic biliary tree. Performing laparoscopic cholecystectomy in them is difficult because of anatomical mirror imaging and ergonomical challenges. Prior diagnosis of the condition, proper workup and meticulous dissection at the Calot’s tringle by an experienced laparoscopic surgeon can end up with a safe surgical outcome. Safe laparoscopic cholecystectomy is feasible in patients with situs inversus provided the condition is diagnosed including the anatomical variations prior hand and the surgery is performed by an experienced laparoscopic surgeon. Moreover, every laparoscopic surgeon must be well conversant with the use of his/her left hand as well. Nowadays, robotic minimal access surgery can be a better solution to this problem.

Pleural effusion with rapid refill: A diagnostic dilemma-series of five cases

Background: A rare complication of acute or chronic pancreatitis is the formation of a mediastinal pancreatic pseudocyst (MPP). Inflammatory injury causes pancreatic ductal disruption leading to leakage of amylase rich pancreatic secretions along the paths of minimum resistance. Thoracopancreatic fistulae are caused by the posterior disruptions while anterior disruptions can cause pancreatic ascites. Patients of pancreatitis can present with symptoms like chest pain, respiratory distress, dysphagia and in extreme cases with pericardial effusion and tamponade. High index of suspicion is needed in diagnosing this condition. Here, we report the imaging characteristics of five such cases. Our results revealed three features in common: (i) extension of pancreatic pseudocyst into the mediastinum; (ii) rapid refill of pleural effusions; and (iii) imaging findings consistent with pancreatitis. Aims: 1) To evaluate the cause of rapid refill of pleural effusion in cases of acute or chronic pancreatitis with pseudocysts. 2) To evaluate the mediastinal extension of the pseudocyst.Materials and Methods: Patients with rapid refill of pleural effusion were sent to the department of surgery and subsequently to radiology for further evaluation. Chest radiographs, diagnostic and therapeutic tap, abdominal ultrasonography, barium swallow and contrast enhanced CT scans of thorax and abdomen were done. Result: All our five patients of pancreatitis with rapid refill of pleural collection were found to have mediastinal extension of the pancreatic pseudocyst with pancreatico-pleural fistula.Conclusion: Mediastinal extension of the pancreatic pseudocyst with pancreatico-pleural fistula is a rare complication following acute or chronic pancreatitis. Detailed radiological investigations are a useful adjunct to surgical management.

Clinical profile of patients with renal stone disease in a tertiary care hospital in Navi Mumbai

Renal stones is a common condition affecting human beings of both genders and all age groups worldwide. Their presentation vary from unilateral loin region pain to nausea vomiting, to burning micturation or even haematuria. Patient profile of renal stone disease differs from one geographical region to another. Therefore this prospective observational study was conducted in Dr. D.Y. Patil Medical College and Hospital, Nerul, Navi Mumbai to find out patient characteristics of this region. 100 patients were included in the study. 82% patients were females most of whom were housewives. 48% patients belonged to the age group 41-60 years. Most common presentation was left sided flank pain. CT scan and USG abdomen were equally accurate in determining the size of the renal stone. Most of the females were managed conservatively whereas most males required intervention like URS or PCNL for their treatment.

Daughter cyst sign in isolated peritoneal hydatid disease.

A 35-year-old patient with no pertinent past medical history presented with recurrent abdominal pain of three months duration. There were no associated symptoms. The abdominal ultrasound showed a homogenous, well-circumscribed cystic mass in the pelvic cavity. The immunology of cystic echinococcosis was negative. Abdomen and pelvis CT scan revealed a pelvic cyst measuring six centimeters in diameter. The cyst wall appeared bumpy and communicated with a second adjacent small rounded lesion corresponding to a daughter cyst (figure). The rest of the imaging findings were unremarkable. The diagnosis of isolated peritoneal hydatid cyst was made. The patient underwent a cystectomy with uneventful postoperative course. Daughter cysts formation is common in the parasite evolution. They are usually endogenous [1]. In some cases, the daughter cysts are progressively pushed outwards and develop as exogenous extensions [2]. The daughter cyst sign is pathognomonic for hydatid disease and is usually seen in liver hydatid cysts. Daughter cysts are associated with a high risk of recurrence after surgery. Radical excision is to be preferred in these cases [3].

CLINICAL PROFILE OF LIVER ABSCESS: A HOSPITAL BASED PROSPECTIVE STUDY.

Objectives: Liver abscess (LA) is defined as collection of purulent material in liver parenchyma which can be due to bacterial, parasitic, fungal, or mixed infection. The liver abscess is mainly classified into amoebic and pyogenic. This present study was to evaluate the aetiology, clinical profile, management and prognosis of liver abscess patients.&#x0D; Methods: A detail history, clinical examinations and relevant investigations were performed to all liver abscess patients. Investigations was performed like as routine blood investigations, chest x-ray, PA view, X-ray abdomen, AP view, ultrasound abdomen, CT scan abdomen (if needed). Culture and sensitivity of the aspirate was performed.&#x0D; Results: Data was analysed by using simple statistical methods with the help of MS-Office software.&#x0D; Conclusions: Liver abscess was commonly seen in elderly age groups. Male was more preponderance than females. Amoebic liver abscess was commonly found. Amoebic liver abscess was commonly seen in alcoholic patients. Abdominal pain, fever and abdominal distension were common clinical symptoms. Tenderness on right hypochondrial, intercostal region and hepatomegaly were the common clinical sign of liver abscess. Abscess was mostly seen in right lobe than left lobe. Most of the patients were managed by percutaneous single aspiration. If aspiration was failed, percutaneous catheter drainage was the choice for management of liver abscess. Hence, A very prompt recognition is important in instituting effective management and achieving good outcomes. Because of the nonspecific symptoms and laboratory findings, the presence of predisposing factors can be helpful in increasing the level of diagnostic suspicion. The key to successful outcome in the management of liver abscess is early diagnosis and appropriate therapy.&#x0D; Keywords: Liver abscess, age group, amoebic liver abscess, pyogenic liver abscess, alcoholic, management of liver abscess

Unusual Location of Intraperitoneal Fibromyoma: Rarity Does Not Rule Out the Diagnosis

Fibromyoma which is commonest benign tumor mostly arises from smooth muscles of uterus present in 20-25% women of reproductive age group. Round ligament Fibromyoma is rare tumor &amp; exact incidence not known. It may mimic ovarian tumor when it was intra peritoneal and located in adnexa. Preoperative diagnosis can be made by history, clinical examination, USG, CT scan of abdomen. Surgical excision is the curative treatment. A 35 years lady para 2 presented with lump in lower abdomen gradually increasing in size for 3-4 yrs and pain for 2 months. On examination firm palpable mass of 28 weeks pregnancy size. Her USG and CT scan detected well defined 28 cm x 22 cm X 20 cm mass in right adnexa &amp; diagnosis given ovarian tumor. Her CA 125 level was 97unit/ml. Laparotomy finding was a big firm lobulated tumor arises from right round ligament. Tumor removed as a whole, uterus, both ovaries, and left sided fallopian tube healthy &amp; preserved. Final histopathological diagnosis benign fibromyoma with degenerative change. So diagnosis of fibromyoma always kept in mind during the differential diagnosis of any pelvic mass.&#x0D; JCMCTA 2020 ; 31 (1) : 130-133