Diagnosis Of Jaundice Research Articles

Su1317 Unresectable Pancreatic Head Carcinoma: The Simultaneous Diagnosis and Sequential Treatment of Jaundice, Pain, and Duodenal Obstruction Can Improve the Quality of Life These Patients? A Prospective Study

Frequently, pancreatic carcinoma (PC) is inoperable at diagnosis and palliation is the treatment of choice. Pain, jaundice and duodenal obstruction deserve immediate palliative care. Endoscopic insertion of self-expandable metallic stents (SEMS) is used to relieve biliary and duodenal obstruction. Management of these patients in a single session with EUS-FNA, pain relief by EUS-guided celiac plexus neurolysis (EUS-CPN), and relief of biliary and duodenal obstruction by endoscopic placement of SEMS, has not yet been accurately defined.

Evaluación de la medición de bilirrubina total en el analizador GEM®Premier™ 4000

IntroductionThe exact and precise measurement of bilirubin is fundamental in the diagnosis and treatment of neonatal jaundice. ObjectiveTo evaluate the measurement of total bilirubin on the co-oximetry module of the Gem® Premier™ 4000 analyser (Instrumentation Laboratory), in order to use it in our hospital. A total of 113 samples of serum and 90 of blood from new-borns (NB), and 111 serum and 64 blood samples from adults, with a range of total bilirubin between 2–20 and 1.5–42 mgldL respectively, were measured. The results were compared with the 2,5-dichlorophenyldiazonium method on the Cobas® 711 analyser (Roche Diagnostics). Comparisons of procedures were calculated with linear regression analysis according to the Passing-Bablok equation and the assessment agreement of methods was analyzed with the Bland-Altman plots. ResultsThe total imprecision (CV) was less than 4%. No significant differences were found in the study of the adult samplesIn samples of newborns the slopes of the regression lines were 1.076 (1.035 to 1.097) in the newborn serum samples and 1.093 (1.028 to 1.148) in blood samples. The absolute difference between the methods was 0.6 (-1.3 to 2.6) mg/dL in serum and 0.3 (-1.3 to 1.9) mg/dL in blood. ConclusionsThere were no significant differences between the procedures evaluated in adult samples. In NB whole blood samples the proportional error was 9,3%, with discrepancies > 2 mg/dL compared to the routine method in 3,3% of them. The GEM® Premier™ 4000 analyzer could be a suitable alternative for the quantification of bilirubin in blood samples from new-borns in the neonatal units and clinical laboratories.

International Perspectives

After completing this article, readers should be able to: 1. Describe the unique characteristics of neonatal jaundice in Chinese infants. 2. Describe the major findings from a recent epidemiological survey of bilirubin encephalopathy or kernicterus in China. 3. Understand the primary causes and current problems for decreasing the incidence of bilirubin encephalopathy or kernicterus in China. 4. Outline future directions for obtaining population based data on bilirubin encephalopathy or kernicterus and formulating optimal management of neonatal jaundice. Hyperbilirubinemia is the number one reason for neonatal admission in most Chinese neonatal units. Early severe neonatal hyperbilirubinemia, resulting in bilirubin encephalopathy, may cause kernicterus, with residual hearing loss, cerebral palsy, neurodevelopmental disabilities, and other complications. It inflicts a heavy burden on both families and society. With the use of phototherapy, exchange transfusion, and other treatment technologies, kernicterus became less common, but an upward trend in incidence has been observed in recent years. China's large population, the very uneven distribution of medical resources between regions, and Asians being at high risk for hyperbilirubinemia suggest that the incidence of bilirubin encephalopathy and kernicterus should be higher than that in Western countries. Because of the lack of large-sample epidemiological surveys and population-based disease reporting systems, the specific incidence is not clear. In 1998, Yeung (1) summarized the characteristics of neonatal jaundice in China: 1) high unconjugated hyperbilirubinemia causing neonatal jaundice is particularly prevalent in South China; 2) he believes there is a “Chinese nonspecific neonatal jaundice” characterized by the clinical jaundice being more severe and longer lasting and having a delayed peak that occurs after the fourth day; 3) hemolytic disease of the newborn due to ABO incompatibility is the most common form of hemolytic jaundice; 4) in neonates with glucose-6-phosphate dehydrogenase (G6PD) deficiency, an acute bilirubin encephalopathy can appear late in the neonatal period; and 5) resolution of …

OBSTRUCTIVE JAUNDICE IN BASRAH

Obstructive Jaundice is a common surgical problem presenting to hospitals as it resulted from many etiological factors like choledocholithiasis or periampullary tumors especially CA head of pancreas. According to the difference in these etiological factors and their progress, symptoms and signs vary in different patients. Diagnostic tools like US, CT scan, MRCP, ERCP and others vary in their ability in diagnosing the main etiology and the operative procedures also differs according to the etiologies, ranging from least invasive like ERCP to very sophisticated procedures like Whipple's procedure for CA head of pancreas. Many factors may affect the morbidity and mortality like the age of patients, presenting etiology and the presence of associated comorbid diseases. This study aimed to demonstrate the main etiological factors of obstructive jaundice in Basrah and the commonest presenting symptoms and signs. Also to study the most applicable investigations and compare their results according to their accuracy in diagnosing the etiology, and to study the most common surgical intervention applied to relieve the obstruction in obstructive jaundice and hospital morbidity and mortality. Both retrospective and prospective study was done in Basrah between January 2006 and December 2009, 243 patients with obstructive jaundice were included in this study from the main general hospitals and private hospitals in Basrah. Data were collected about the presenting clinical features, the diagnostic techniques, operative procedures and the causes of in hospital mortality and morbidity and were analyzed so that a complete picture of these details can be assessed for obstructive jaundice in Basrah. The study shows no significant difference between male and female in obstructive jaundice. The majority of cases found in the age group 50-59 years. Most common etiology was choledocholithiasis. The most frequent applied investigation was the liver function test which was done to all patients. Imaging techniques were applied variably with the US was the most applied while MRCP and ERCP were the least; however, the accuracy was higher with the latter two techniques. Intervention depends on the main etiology: for the choledocholithiasis, most common operation was CBD exploration, for CA head of pancreas the most common operation done was bypass procedure and for complicated hepato-biliary hydatid disease the CBD exploration with T-tube was the common. The post operative morbidity was 20.07% mostly due to respiratory complications, while mortality was 9.86 % mostly due to sepsis. In conclusion, the most common cause of obstructive jaundice in Basrah is choledocholithiasis and CA head of pancreas comes second. ERCP and MRCP are the least applied imaging techniques in diagnosis of obstructive jaundice. The threshold for their application was very high. The least applied intervention to treat obstructive jaundice was the therapeutic ERCP, while the most common was open surgical procedures.

Endoscopic diagnosis and treatment of malignant obstructive jaundice

Malignant obstructive jaundice is biliary obstruction caused by malignant tumors.When a patient presents to a doctor,he/she is usually too late to be operated,so endoscopic treatment has gradually replaced surgery in its management.Diagnostic endoscopic methods include endoscopic retrograde cholangiopancreatography (ERCP),endoscopic ultrasonography (EUS),and per oral cholangioscopy (POCS),etc.Biliary stent placement at ERCP is the mainstay of endoscopic palliation for jaundice.Other methods include EUS-guided bilioenteric drainage (EGBD),endoscopic radiofrequency ablation,intraluminal brachytherapy of bile duct,endoscopic photodynamic therapy,etc.Magnetic Compression Anastomosis Technique (MCAT) is a new technology which has been developed recently,and its role in the management of malignant obstructive jaundice remains to be seen.Science and technology have brought along progress in endoscopic and consumable technologies.It is predicted that in the future,endoscopic diagnosis and treatment will have more applications. Key words: Malignant obstructive jaundice; Endoscopic retrograde cholangiopancreatography; Biliary stents

Pancreatic Involvement by Plasma Cell Neoplasms

Pancreatic involvement by plasma cell neoplasms is an extremely rare event, with only 50 cases described in the literature. They can present as a primary solitary extramedullary plasmacytoma or plasmacytoma secondary to a plasma cell myeloma. Clinical manifestations are due to the presence of a pancreatic mass usually in the pancreas head, which causes extra-biliary obstruction and abdominal pain. Abdominal imaging including CT scan or endoscopic ultrasound with fine-needle aspiration tissue sampling is essential for the initial diagnostic procedure. However, immunohistochemical analysis of the biopsy specimen or flow cytometry of the aspirated material is crucial to prove the monoclonality and the final diagnosis of a plasma cell neoplasm. Management of these situations include radiotherapy, chemotherapy, surgery or combined therapy. Novel medications including the immunomodulatory drugs or the proteasome inhibitors followed by consolidation with intensive chemotherapy and haematopoietic stem cell transplantation are nowadays used as upfront treatment in the cases associated to a plasma cell myeloma. Despite the rarity, plasma cell neoplasms should be considered in the differential diagnosis of obstructive jaundice and pancreatic neoplasms since they are potentially treatable situations.

Etiological spectrum and treatment outcome of Obstructive jaundice at a University teaching Hospital in northwestern Tanzania: A diagnostic and therapeutic challenges

BackgroundObstructive jaundice poses diagnostic and therapeutic challenges to general surgeons practicing in resource-limited countries. This study was undertaken to highlight the etiological spectrum, treatment outcome of obstructive jaundice in our setting and to identify prognostic factors for morbidity and mortality.MethodsThis was a descriptive prospective study which was conducted at Bugando Medical Centre between July 2006 and June 2010. All patients with a clinical diagnosis of obstructive jaundice were, after informed consent for the study, consecutively enrolled into the study. Data were collected using a pre-tested structured questionnaire and analyzed using SPSS computer software version 11.5.ResultsA total of 116 patients were studied. Females outnumbered males by a ratio of 1.3:1. Patients with malignant obstructive jaundice were older than those of benign type. Ca head of pancreas was the commonest malignant cause of jaundice where as choledocholithiasis was the commonest benign cause. Abdominal ultrasound was the only diagnostic imaging done in all patients and revealed dilated intra and extra-hepatic ducts, common bile stones and abdominal masses in 56.2%, 78.9%, 58.1% and 72.4% of the cases respectively. A total of 110 (94.8%) patients underwent surgical treatment and the remaining 6 (5.2%) patients were unfit for surgery. The complication rate was 22.4% mainly surgical site infections. The mean hospital stay and mortality rate were 14.54 days and 15.5% respectively. A low haematocrit and presence of postoperative sepsis were the main predictors of the hospital stay (P < 0.001), whereas age > 60 years, prolonged duration of jaundice, malignant causes and presence of postoperative complications mainly sepsis significantly predicted mortality (P < 0.001).ConclusionObstructive jaundice in our setting is more prevalent in females and the cause is mostly malignant. The result of this study suggests that early diagnosis and treatment plays an important role in the prognosis of patients with obstructive jaundice.

Successful operation for mitral regurgitation in a patient with Gilbert’s syndrome

A 72-year-old woman complaining of dyspnea on effort was diagnosed as having mitral regurgitation (MR). Asymptomatic jaundice had initially been noticed during primary school, and an examination had shown hyperbilirubinemia. After the diagnosis of constitutional jaundice, she had remained well without further examination or medical treatment. Laboratory data showed a total serum bilirubin (TB) level of 12.2 mg/dl and a direct bilirubin level of 0.6 mg/dl. Transesophageal echocardiography showed severe MR, and we replaced the mitral valve. Postoperatively, genetic analyses identified constitutional jaundice as Gilbert's syndrome with Y486D mutation. The TB level gradually decreased. Four years after operation she is doing well with moderate hyperbilirubinemia and a TB level of 5 mg/dl. She is free from heart failure.

Jaundice-Autism Link Unconvincing

The article by Maimburg et al,1 in which an association between diagnoses of jaundice and autism in Denmark was described, received considerable media attention. This coverage is unfortunate, because it has been potentially alarming to families of jaundiced newborns, the evidence that the association is real and causal is weak, and its clinical implications are uncertain. The authors did not have access to perinatal bilirubin levels. Instead, they used diagnoses of jaundice in birth and hospital registers, which occurred in only 4.9% of the children in their study. Given that, in fact, 60% to 80% of newborns develop jaundice in the newborn period,2,3 …

An increase in the burden of neonatal admissions to a rural district hospital in Kenya over 19 years

BackgroundMost of the global neonatal deaths occur in developing nations, mostly in rural homes. Many of the newborns who receive formal medical care are treated in rural district hospitals and other peripheral health centres. However there are no published studies demonstrating trends in neonatal admissions and outcome in rural health care facilities in resource poor regions. Such information is critical in planning public health interventions. In this study we therefore aimed at describing the pattern of neonatal admissions to a Kenyan rural district hospital and their outcome over a 19 year period, examining clinical indicators of inpatient neonatal mortality and also trends in utilization of a rural hospital for deliveries.MethodsProspectively collected data on neonates is compared to non-neonatal paediatric (≤ 5 years old) admissions and deliveries' in the maternity unit at Kilifi District Hospital from January 1st 1990 up to December 31st 2008, to document the pattern of neonatal admissions, deliveries and changes in inpatient deaths. Trends were examined using time series models with likelihood ratios utilised to identify indicators of inpatient neonatal death.ResultsThe proportion of neonatal admissions of the total paediatric ≤ 5 years admissions significantly increased from 11% in 1990 to 20% by 2008 (trend 0.83 (95% confidence interval 0.45 -1.21). Most of the increase in burden was from neonates born in hospital and very young neonates aged < 7days. Hospital deliveries also increased significantly. Clinical diagnoses of neonatal sepsis, prematurity, neonatal jaundice, neonatal encephalopathy, tetanus and neonatal meningitis accounted for over 75% of the inpatient neonatal admissions. Inpatient case fatality for all ≤ 5 years declined significantly over the 19 years. However, neonatal deaths comprised 33% of all inpatient death among children aged ≤ 5 years in 1990, this increased to 55% by 2008. Tetanus 256/390 (67%), prematurity 554/1,280(43%) and neonatal encephalopathy 253/778(33%) had the highest case fatality. A combination of six indicators: irregular respiration, oxygen saturation of <90%, pallor, neck stiffness, weight < 1.5 kg, and abnormally elevated blood glucose > 7 mmol/l predicted inpatient neonatal death with a sensitivity of 81% and a specificity of 68%.ConclusionsThere is clear evidence of increasing burden in neonatal admissions at a rural district hospital in contrast to reducing numbers of non-neonatal paediatrics' admissions aged ≤ 5years. Though the inpatient case fatality for all admissions aged ≤ 5 years declined significantly, neonates now comprise close to 60% of all inpatient deaths. Simple indicators may identify neonates at risk of death.

A ductus choledochus adenomyosisa

A woman 80 years of age had diffuse adenomyosis in the wall of the choledochus, near to the papilla of Vater. The lesion caused icterus and was operated (partial pancreatoduodenectomy). Adenomyosis should be considered in the differential diagnosis of obstructive jaundice.

Laparoscopic cholecystocholangiography for diagnosis of prolonged jaundice in infants, experience of 144 cases

Cholangiography is often crucial for establishing the definitive diagnosis in infants with prolonged jaundice. Here, we describe our protocol of using the two-hole laparoscopic technique and discuss its benefits. 144 consecutive patients with suspected biliary atresia were included in this retrospective study. A 5-mm umbilical port is introduced for a 30 degrees laparoscope. An additional 5-mm trocar was inserted at right subcostal incision. A liver biopsy was performed first if needed. The fundus of gallbladder was then exteriorized through the incision of the working port after pneumoperitoneum was released and a catheter is inserted into the gallbladder for cholangiography. The average duration of operation was 34 min (range 20-55 min). Laparoscopic cholangiography failed in 21 cases (14.6%) where atrophic gallbladder was found and BA was confirmed by subsequent laparotomy. For the remaining 123 cases, biliary atresia were diagnosed in 88 (71.5%), biliary hypoplasia in 14 (11.4%), and cholestasis in 21 (17.1%), respectively. There was no bleeding or any other complications intraoperatively. The technique of laparoscopic cholecystocholangiography is simple, safe and efficient. It can provide an accurate diagnosis. Furthermore, for patients without biliary atresia, unnecessary laparotomy can be avoided.

Laparoscopic-assisted with methylene blue staining in biliary for the diagnosis of ob-struetive jaundice in infants

Objective To explore the value of laparoscopic-assisted with methylene blue staining in biliary for the diagnosis of obstructive jaundice in infants.Methods 32 infants with obstructive jaundice, 12 male and 20 female, which were day of 52 ～ 155 ( average 68d ), were checked by laparoscopic-assisted with methylene blue staining in biliary and then inserted a catheter into the gallbladder for cholangiography.Results 10 cases were failed in laparoscopy because of the little gallbladder, while methylene blue staining in biliary showed congenital biliary atresia in 20 cases,cholestasis in 12.Cholang-iography showed congenital biliary atresia in 18 cases, cholestasis in 14 cases.There was no significant difference in the two groups by Chi Square Test.Conclusions Laparoscopie-assisted with methylene blue staining in biliary is a simple, economical, safe, obvious method in the diagnosis of obstructive jaundice in infants.By this method and combining the shape and puncturing of gallbladder, biliary atresia and cholestasis can be diagnosed.lt is a good method of diagnosing obstructive jaundice in infants in the primary hospital. Key words: Laparoscopy; Infants; Obstructive jaundice; Methylene blue staining

The Evaluation of Laparoscopy-Assisted Cholangiography in the Diagnosis of Prolonged Jaundice in Infants

Biliary atresia (BA) is the progressive inflammatory obstruction and fibro-obliteration of all or part of the extrahepatic biliary tree and the intrahepatic bile ducts and has its onset exclusively within the first several months of life. This study was undertaken to present the value of diagnostic laparoscopy in infants with prolonged jaundice and technique for laparoscopic cholangiography. A 5-mm umbilical trocar was introduced to create a port for a 30-degree laparoscope. If the gallbladder was of good size, the fundus was exteriorized through the right subcostal trocar site and a catheter was inserted into the gallbladder for cholangiography, following partial dissection from the liver bed, if required. If the gallbladder was atretic, the fundus was not exteriorized and a laparotomy was performed and cholangiography was abandoned, because the lumen of an atretic gallbladder was usually not fully patent. At laparoscopy, 12 patients had good-sized gallbladders and minimal-to-mild liver fibrosis. They underwent cholangiography via the exteriorized fundus, and infantile hepatitis syndrome (HIS) or cholestatic syndrome (CS) in 8 cases, BA in 2 cases, and biliary hypoplasia (CBDH) in 2 cases were identified. Five patients' gallbladders dissected from the liver bed underwent cholangiography, and BA in 3 cases and CBDH in 2 cases were identified. The remaining 21 had atretic gallbladders and varying degrees of liver fibrosis, so cholangiography via the exteriorized fundus was abandoned and converted to open Kasai portoenterostomy. Laparoscopy-assisted cholangiography is a simple, accurate, and safe method in the diagnosis of prolonged jaundice in infants and allows the anatomic structure of the biliary tree to be obtained accurately with minimal surgical intervention.

Biliary Non-Hodgkin Lymphoma Detected by F-18 FDG PET/CT

Abstract: Biliary involvement by non-Hodgkin lymphoma is rare with an incidence ranging from 0.5% to 2%. In this article, we describe fluoro-deoxy-glucose (FDG) avid common bile duct involvement in a patient being staged for diffuse large B-cell lymphoma with F-18 FDG positron emission tomography/computed tomography (PET/CT). We conclude that FDG PET can be a convenient noninvasive method of imaging extrahepatic biliary obstruction due to a lymphoma which should be considered in the differential diagnosis of obstructive jaundice in such patients. A positive FDG PET warrants histopathological correlation for appropriate treatment.

Clinical Value of Continuous Scanning Method of Ultrasound in Orlentaflonal Diagnosis of Obstructive Jaundice

Objective To evaluate clinical value of Continuous Scanning Method(CSM) of ultrasound in orientational diagnosis of obstructive iaundice.Methods 83 cases of obstructive iaundice were examined by Ultrasound with CSM.The results were compared with operation and pathology.Results In 83 cases of obstructire iaundice,the positions of obstructive were 5 in hepatic duct,37 in mesomere bile duct and 41 in inferior bile duct.According to the operation results,79 were coincident.The coincidence rate was 95.2% (75/83).Conclusion The CSM of ultrasound has important value in orientational diagnosis of obstructive iaundice. Key words: Continuous Scanning Method(CSM); Obstructive Jaundice; Ultrasonography; Orientational Diagnosis

Primary extranodal non-Hodgkin’s lymphoma of the common bile duct manifesting as obstructive jaundice: Report of a case

Primary non-Hodgkin's lymphoma (NHL) of the common bile duct (CBD) manifesting as obstructive jaundice is extremely rare: to our knowledge, only 22 cases of primary NHL arising from the CBD have been reported. The patient in this case report was a 63-year-old man who presented with obstructive jaundice. Abdominal sonography, positron emission tomography, and computed tomography showed a mass with abnormal 18-fluorodeoxyglucose uptake in pancreatic head. Magnetic resonance cholangiopancreatography demonstrated a strictured segment of the CBD with proximal bile duct dilatation. We performed pancreaticoduodenectomy for a presumptive diagnosis of pancreatic head carcinoma or cholangiocarcinoma of the CBD. However, the histological diagnosis was a primary, diffuse, large B-cell lymphoma of the CBD. He received three courses of combination chemotherapy, including rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). The patient remains well, without evidence of tumor recurrence, 8 months after surgery. In summary, primary NHL of the CBD, despite its rarity, should be considered in the differential diagnosis of obstructive jaundice. An accurate histopathologic diagnosis and complete surgical resection, followed by combination chemotherapy plus rituximab may be effective.

Trends in Hospitalizations for Neonatal Jaundice and Kernicterus in the United States, 1988–2005

Recent reports have raised global concerns about a reemergence of kernicterus. Accurate information on the incidence of kernicterus is unavailable because of the rarity of the condition and the lack of a systematic surveillance strategy. We used nationally representative hospital discharge data to evaluate trends in the diagnosis and management of neonatal jaundice and the incidence of kernicterus in relation to the American Academy of Pediatrics hyperbilirubinemia clinical practice guideline. The data came from the Healthcare Cost and Utilization Project family of databases. The Nationwide Inpatient Sample and the Kids' Inpatient Database were combined to generate trend data for the years 1988-2005. All neonatal discharges with primary or secondary International Classification of Diseases, Ninth Revision, Clinical Modification diagnoses codes for jaundice or kernicterus occurring within the first 30 days of life were selected with population incidence rates calculated from estimates of term and preterm newborn hospitalizations derived from the Healthcare Cost and Utilization Project data. To increase the reliability of identified kernicterus hospitalizations, newborns with a diagnosis of kernicterus and a procedure code for phototherapy or exchange transfusion were included as cases. Hospital diagnosis codes for kernicterus likely included a substantial number of rule-out cases, because approximately 70% did not include a procedure code for phototherapy or exchange transfusion. Including only cases with a procedure code for phototherapy or exchange transfusion resulted in 2.7 per 100000 diagnosed with kernicterus over the entire study period. A diagnosis code for jaundice was recorded for 15.6% of newborns. The diagnosis of jaundice and kernicterus differed according to race and gender. Rates also were elevated in preterm relative to term infants for both jaundice and kernicterus. Trends in diagnosis for newborn jaundice were u-shaped, with rates falling in the years before the initial American Academy of Pediatrics guideline (1988-1993) and increasing in the years after publication of the guideline (1997-2005). In contrast, the number of newborn hospitalizations with a diagnosis of kernicterus generally declined throughout the study period. Most of the decline in hospitalizations for term infants with a diagnosis of kernicterus occurred before and immediately after publication of the 1994 guideline, going from 5.1 per 100000 in 1988 to 1.5 per 100000 in the years from 1994 to 1996 and has since remained constant. Nationally representative hospital data indicate a declining incidence of hospitalizations with a diagnosis of kernicterus in newborn infants over the period 1988-2005. The decline occurred before and immediately after publication of the 1994 American Academy of Pediatrics guideline on hyperbilirubinemia. Epidemiologic findings were mostly consistent with other studies. Healthcare Cost and Utilization Project data provide an important system for monitoring hospitalizations of uncommon newborn conditions such as kernicterus.

Extramedullary plasmacytoma of the pancreas as an uncommon cause of obstructive jaundice: a case report

IntroductionThough uncommon, extramedullary plasmacytoma of the pancreas should be considered in the differential diagnosis of obstructive jaundice and pancreatic neoplasms. This report highlights a case of obstructive jaundice in a 46-year-old West Indian man that resulted from an extramedullary plasmacytoma.Case presentationA 46-year-old West Indian man presented to our hospital with evidence of a significant upper gastrointestinal bleed. He gave a recent history of jaundice, constitutional symptoms and back pain. Ultrasonography revealed a mass in the head of the pancreas with resultant common bile duct dilatation. The patient required urgent surgical intervention for ongoing bleeding at which time a biopsy of the pancreas was taken. Histological analysis revealed a plasmacytoma of the pancreas. A blood film showing rouleaux formation and a skeletal survey demonstrating multiple lytic lesions confirmed multiple myeloma. Before further evaluation or treatment was carried out, the patient defaulted from follow-up and died from his illness seven months later.ConclusionThis case represents an example of multiple myeloma with visceral involvement, brought to clinical attention through involvement of the pancreas. The report serves to reaffirm knowledge of the various presentations, the optimal diagnostic tools and the current proposed treatment strategies for extramedullary plasmacytomas of the pancreas.

Carotenemia in an African lady

Carotenemia is characterized by an abnormal yellowish orange pigmentation of the skin, predominantly seen on the palms and soles. Although it may be associated with several diseases such as diabetes, hypothyroidism and anorexia nervosa, it is caused by excessive intake of carotene-rich food such as oranges and carrots in most cases. The condition is harmless, but it can lead to a mistaken diagnosis of jaundice. Herein, an interesting case of carotenemia is described in a 32-year-old female secondary to increased ingestion of oral sweet potatoes and oranges.<br>