Pain In Right Upper Quadrant Research Articles

SUN-325 A Neuroendocrine Tumor with Liver Metastases in a patient with Acid Peptic Disease

Introduction: Gastrinomas are neoplasms that occur in 0.1% of patients with peptic ulcer disease (PUD). We present the case of a neuroendocrine tumor with liver metastasis in a woman with acid peptic disease. Clinical case: 46 yo F with 2 year diagnosis of gastroesophageal reflux disease (GERD) presents with epigastric pain and pyrosis, in addition to colicky right upper quadrant (RUQ) abdominal pain. Upper gastrointestinal endoscopy showed gastritis, multiple antral ulcers and erosive duodenitis. Positive rapid urease test prompted the start of a Helicobacter pylori eradication regimen. Due to continuing RUQ pain, an abdominal ultrasound (US) was ordered. It showed a lesion in the right lobe of the liver measuring 6.4 x 8.3 cm. The patient was referred for admission for further studies. At admission, the patient continued with symptoms of GERD. Laboratory testing showed: glucose: 87 mg/dl (n <100 mg/mL), creatinine: 0.5 mg/dl (n 0.4 - 1.1 mg/mL), total leucocytes: 7.3 x 109/L (n 4.0 -11.0 x 109/L), hemoglobin: 13.2 g/dL (n 12.3-15.3 g/dL), and no alterations on coagulation tests. Gastroscopy showed erythematous mucosa and three duodenal ulcers in scarring stage. A hormone evaluation showed: gastrin: 19,500 pg/ml (n 0-100 pg/mL), ACTH: 17pg/mL (n 5-27 pg/mL), cortisol: 21 µg/dL (n 7-28 µ/dL), GH: 0.3 ng/mL (n <10 ng/mL) , prolactin: 23 ng/mL (n 2-29 ng/mL), PTH: 64 pg/ml (n 10-65 pg/mL), calcium: 8.8 mg/dl (8.9-10.2 mg/dL), and phosphorus: 3.6 mg/dl (n 2.5-4.5 mg/dL). Liver biopsy revealed a neuroendocrine tumor (NET). Octreoscan corroborated the liver lesion, in addition to a lesion in the tail of the pancreas. The patient underwent extended right hepatectomy, distal pancreatectomy and splenectomy. Two lesions were identified in the pancreas, one of 2.4 x 1.6 cm and another one of 1.1 x 0.5 cm. A lesion measuring 13.2 x 8.7 cm and another one of 2.4 x 2 cm was found on the liver surgical sample. Immunohistochemical staining for gastrin and glucagon for the neuroendocrine metastatic tumor was positive. Conclusion: Approximately 25% of gastrinomas are associated with multiple endocrine neoplasia type 1; in this case, the gastrinoma appears to be sporadic. Gastrinomas occur more frequently in men (3:1), and it is diagnosed most frequently between the ages of 20 and 50. Zollinger-Ellison syndrome presents with recurrent PUD in over 90% of cases. The diagnosis is suspected because of clinical presentation, and gastrin levels, which are generally above 1000 pg/ml. Octreoscan is preferred due to its superior sensibility in comparison to other tests for tumor detection. Alternatively, MRI, spiral CT scan, and endoscopic US can be used. Metastases resection, when anatomically possible, is recommended for the treatment of liver metastasis, in addition to somatostatin analogs for symptoms management. Other treatment modalities are chemoembolization and systemic chemotherapy.

Metastaza kutanog melanoma u žučnu kesu - prikaz slučaja

Melanoma is an aggressive malignant tumor that originates from melanocytes and most commonly occurs on the skin. Dominantly metastasize to regional lymph nodes, in the brain and lungs and rarely in the gastrointestinal (GI) system. The aim of this report is to present a rare case of metastasis of cutaneous malignant melanoma in the gallbladder, discovered 10 months after excision of the primary melanoma of the skin. A45-year-old patient was hospitalized in our hospital due to abdominal pain in right upper quadrant and nausea lasting for 7 days. An intraluminal substrate was found in the gallbladder with computed tomography and later a CT guied biopsy was performed on it, thus proving a metastatic deposit of primary malignant melanoma. Metastatic deposits in the gallbladder are extremely rare finding, and 238 cases have been described in the literature.

A Common Presentation of Right Upper Quadrant Pain in an Uncommon Disease

The presentation of right upper quadrant abdominal pain is common, non—specific and challenging to diagnose. Right upper quadrant (RUQ) pain can be benign but may also signal serious pathology. Early diagnosis is key to preventing possible complications. This case aims to highlight a presentation of RUQ pain in a young male which heralded a more sinister pathology. A previously healthy 36year—old male presented with one—week of intermittent fevers and progressive sharp RUQ pain with chills, night sweats, early satiety and fatigue. Initial assessment was significant for HR 116, RUQ tenderness with guarding, no rebound or organomegaly. Laboratory findings were only significant for lactate 11.08mg/dL. Cultures were negative, AFP was normal. HIV, HBV and HCV were negative.Abdominal ultrasound revealed heterogeneous large right hepatic lobe mass suggestive of hemorrhage, hepatic adenoma, metastasis, fibrolamellar hepatocellular carcinoma (HCC) or hepatic abscess. MRI with contrast had similar findings with large non—enhancing geographic regions, T2—hyperintense and T1—hypointense, consistent with necrosis or blood products. MRI was suggestive of atypical HCC, fibrolamellar HCC, angiosarcoma or metastases; hepatic adenoma unlikely in the absence of risk factors. CT—guided biopsy revealed hepatic neoplasm favoring adenoma with atypical findings evidenced by immunostaining, diffuse strong glutamine synthetase staining and no nuclear beta—catenin staining, positive serum amyloid A, and retained LFABP. Glutamine synthetase staining was concerning for beta—catenin invasion. He underwent a right hepatic lobectomy, with pathology finding of hepatic adenoma, and no recurrence at 1—year follow—up. Hepatocellular adenomas (HCA) are rare, benign tumors which occur mostly in women and are strongly associated with the use of estrogens, anabolic and androgenic steroids. There are no specific diagnostic serologic or imaging studies. The new Bordeaux HCA subtype classification is based on genetic and phenotypic characteristics and provides insight into the pathological and radiological diagnosis and clinical management. Complications such as rupture, hemorrhage and malignant transformation to HCC increase mortality markedly. Mortality is low when recognized and treated early. It is, therefore, an important differential to consider in a patient with RUQ pain in the presence of a liver mass with no underlying cirrhosis. The absence of risk factors does not exclude the diagnosis.3020_A.tif Figure 1: Abdominal ultrasound: Large heterogeneous right hepatic lobe mass with suggestion of internal hemorrhage.3020_B.tif Figure 2: Contrast—MRI, coronal and axial views: marked enlargement of the right hepatic lobe secondary to a large mass with intrahepatic blood products suggesting rupture/hemorrhage3020_C.tif Figure 3: Liver biopsy histology: Hepatocellular neoplasm, favor adenoma with atypical findings. Diffuse strong glutamine synthetase staining, serum amyloid A positive, retained LFABP, no nuclear beta—catenin staining and noncontributory reticulin special stain

Pediatric Biliary Dyskinesia: Evaluating Predictive Factors for Successful Treatment of Biliary Dyskinesia with Laparoscopic Cholecystectomy

Biliary dyskinesia (BD) is a motility disorder of the gallbladder that can result in right upper quadrant (RUQ) pain, nausea, vomiting, and diarrhea. Cholecystectomy is considered the standard of care for BD. Up to 23 per cent of pediatric patients who undergo surgery for BD have persistent symptoms postoperatively. We performed a retrospective review to identify preoperative factors significantly associated with symptom resolution after cholecystectomy. We retrospectively reviewed pediatric patients aged 10-17 years diagnosed with BD who underwent cholecystectomy between 2006 and 2016. Patients were divided into two groups based on postoperative symptom resolution. Chi-squared and student t tests were used to compare patient groups. Two hundred and thirty-six patients were included in the study. The most common preoperative symptoms included RUQ pain (80.1%), nausea (54.2%), postprandial pain (44.5%), vomiting (32.6%), and epigastric pain (19.9%). The rate of postoperative symptom resolution was 68.6 per cent. Comparative analysis showed patients who presented with RUQ pain, nausea, postprandial pain, or constipation experienced significantly higher rates of symptom resolution postoperatively. In addition, patients with ejection fraction <35 per cent or pain reproducible with cholecystokinin were found to have significantly higher rates of symptom resolution as well. To date, it remains difficult to predict successful outcomes for pediatric patients undergoing cholecystectomy for BD. In our study, patient demographics and duration of symptoms did not affect postoperative outcomes. Pediatric patients who presented with RUQ pain, nausea, postprandial pain, constipation, an ejection fraction of <35 per cent on hepatobiliary iminodiacetic acid, or pain reproducible with cholecystokinin injection, were found to have significantly higher rates of symptom resolution.

Symptomatic Cholelithiasis of a Remnant Gallbladder after Open Cholecystectomy

BackgroundRecurrent abdominal pain, particularly in the right upper quadrant (RUQ) in a patient with a history of cholecystectomy, known as postcholecystectomy syndrome, requires a broad differential diagnosis. Pathology of a retained gallbladder remnant is an exceedingly rare etiology of this pain. Case ReportA 49-year-old woman who had previously undergone an open cholecystectomy presented to the emergency department with several hours of postprandial RUQ pain and emesis. Liver function tests and lipase were not significantly elevated. RUQ ultrasonography revealed a cystic structure containing a stone with mild prominence of the common bile duct at 7 mm, and magnetic resonance cholangiopancreatography confirmed the presence of a remnant gallbladder without common bile duct obstruction. Her pain subsided, she tolerated a diet, and was discharged with a referral for an elective cholecystectomy. Why Should An Emergency Physician Be Aware of This?Abdominal pain is the most common chief complaint of patients presenting to the emergency department in the United States, and emergency physicians routinely encounter patients with postcholecystectomy syndrome. Emergency physicians should not exclude the possibility of remnant gallbladder pathology, such as symptomatic cholelithiasis or cholecystitis, in patients presenting with symptoms concerning for biliary colic, even if the patient has undergone previous cholecystectomy.

Emergency Department Bedside Ultrasonography for Diagnosis of Acute Cholecystitis; a Diagnostic Accuracy Study.

Using bedside ultrasound in diagnosing acute cholecystitis in the emergency department (ED) can save time, help the decision making process and allocate resources wisely. This study aimed to evaluate the diagnostic accuracy of bedside right upper quadrant (RUQ) ultrasonography in detection of acute cholecystitis. In this diagnostic accuracy study, patients presenting to ED, suffering from RUQ pain in favor of acute cholecystitis underwent RUQ ultrasonography in emergency and radiology departments and interrater agreement between reports was calculated. 342 patients with the mean age of 53.92 ± 11.18 (20 - 83) years were studied (63.2% female). The number of patients with at least one sonographic finding of acute cholecystitis were 53 (15.50%) and 48 (14.00%) based on ED and radiology reports (Kappa = 0.826). Sensitivity, specificity, positive and negative predictive values, as well as positive and negative likelihood ratios of bedside sonography were 89.58 (95%CI: 76.55 - 96.10), 96.59 (95%CI: 93.63 - 98.29), 81.13 (95%CI: 67.58 - 90.11), 98.26 (95%CI: 95.77 - 99.36), 4.30 (95%CI: 2.42 - 7.62) and 0.017 (95%CI: 0.007 - 0.041), respectively. There was a very good agreement between ED and radiology departments' sonography reports regarding the presence or absence of acute cholecystitis. Sensitivity and specificity of bedside RUQ sonography were 89.58 and 96.59, respectively.

Postcholecystectomy syndrome: symptom clusters after laparoscopic cholecystectomy.

PurposePostcholecystectomy syndrome (PCS) is characterized by abdominal symptoms following gallbladder removal. However, there is no consensus for the definition or treatment for PCS. The purpose of this study was to define PCS among various symptoms after laparoscopic cholecystectomy, and to identify risk factors affecting PCS.MethodsThis study was conducted at Dongguk University Ilsan Hospital and Chung-Ang University Hospital (2012–2013). Outcomes were assessed using European Organization for Research and Treatment of Cancer QLQ–C30 questionnaire. Symptom cluster for determining PCS was made by factor analysis. Cluster analysis evaluating risk factors of PCS was made by Ward methods and Dentogram.ResultsFactor analysis revealed three distinct symptom clusters, those are ‘insomnia and financial difficulties (eigenvalue, 1.707; Cronbach α, 0.190),’ ‘appetite loss and constipation (eigenvalue, 1.413; Cronbach α, 0.480),’ and ‘right upper quadrant (RUQ) pain and diarrhea (eigenvalue, 1.245; Cronbach α, 0.315).’ Among these symptom clusters, the cluster of ‘RUQ pain and diarrhea’ was determined as PCS. However, we could not find any risk factors between high symptomatic group and low symptomatic group.ConclusionPCS could consist of RUQ pain and diarrhea. Well-designed prospective trials are needed to determine risk factors of PCS.

A case of choledocholithiasis secondary to post cholecystectomy clip migration

Introduction The commonly reported risks of a cholecystectomy include bile leak, bile duct injury, infection, bleeding, and retained gallstones. Approximately 1-2% of all patients who undergo cholecystectomy have stones left in the common bile duct (CBD) that require further intervention. The use of surgical clips to ligate the cystic duct has been routine since the advent of the laparoscopic cholecystectomy as the standard of care in the 1990s. One rare risk associated with the use of surgical clips is a migrated clip that can result in an obstructed CBD. Case description The patient is a 72 year old male who presented with sudden onset, severe, right upper quadrant (RUQ) pain with associated nausea and vomiting after eating fried food. His past surgical history was significant for an uncomplicated laparoscopic cholecystectomy 7 years prior for acute cholecystitis. The patient had been having intermittent RUQ pain for 2 years prior to his presentation and had undergone an esophagogastroduodenoscopy that demonstrated mild gastritis. The patient had no other surgical or procedural history. On examination, the patient had mild tenderness to palpation in the RUQ. Of note, his labs were significant for a white blood cell count of 11000, aspartate aminotransferase of 760, alanine aminotransferase of 427 and total bilirubin of 3.0. A computed tomography scan demonstrated a hypodense lesion in the intrapancreatic common bile duct with the morphology of a surgical clip measuring 7mm. Magnetic resonance cholangio-pancreatography confirmed the CT findings. The decision was made to proceed with an endoscopic retrograde cholangio-pancreatography (ERCP) from which a clip inside a sludge ball was extracted. The patient tolerated the procedure well and underwent a routine post-procedure course. Results and Conclusions Post cholecystectomy clip migration is a rare condition that can lead to choledocholithiasis and cholangitis. Predisposing factors that have been suggested include cholecystitis, postoperative complications and the use of an excessive amount of clips. It has been theorized that the mechanism for clip migration is secondary to inadvertent placement of clips in the biliary tree, clip slippage or subclinical bile duct injuries. The appropriate treatment strategy for choledocholithiasis secondary to post cholecystectomy clip migration is ERCP.

Misdiagnosis of Caroliʼs Disease: A Case Report

Caroli's disease (CD) is a rare inherited condition characterized by localized or diffused, multifocal, segmental dilatation of the intrahepatic bile ducts. Caroli's syndrome (CS) is a more complex form of a disease associated with congenital hepatic fibrosis (CHF) and often accompanied by cholangiocarcinoma, calculi of the intrahepatic duct, cholangitis, pancreatic cyst, and various renal disorders including autosomal polycystic kidney disease (PKD), medullary sponge kidney and medullary cystic disease. A 41-years-old man presented with high fever, chills, fatigue, nausea, vomiting, and pain in right upper abdominal quadrant. Physical examination showed poor general state, tachycardia, mild icterus and hepatosplenomegaly. Laboratory evaluation (Table 1) revealed increased parameters of acute inflammation, liver and kidney function tests; MRCP showed hepatosplenomegaly, multiple cysts in both kidneys with reduced parenchyma, and diffuse cystic/fusiform dilatation of the intrahepatic bile ducts (Image 1 and 2). As 9-month-old infant, he experienced first episode of pyelonephritis that became recurrent and accompanied with vesicoureteral reflux, resulted in chronic renal insufficiency diagnosed 23 years ago. Althought hepatosplenomegaly was verified in early childhood, no further testing were performed. During time, our patient developed recurrent cholangitis but without clear consensus between radiologist and gastroenterohepatologists about pathological substrate - CD, CS or primary sclerosing cholangitis (PSC), although MRCP was performed several times. Liver biopsy in 2007 showed multiple bile duct hamartomas (MBH), without evidence of CHF. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 2008, and endoscopist reported changes in bile duct suggesting PSC. In order to resolve the diagnostic dilemma, after resolving current episode, genetic testing (exome sequencing) was carried out, now we waiting the results. Based on recurrent cholangitis, cystic dilatation of the intrahepatic bile ducts associated with PKD, normal findings on extrahepatic bile ducts, and presence of MBH, we concluded that our patient most likely has CS. In some cases MRCP, ERCP, not even liver biopsy is not sufficient to clearly diagnose CD; in this case genetic analysis may be helpful. In children and adult patients who present with recurrent cholangitist and hepato/splenomegaly or in all cases with cholagitis and PKD, we must consider CD or CS.Table: Table. Laboratory Data on Admission to the HospitalFigure: MRCP, frontal section: Diffuse cystic/fusiform dilatation of the intrahepatic bile ducts, but more in the left lobe, with enlarged polycystic kidneys.Figure: MRCP reconstruction of the biliary tree: Multiple cystic dilatations communicating with intrahepatic biliary tree and normal caliber of common choledochal duct.

Laparoscopic management of liver echinococcal cyst at B.P.Koirala Institute of Health Sciences Dharan, Nepal an institutional review

Background: Hydatid disease is an endemic disease in several parts of the world. Surgeons and physicians in the non-endemic areas may encounter the disease. Surgery remains the mainstay of therapy. Recently, laparoscopic treatment of hepatic hydatid disease has been increasingly popular and has undergone a revolutionary parallel to the progress in laparoscopic surgery. It is a new and encouraging approach with minimum morbidity and mortality.Objective: To assess the outcome of laparoscopic management of hydatid cyst.Methods: A retrospective &amp; prospective case series study included all patients of hydatid liver cysts who were managed laparoscopically from 1st January 2008- 31st June 2013 (five &amp; half yrs). Patients with deep intraparenchymal location of the cyst, more than 3 cysts and cysts with calcified walls were excluded.Results: Thirty two patients were included in this study to know the results of the laparoscopic management of hepatic hydatid cyst disease. Majority of patients in the age group of 21-40 years. The mean age was of 38± 5.25 with range being 19-65 years. The commonest presentation of dull aching pain in right upper quadrant was seen in 21(62.5%) patients followed by hepatomegaly in 12 (37.5%) patients &amp; right upper abdominal lump in 8 (25%) patients. Twenty seven (84.3%) patients had single cyst &amp; 5 (15.6%) patients had two cysts. The mean diameter of the cyst was 9.2±2.72 cm in size. The mean operative time was (65.42±12.67min) with range being 45-125 mins.Conclusion: The laparoscopic approach is safe &amp; feasible in selected patients. The treatment choices of hydatid disease of the liver have increased in the last 2 decades including medical treatment, percutaneous drainage, or a combination.Health Renaissance 2015;13 (1): 86-94

THREE PORTS LAPAROSCOPIC REPAIR OF ADULT MORGAGNI HERNIA AND RARE SIMULTANEOUS PRESENTATION OF PARA-ESOPHAGEAL HERNIA WITH MORGAGNI HERNIA

We report two case reports of Morgagni hernia repair. Our first case was on 65 year old white male who presented with abdominal pain in right upper quadrant and right side of chest for last 3 days. He was having 3 episodes of dark appearing vomiting associated with pain. He also had two episodes of hematemesis. Patient had gastric outlet obstruction with severe distension of stomach because of incarcerated small bowel and colon in the right sided anterior diaphragmatic Morgagni hernia. Laparoscopic repair of incarcerated Morgagni hernia under general anesthesia was planned. We report our second case on rare simultaneous presentation of Morgagni Hernia with type 3 Para esophageal hernia. 60 years old female patient presented in clinic with a follow up of chest discomfort which was progressively increasing with shortness of breath and a chronic gastric reflux. Her vitals were within normal limits and had body mass index (BMI= 29.52kg/m2) (overweight category). Previous past medical history included multiple episodes of gastric regurgitation and cardiovascular intervention for coronary stenting. CT scan showed type 3 paraesophageal hernia (gastro esophageal junction with fundus of stomach displaced above diaphragm). The patient had more than 30% of her stomach incarcerated in the chest as a paraesophageal hernia. The gastro esophageal junction was intra-abdominal after lysis of adhesion. Mesh was placed after posterior crural repair, followed by Nissen fundoplication over a 54 French bougie patient also had an incidental finding of a reducible Morgagni hernia through an anterior defect, followed by a repair without mesh. Esophago-gastro-duodenoscopy showed there was no evidence of any air leak with good valve creation on retroflexion through a fundoplication.

Endoscopic ultrasound-guided coiling of hepatic artery pseudo-aneurysm in two stages

Background:Hepatic artery pseudo-aneurysms are rare and have been reported after abdominal trauma and after abdominal surgery. Hepatic artery pseudo-aneurysms constitute 20% of all visceral artery aneurysms. It carries very high risk of rupture with severe bleeding into peritoneal cavity, bile duct, or portal vein. Essentially, all pseudo-aneurysms, whether symptomatic or not symptomatic, require early treatment to prevent lethal complications. Surgical treatment consists of ligation or revascularization of the hepatic artery but is associated with higher morbidity compared to endovascular treatment. The goal of endovascular treatment of hepatic aneurysms is to obtain a complete, stable exclusion of the sac from arterial circulation with preservation of the parent vessel. Endovascular, percutaneous, and endoscopic ultrasound (EUS)-guided interventions are used in the treatment of visceral artery pseudo aneurysms.Case Report:A 20-year-old male presented with abdomen pain in right upper quadrant for two months. He had undergone ultrasound-guided aspiration of liver abscess two months ago. Ultrasound abdomen showed an aneurysm arising from hepatic artery. Computed tomography angiography of the abdomen confirmed a saccular pseudo-aneurysm arising from proximal part of hepatic artery. The lesion was not considered feasible for percutaneous intervention. Interventional radiologist suggested hepatic artery stenting across the neck of aneurysm to block the flow of blood into the aneurysm and explained the associated risk of ischemia, infarction due to stent stenosis, thrombosis, and distal migration of the stent. After discussing the pros and cons of EUS-guided procedure, the patient chose EUS-guided coil embolization. The sack packing with helical coils was planned. Packing with one coil of 10 mm and five coils of 6mm size through a 19-gauge needle caused 80% obliteration of the sac. Five days later, EUS assessment showed the injected coils were collected into the most distal part of the aneurysm but the flow into a smaller cavity continued with high velocity. During the second attempt, four coils of 10 mm size were deployed. Postcoiling EUS assessment still showed flow into the aneurysm. Three more coils of 8 mm size were placed and complete obliteration of aneurysm was confirmed by contrast injection and EUS. One week later, follow-up color Doppler abdomen showed no flow in the pseudo-aneurysm.Conclusion:This case showed the practical problems of EUS-guided coil embolization of hepatic artery aneurysm. Initial attempt resulted in 80% obliteration of aneurysm cavity but did not cause progressive thrombosis of rest of the cavity of the aneurysm. However, successful and complete obliteration of pseudo-aneurysm was achieved in second attempt of coiling.

Comparative Study of Clinical Profile in Patients with Solitary versus Multiple Gall Stone

BACKGROUND: Gallstones represent a major health problem across the world.1 In the United States the prevalence is about 10% and increasing up to 30% in advance age people.2 Its Prevalence in Islamic Republic Pakistan is around 15 to 20 %.3 OBJECTIVE: Aim of our study is to assess the differences in clinical presentation between single and multiple gallstones. DESIGN: Comparative study. SETTING: This study was conducted at surgical department of Liaquat University Hospital Jamshoro, Sindh, Pakistan. DURATION: 1st Feb 2010 to 31st January 2014. SAMPLE SIZE: Total one hundred patients. METHODOLOGY: All sonographically diagnosed patients of gallstones admitted into the ward. Clinical presentation like signs, symptoms and preoperative ultrasound findings of all patients were noted on predesigned performa, than after all necessary preoperative workup patients fit for surgery underwent cholecystectomy under elective conditions. The gallbladder was incised and the gallstones were exposed. The number of stones (single or multiple) in each gallbladder was recorded and on this basis all patients were divided into two groups. Group “A” labeled as a single stone and group “B” multiple stone. RESULTS: The age range from 20 to 70 years, mean age was 44±5.5 years. Incidence of disease is about five times higher in female than males (80% female, 20% male). 80% of patients had multiple stones, 20% patients had single stones. Majority of patients of group “A” has colicky type of pain and located in right upper quadrant and majority of group “B” patients has dull pain and located in Epigastrium. Other clinical symptoms like dyspepsia, vomiting and fever have no major difference in both groups. Sonographic findings are also almost same in both groups. CONCLUSION: It is concluded from our study that the clinical and Sonographic presentation is almost same in both groups, except site and type of pain.

Hepatic subcapsular hematoma: a rare late complication after ERCP

We present a clinical case of a 83 years old man, who consulted to the Emergency Department by continuous pain in right upper quadrant, having been discharged a week ago after ERCP for choledocholithiasis. TAC was performed showing a subcapsular hematoma without active bleeding. This complication post ERCP has been described on few occasions.

Myriad Imaging Appearances of Biliary Hydatidosis

A 35 years old lady, farmer by occupation, presented to the outpatient department with intermittent pain in right upper quadrant for the last 3 months which was mild to moderate intensity, dull ache, non-radiating with occasional nausea and nonbilious vomiting, no relation of pain to meals. She had experienced similar episodes of pain 3 years back for 1 year and was managed conservatively. Pain was not associated with fever, jaundice, abdominal distension, lump in abdomen or altered sensorium. On examination she was conscious, afebrile and her vitals were normal. On per abdominal examination she had hepatomegaly. There was no evidence of splenomegaly, ascites or lump in abdomen. Investigations revealed normal haemogram and renal function tests. Liver function tests revealed normal bilirubin with elevated aspartate aminotransferase [180 U/L (40U/L)], alanine aminotransferase [97U/L (40U/L)] and alkaline phosphatase [564U/L (91U/L)]. Contrast enhanced computed tomography (CECT) showed well defined cystic lesion of size 5 × 4 cm in segment 4 of liver with peripheral calcification, showing communication with one of the peripheral branches of left hepatic duct with intrahepatic biliary radicle dilatation (IHBRD) and common bile duct dilatation up to 12 mm (Image A-C). In view of dilated common bile duct up to 12 mm and normal bilirubin, endoscopic ultrasonography examination (EUS) was planned. It showed normal gall bladder with common bile duct diameter of 11 mm with presence of longitudinal floating membranes within CBD (Image D). She underwentendoscopic retrograde cholangiography (ERCP) which revealed CBD of 15 mm with longitudinal filling defects with cystobiliary communication (Image E). On flushing and suctioning, green membranes were seen oozing from papilla (Image F). A 10 Fr x 10 cms plastic biliary stent was placed. Post biliary stenting, she was given Tablet albendazole 400 mg once a day for 3 months and repeat ERCP with cholangiogram was performed. It showed normal CBD with no filling defects. Her CBD stent was removed and discharged in clinically stable condition after stent removal.

Congenital Diaphragmatic Hernia with Delayed Presentation.

Congenital diaphragmatic hernia (CDH) is caused due to abnormal formation of the muscular parts of diaphragm. The incidence of CDH in common births ranges from 1/25000 to 1/30000. Pulmonary hypoplasia and pulmonary hypertension are factors that associate with the increase of mortality and morbidity due to CDH. We presented a 68-year-old Iranian woman with abdominal pain and tenderness in right upper quadrant who was diagnosed as having CDH. The disease was detected using chest X-ray and chest and abdomen sonography and confirmed with chest and abdomen CT scan with and without oral contrast. A defect was revealed in posterolateral right diaphragm with omentum and transverse colon herniated through it. Right posterolateral thoracotomy was performed to cure the disease. CT and CXR were the two useful methods in diagnosis of CDH in this patient, although CDH detection prior to surgery is too challenging because of rare cases and different types of CDH. In order to improve clinical cares in adult CDH patients, investigating more cases and long term follow-up are recommended.

Mirizzi’s Syndrome

Mirizzi’s syndrome was an obstruction caused by gallstone located in gallbladder neck (or cystic duct) or outside gallbladder that caused a dilatation of gallbladder and narrowing of adjacent duct, sometimes with the presence of cholecystocholedochal fistula. Mirizzi’s syndrome was a rare complication of gallbladder stone. We reported a 42 years old woman complained progressive icteric sclera. Patients also complained dark urine and light stool. During physical examination, we found an icteric sclera, pain in right upper quadrant (visual analogue scale/VAS 3), and generalized icterus (greenish yellow). Complete examination revealed a Mirizzi’s syndrome.

Epstein Barr virus infection and acalculous cholecystitis, a rare association in a pediatric patient

Acute acalculous cholecystitis associated with Epstein Barr virus (EBV) infection is a known entity, as opposed to the extremely rare cases of cystic duct stenosis secondary to EBV- related inflammation. The authors present the case of a 10-year-old male patient admitted with altered general state, anorexia, painful and distended abdomen. The patient had a history of EBV acute hepatitis two years prior to the current presentation, diagnosed based on clinical examination (fever, vomiting, and severe pain of right upper abdominal quadrant), and abdominal ultrasound revealing acute acalculous cholecystitis with gallbladder hydrops; still no indication for surgical treatment was made. The clinical outcome was favorable, but during those two years he suffered two episodes of chronic acalculous cholecystitis exacerbation, which required a MRI examination, indicating gallbladder hydrops and narrowing of terminal segment of the cystic duct (secondary inflammatory processes). The biological investigations revealed cholestasis, hepatocytolysis and inflammatory syndrome and the abdominal-ultrasound indicates an acalculous gallbladder and gallbladder hydrops. After cholecystectomy, the histopathological examination revealed chronic inflammation of the gallbladder wall, setting the diagnosis of exacerbation of chronic acalculous cholecystitis. Particularly for the case is the development of cystic duct stenosis, after the EBV acute infection. The clinical and laboratory outcome (monitored after 1, 3, 6, and 12 months) was favorable.

Abdominal Pain: An Omental Occasion: Presidential Poster

A 45-year-old woman with no significant medical history presented with two days of right upper quadrant (RUQ) pain. The pain started as vague, diffuse abdominal discomfort but progressed to severe RUQ pain that worsened with inspiration, movement and food intake. Bowel movements were unchanged. On initial examination she was afebrile with normal vital signs. Abdominal exam revealed RUQ tenderness and positive Murphy's sign. Blood work was significant for WBC of 20,200/mm (83% neutrophil), total bilirubin 1.0mg/dL, and direct bilirubin 0.2mg/dL. Abdominal ultrasound demonstrated a mildly enlarged liver without focal masses or nodularity and normal gallbladder; CT abdomen was initially unremarkable. The severe RUQ pain persisted; MRCP revealed stranding and edema in omental fat at the dome of the liver and small right pleural effusion. The patient was treated with analgesics with subsequent resolution of her pain. Omental infarction, until recently, has been an elusive diagnosis in patients presenting with abdominal pain because of its relative rarity and nonspecific clinical presentation. A result of vascular compromise, omental infarction typically presents with sudden-onset right lower quadrant abdominal pain without fever or gastrointestinal symptoms. Secondary infarction is caused by omental torsion, thrombosis from hypercoagulopathy or vascular abnormalities. Idiopathic infarction may be related to obesity, heavy food intake, local trauma or use of laxatives. Imaging findings on ultrasound or CT include a focal area of increased echogenicity in the omental fat or as fat stranding and swirling of omental vessels. Radiographic diagnosis of omental infarction is critical as laparoscopic evaluation can be avoided. Abdominal pain from omental infarction is often managed conservatively with analgesics and anti-inflammatory drugs due to the self-limited disease course. However, a standard treatment modality has yet to be established. Rarely, persistent pain, bleeding, adhesions or abscesses may develop and require surgical intervention.Figure 1Figure 2This patient, with no known abdominal pathology or risk factors, had an atypical presentation of a rare clinical disease, in which imaging was paramount for diagnosis. There have been no reported cases of omental trapping in the liver dome and thus is a newly reported mechanism of infarction. The abdominal pain was initially attributed to hepatobiliary disease given location and thus multiple imaging modalities were utilized before a final diagnosis was made. In patients presenting with acute abdomen, regardless of location, omental infarction should remain on the differential as it may minimize diagnostic imaging and avoid surgery.

Hepatic Tuberculosis: A Rare Cause of a Liver Mass in an Immunocompetent Host

Hepatic tuberculosis (TB) is an uncommon clinical entity seen in immunocompetent hosts and its diagnosis may be challenging. Hepatic TB may present in three main forms: diffuse hepatic involvement associated with miliary or pulmonary TB, granulomatous hepatitis, or tuberculoma/abscess that may mimic malignancy. Clinicians must maintain a high index of suspicion in order to avoid missing or delaying this diagnosis. A 24-year-old woman from the Philippines presented for evaluation of right upper quadrant (RUQ) pain and 20 lb weight loss. Five years prior to presentation, an abdominal MRI done for RUQ pain revealed a heterogeneous right liver lobe with mixed attenuation partially cystic focal lesions, punctate calcifications and peripheral biliary ductal dilatation concerning for neoplasm. She was subsequently lost to follow up. Upon re-presentation, her exam was notable for RUQ tenderness to palpation. Labs revealed total bilirubin 1.1 mg/dL, AST 169 U/L, ALT 280 U/L, and alkaline phosphatase 496 U/L. Serologic evaluation for underlying liver disease, HIV and infectious agents were negative except TB quantiferon was positive. Chest CT demonstrated scattered bilateral pulmonary nodules and a prominent right hilar lymph node. Abdominal CT revealed a complex mass in the right hepatic lobe with associated biliary ductal dilatation and calcifications concerning for metastatic malignancy. Sputum acid fast bacilli (AFB) stain and culture were negative. Fine needle aspiration of the liver mass revealed extensive granulomatous inflammation. Stains and cultures for fungi and AFB were negative. Core biopsy of the liver mass was performed, again yielding negative AFB stains and culture. Ultimately, TB PCR from the core samples returned positive. She was initiated on rifampin, isoniazid, pyrazinamide and ethambutol with continued follow up in TB clinic. This case highlights the diagnostic challenges associated with hepatic TB. While AFB stain and culture should be performed to evaluate for this entity, these are highly insensitive tests with culture yielding organisms in less than 10% of cases. TB PCR has demonstrated sensitivity of 53% with specificity of 96%, resulting in 90% positive and 76% negative predictive value. While PCR is not an ideal test, it's improved sensitivity over culture makes it extremely valuable in making the diagnosis of hepatic TB.Figure 1