Tenderness In Right Hypochondrium Research Articles

151 Isolated tuberculosis liver abscess in an immuno-competent patient – A case report

Abstract Introduction Tuberculosis presenting as an isolated liver abscess is extremely rare. Case Summary A 55 year old woman presented with complaints of pain right hypochondrium associated with low grade fever and weight loss for last 1 year. Abdominal examination revealed mild tenderness in right hypochondrium. Rest of system examination was unremarkable. Laboratory investigations and chest radiograph were normal. Ultrasound abdomen showed coarse heterogeneous liver parenchyma with increased echogenicity. Single irregular hypoechoic area in segment IV A of the liver was noted. CECT scan of abdomen showed a single well defined focal lesion of 4.2*5.5*4.9 cm in segment V/VI, which was hypovascular on both arterial and venous phases. Delayed imaging revealed thick rim of contrast enhancement suggestive of fibrous capsule. Ultrasound guided biopsy of the lesion was done which showed chronic caseating granulomatous inflammation suggestive of tuberculosis. Patient was started on anti- tuberculous therapy. However, she showed worsening of symptoms. A repeat triphasic CT scan showed a complex multiseptated thick-walled necrotic lesion measuring 8.5*6.9*6.4 cm in segment V/VI of the liver. Her total leucocyte count was 14,500/mm3, CRP levels 19.4 mg/l and ESR 99mm3. Ultrasound guided drainage was done and a drain was placed in right hypochondrium. Patient was discharged on oral antibiotics. The follow- up CT scan showed a significant decrease in the size of abscess (3.8*4.2*5.8 cm) with marked improvement in the symptoms. Conclusion An isolated tuberculous liver abscess poses challenge to the clinical acumen of the treating physician and an early diagnosis can help reducing the morbidity and mortality associated with it.

OGBN P17 Preoperative scoring system in predicting difficulty in laparoscopic cholecystectomy

Abstract Background For a long time now, laparoscopic cholecystectomy (LC) has been the gold standard treatment for gallstone disease. Having said that, approximately 2–15% of attempted LCs have to be converted to an open procedure due to various difficulties faced while performing the procedure. This study has been structured and planned taking into account the various difficult situations a laparoscopic surgeon faces during laparoscopic cholecystectomy and assigns an objective outlook to the difficulty in the form of a difficulty score. The main objective of the study is to evaluate a scoring system in predicting difficulty in laparoscopic cholecystectomy. Methods Patients with symptomatic gallstone disease that were admitted in SU-1 of Holy family hospital during the above period were included in the study. For collection of data, a pre-tested questionnaire was used after taking informed oral consent. On admission, one day before the surgery, preoperative points were allotted on basis of patient's history, examination, hematological (CBC), biochemical (LFTs) and ultrasound results. Preoperative scores up to 5 was summed up as easy, scores 6–10 as difficult, 11–16 as very difficult. Calculated sample size was 229. SPSS version 22 and WHO Anthro calculator version 3.2.2 were used for data entry and analysis Results Among 230 patients that were included in the study, 188 were female and 42 were male. Various risk factors were found to have significant positive correlation with intraoperative difficulty during cholecystectomy. These are: Previous episodes of cholecystitis and pancreatitis (p=0.00), ERCP (p=0.00), tenderness in right hypochondrium (p=0.002), hepatitis serology (p=0.02), and Total Leukocyte Count (p=0.006). Whereas the following factors had insignificant relation with intraoperative difficult cholecystectomy: ALT and ALP (p>0.05, p=0.06 and 0.26 respectively) and hepatitis serology (p=0.406). A significant correlation was found between preoperative and intraoperative scores of the patients (p=0.003) indicating that preoperative assessment of various risk factors can predict the level of difficulty of cholecystectomy and its conversion to open cholecystectomy. Conclusions We may conclude that the scoring system evaluated in our study is a sturdy, reliable and useful benchmark to predict difficult cases. Preoperative prediction of the risk factors of conversion or difficulty of operation is an important point for operative planning and the high-risk patients may be informed accordingly.

Preoperative scoring system in predicting difficulty in laparoscopic cholecystectomy.

Objective: To evaluate a scoring system in predicting difficulty in laparoscopic cholecystectomy. Study Design: Non-Randomized Prospective study. Setting: Surgical Unit-1 of Holy Family Hospital, Rawalpindi. Period: January 2018 to September 2018. Material & Methods: Patients with symptomatic gallstone disease that were admitted in SU-1 of Holy family hospital during the above period were included in the study. For collection of data, a pre-tested questionnaire was used after taking informed oral consent. On admission, one day before the surgery, preoperative points were allotted on basis of patient’s history, examination, hematological (CBC), biochemical (LFTs) and ultrasound results. Preoperative scores up to 5 was summed up as easy, scores 6 – 10 as difficult, 11 – 16 as very difficult. Calculated sample size was 229. SPSS version 22 and WHO Anthro calculator version 3.2.2 were used for data entry and analysis. Results: Among 230 patients that were included in the study, 188 were female and 42 were male. Various risk factors were found to have significant positive correlation with intraoperative difficulty during cholecystectomy. These are: Previous episodes of cholecystitis and pancreatitis (p=0.00), ERCP (p=0.00), tenderness in right hypochondrium (p=0.002), hepatitis serology (p=0.02), and Total Leukocyte Count (p=0.006). Whereas the following factors had insignificant relation with intraoperative difficult cholecystectomy: ALT and ALP (p>0.05, p=0.06 and 0.26 respectively) and hepatits serology (p=0.406). A significant correlation was found between preoperative and intraoperative scores of the patients (p=0.003) indicating that preoperative assessment of various risk factors can predict the level of difficulty of cholecystectomy and its conversion to open cholecystectomy. Conclusion: We may conclude that the scoring system evaluated in our study is a sturdy, reliable and useful benchmark to predict difficult cases. Preoperative prediction of the risk factors of conversion or difficulty of operation is an important point for operative planning and the high-risk patients may be informed accordingly.

Gallbladder clear cell carcinoma: A case report

Worldwide, the highest incidence rates (up to 7.5 per 100,000 in male and 23 per 100,000 in female) occur among populations in the Western part of South America (Chile and Peru), in North American Indians, in Mexican Americans, and in Northern India. The best characterized risk factor for the development of gallbladder cancer is chronic inflammation associated with gallstones. Metastatic clear cell carcinoma in the gallbladder is extremely rare, with reported frequencies of less than 0.6% in large autopsy reviews. Patient was a 54 year old female. Patient was right upper abdominal pain and epigastric middle pain. Nausea and vomiting, pain was started 10 days ago, after ate dumplings. No history of previous any gastrointestinal disease. The physical examination: Tenderness in right hypochondrium. Lump in the hypochondrium. Murphy's sign was positive. The patient's in blood test increased white blood cell and C-reactive protein. Abdominal ultrasound examination: Gallbladder is enlargement, about 6.0 cm × 3.0 cm like the mudstone in the gallbladder. GB wall thickening/double, common bile duct is dilated 1.2 cm. Abdominal contrast computed tomography examination: Moderate thickening with surrounding mild edematous changes in wall of the gallbladder. Size of the GB is moderated dilated with diffuse. We were emergency surgery of under general anesthesia open cholecystectomy and intraoperative cholangiogram. During surgery gallbladder was distended and gallbladder wall very thickness, hardness. In cholangiogram common bile duct no obstructive sign. Clear cell carcinoma very rare disease. Our team diagnosed during surgery and histological analysis.

A case of acute calculous cholecystitis with contained gall bladder perforation with pericholecystic collections extending to liver parenchyma

Gall bladder perforation is a serious complication of acute cholecystitis and represents an advanced stage of the disease. Its clinical presentation is varied and can range from non-specific symptoms to acute generalized peritonitis. In many cases, GB perforation in diagnosis during exploratory laparotomy for peritonitis and with no definite source identified. The presentation of gall bladder perforation can be indistinguishable from uncomplicated acute cholecystitis. A 60 yrs. old male with no known comorbidities presented to a tertiary care hospital with diffuse pain abdomen associated with vomiting and constipation of 04 days’ duration. Clinical evaluation revealed icterus and tenderness in right hypochondrium and generalized peritonitis. Lab investigations revealed conjugated type hyperbilirubinemia and elevated serum Lipase levels and normal Amylase levels. Initial USG revealed Acute acalculous cholecystitis with normal IHBR and normal CBD. Later NCCT abdomen and MRCP were done which revealed calculous cholecystitis with sealed off GB perforation IHBR, CBD, and normal pancreas. The patient was managed non-operatively and responded well. The inflammatory reaction of the peritoneum in bile peritonitis increases the absorption of the spilled conjugated bile from the peritoneal cavity. The conjugated type hyperbilirubinemia without dilatation of the bile duct on imaging examination was the sign of bile leakage into the peritoneal cavity.

A Rare Case of Adrenal Pheochromocytoma With Unusual Clinical and Biochemical Presentation: A Case Report and Literature Review

A 45 years old male, nondiabetic, hypertensive, nonasthmatic, nonsmoker, farmer from Pabna presented with the complaints of pain over right hypochondrium for 4 months andalso gave history of significant weight loss of about 15 kg in the last 6 months. He also developed bilateral gynecomastia for 2 years.On examination, Blood pressure was 200/100 mm of Hg and bilateral gynecomastia were present.Both testes were mildly atrophied.Systemicexamination revealed mild tenderness in right hypochondrium on deep palpation of abdomen.USG of W/A revealed A heterogenous mixed echogenic mass (9.9*8.9) was seen in upper polar region of right kidney. Suggestive of Right suprarenal mass. CT scan W/A with contrast showed heterogenous contrast enhancing well defined rounded soft tissue density lesion measuring about 90*86 mm was noted in right adrenal region which revealed a right adrenal mass consistent with adrenal pheochromocytoma. However,clinical biochemistry tests revealed normal levels of plasma catecholamines (dopamine,norepinephrine, and epinephrine) and metanephrine, which are unusual findings in adrenal pheochromocytoma.Serum Aldosterone,Basal cortisol, Renin in plasma, ACTH and 24 hours Urinary Free cortisol were normal.Meanwhile, The patient had persistent hypokalemia and serum Testosterone, LH and FSH were below normal level. Open right adrenalectomy was done. Histopathology and immunohistochemistryconfirmed the diagnosis of adrenal pheochromocytoma. Following surgery, the patient did well and showed full recovery at follow-up after one month. To our knowledge, this is the first report in Dhaka Medical college hospital of the extremely rare entity of pheochromocytoma with an unusual clinical and biochemical scenario. Bangladesh Journal of Urology, Vol. 21, No. 2, July 2018 p.168-171

A clinical study for preoperative prediction of cyst-biliary communications in hepatic hydatid cyst disease

Background: Cyst-biliary communication with hepatic hydatid cyst disease is responsible for postoperative bile leakage after surgical management. This study aims to detect various predictors of cyst-biliary communication and their predictive accuracy.Methods: This study was done in the patients of hydatid cysts who underwent surgical management for hydatid disease of the liver. Various factors were studied and their accuracy for preoperative prediction of cyst-biliary communication analyzed.Results: There were 38 (22 males, 16 females) patients with hepatic hydatid cysts with a mean age of 38.7±15.4 years. Cyst-biliary communications were detected in 12 patients (31.6%). Independent strong predictors were tenderness in right hypochondrium (p=0.035), total leucocyte count (TLC)>12,000/mm3 (p=0.0017), eosinophil count >5 × 108/l (p=0.0086), red blood cell distribution width (RDW) >15% (p=0.014), segment IV,V,VII involvement and cyst size >10 cms (p=0.01) on multivariate analysis.Conclusions: Cyst-biliary communication is more common in patients presenting with tenderness in right hypochondrium, large cyst size, location in the central segments of liver close to biliary confluence, and with high values of TLC, Eosinophil count and RDW. The predictors demonstrated in this study should allow the likelihood of cyst-biliary communication to be determined preoperatively and, thus, indicate the need for additional procedures during operations to prevent the complications of biliary leakage.

A Study of Management of Hepatic Abscess by Percutaneous Catheter Drainage

Background: Aim and Objectives: To distinguish the efficacy of percutaneous catheter drainage (PCD) approaches in the management of hepatic abscess.Methods: In this study, 60 cases of liver abscess were taken with age group between 25-60 years. Study was done in surgery department of government hospital Sikar from October 2014 to September 2016. All cases were registered satisfied the inclusion criteria and exclusion criteria. Group A was given conservative treatment and Group B was given percutaneous catheter drainage. Results were analyzed statistically. Results: ‘it was revealed in this study that mostly males were there, 55 out of 60 cases. The most frequent complaint was abdominal pain and tenderness in right hypochondrium in 85% of the cases. The average hospital stay for patients in group B was 5 days as compared to 7 days in group A. Pain relieved in just 4 days in group B as compared to group A, it was 6 days. Conclusions: Percutaneous catheter drainage is a successful option of treatment in hepatic abscess as compared to conservative management.

A clinical study to determine predictive factors for difficult laparoscopic cholecystectomy

Background: Forecast of a difficult laparoscopic cholecystectomy (LC) can help the surgeon as well as the patient to prepare better for any intraoperative risk and its effective management. Objectives: The objectives of this study were to assess the clinical and radiological parameters for predicting the difficult LC and its conversion. Materials and Methods: Hundred patients of gallstone disease undergoing LC were studied from September 2014 to August 2015. All the patients underwent detailed pre-operative history, clinical examination, laboratory investigations, and transabdominal sonography. The study group was subjected to LC using the general anesthesia. Peroperative degree of difficulty was evaluated depending on objective variables which included the presence of adhesions at CalotÂ’s triangle and between omentum and gallbladder (GB), obvious injury to GB, biliary ducts, bowel, diaphragm or other abdominal viscera, stone/biliary spillage, injury to vessels, need of conversion to open procedure (OP), and post-operative complications in the early post-operative period arising as a result of intra-operative difficulty, for example, biliary fistula, biloma, biliary peritonitis, and bowel injury unmasking after surgery. Results: Female (n = 82) preponderance was observed. Mean age and body mass index (BMI) was 38.60 ± 11.62 years and 27.29 ± 3.59 kg/m2, respectively. The incidence rate of difficult LC was 34%, whereas conversion rate to open cholecystectomy was 11%. Rate of difficult LC was significantly more in patients with a history of previous abdominal surgery (n = 34, P < 0.001), tenderness in right hypochondrium (n = 31, P = 0.003), and thickening of GB (n = 19, P < 0.001), whereas conversion to OP was significantly high in patients with thickening of GB (n = 19, P = 0.001) and distended or contracted GB (n = 18, P = 0.001). Most common intra-operative findings which made the procedure difficult was dense adhesions at CalotÂ’s triangle (n = 32). Most common reason for conversion to OP was stone/biliary spillage (36.4%). Conclusion: BMI, history of previous abdominal surgery, tenderness in the right hypochondrium, and thickening of the GB are the significant predictive factors for difficult LC, whereas conversion to OP was high in patients with thickening of GB and GB contracted.

Haemophilus parainfluenzae as a rare cause of pyogenic liver abscess: A case report and literature review

We report a case of Haemophilus parainfluenzae pyogenic liver abscess in a 53-year-old Filipino female who was admitted with a 3-day history of abdominal pain and fever. Clinical examination showed tenderness in right hypochondrium, and the liver edge was just palpable. Abdominal ultrasound revealed heterogeneous lesion in the left liver lobe, consistent with liver abscess, which was aspirated and the patient received ceftriaxone and metronidazole empirically. Two days after admission, pus culture grew profuse growth of H. parainfluenzae which was sensitive to ampicillin and ceftriaxone, accordingly metronidazole was stopped and ceftriaxone was continued 2 g daily intravenously. The drain was removed on 14th hospital day. Patient made a good recovery and was discharged home on oral cefuroxime for 2 weeks more.

Case report: Gallbladder volvulus

Introduction: Gallbladder volvulus is a rare entity, with a predilection for elderly women in their 7th or 8th decades of life. The condition results in rotation of the gallbladder on its mesentery along the axis of cystic duct and artery. Presence of redundant mesentery is a prerequisite. The disease is a frequent mimicker of acute cholecystitis, often difficult to diagnose preoperatively. Till date only about 300 cases have been reported in the literature, with children and adolescent presentations being exceedingly rare. Case description: We report a case of an 18-year-old female who presented to emergency with right upper quadrant pain for a day associated with repeated vomiting. The patient was stable, had tenderness in right hypochondrium. Patient was evaluated as a potential case of acute cholecystitis. Laboratory investigations have shown normal white cell count, double normal liver function tests. Ultrasound showed that the gallbladder was out of the fossa with significant edema and wall thickness suggestive of gallbladder torsion. Further workup with MRCP was done, which showed retrohepatic gallbladder, with partial volvulus and hemorrhagic acalcular cholecystitis. The patient underwent laparoscopic detorsion and cholecystectomy and had an intraoperative evidence of gallbladder volvulus with gangrene with an uneventful course of hospital stay. Conclusion: We believe that this may be the first documented case of this rare condition from Qatar. Gallbladder volvulus mostly occurs in elderly, but it might occur in young patients as well and should be included in differential diagnosis of abdominal pain. Ultrasound is a safe, feasible diagnostic tool, as sensitive as MRI in diagnosis of gallbladder volvulus.

Large liver abscess after ERCP and laparoscopic cholecystectomy

Introduction: Endoccopic retrograde cholangio pancreatogram is a technique used for common bile duct (CBD) stone clearance in patients with choledocholithiasis. The complications associated with this procedure are pancreatitis, haemorrhage and infection. Case report: A 71 year-old male patient underwent ERCP and stenting and complete clearance of CBD stones for choledocholithiasis with cholangitis. Patient was lost to follow-up for 18 months. Patient underwent repeat ERCP, sphincterotomy, stent removal and CBD clearance for recurrent choledocholithiasis with cholangitis. Patient presented to the outpatient for laparoscopic cholecystectomy after 4 weeks. Preoperative liver function tests were normal. Ultrasound abdomen showed multiple gall stones. Patient underwent laparoscopic cholecystectomy and had uneventful recovery. On 10th post-operative day, patient presented with complaints of dull aching pain in the right hypochondrium on inspiration and vomiting. Patient had tenderness in right hypochondrium on abdomen examination. Ultrasound showed a liver abscess. Contrast enhanced computed tomogram abdomen revealed 13 × 7 cm abscess in the right lobe of liver. Patient underwent ultrasound guided pig-tail drainage. 500 cc pus was drained. Culture showed E.coli. Patient was discharged with oral antibiotics. Pigtail catheter was removed after ultrasound abdomen showed no residual collection. Conclusion: Delayed complications after ERCP can occur in patients with choledocholithiasis with cholangitis. Careful evaluation of symptoms is required on follow-up.

Pyogenic liver abscesses in adults: A 3-year study

Background: Pyogenic liver abscess (PLA), a potentially life-threatening disease, has undergone significant changes in epidemiology, management, and mortality over the past several decades. This study was undertaken to evaluate PLA in relation to age, sex, anatomical relation, etiological factors, and response to various lines of management. Materials and Methods: A prospective study was conducted during the period from September 2010 to September 2013. Amebic and hydatid liver abscesses were excluded. We recorded and analyzed the clinical presentations, diagnostic modalities, and treatment programs of PLAs. Results: A total of 423 patients were studied. The average age of patients was 42 years, ranged from 20 to 80 years. Of a total 423 patients, 386 patients (91.2%) were males and 37 (8.8%) were females. The most common symptom was fever associated with chills. The most common sign was hepatomegaly and tenderness in right hypochondrium 209 (49.4%). Alcoholism was identified as a major risk factor in 309 (73%) patients. Diabetes was present in 86 (20.3%), tuberculosis in 34 (8%), and HIV infection in 10 (2.3%) patients. Abdominal ultrasonography had a sensitivity of 97% in diagnosing liver abscess. There was a single abscess in 326 (77%) patients, the right lobe being involved in 282 (66.6%) patients. Multiple abscesses were found in 97 (22.9%). Most patients were managed conservatively with antibiotics and percutaneous drainage. 46 patients (10.8%) had ruptured liver abscesses and required peritoneal lavage at laparotomy. Death occurred in seven (2%) patients. Conclusion: Pyogenic liver abscess is a potentially fatal disease if untreated. Early diagnosis remains the cornerstone of management. Majority can be managed conservatively with antibiotics and percutaneous drainage.

Outcomes of Xanthogranulomatous cholecystitis in laparoscopic era: A retrospective Cohort study

INTRODUCTION:Xanthogranulomatous cholecystitis (XGC) is a rare variant of cholecystitis and reported incidence of XGC varies from different geographic region from 0.7% -9%. Most of the clinicians are not aware of the pathology and less evidence is available regarding the optimal treatment of this less common form of cholecystitis in the present era of laparoscopic surgery.MATERIALS AND METHODS:A retrospective cohort study was conducted in a tertiary care university hospital from 1989 to 2009. Histopathologically confirmed XGC study patients (N=27) were compared with non-Xanthogranulomatous cholecystitis (NXGC) control group (N=27). The outcomes variables were operative time, complication rate and laparoscopic to open cholecystectomy conversion rate. The study group (XGC) was further divided in to three sub groups; group I open cholecystectomy (OC), laparoscopic cholecystectomy (LC) and laparoscopic converted to open cholecystectomy (LCO) for comparative analysis to identify the significant variables.RESULTS:During the study period 6878 underwent cholecystectomy including open cholecystectomy in 2309 and laparoscopic cholecystectomy in 4569 patients. Histopathology confirmed xanthogranulomatous cholecystitis in 30 patients (0.43% of all cholecystectomies) and 27 patients qualified for the inclusion criterion. Gallbladder carcinoma was reported in 100 patients (1.45%) during the study period and no association was found with XGC. The mean age of patients with XGC was 49.8 year (range: 29-79), with male to female ratio of 1:3. The most common clinical features were abdominal pain and tenderness in right hypochondrium. Biliary colic and acute cholecystitis were the most common preoperative diagnosis. Ultrasonogram was performed in all patients and CT scan abdomen in 5 patients. In study population (XGC), 10 were patients in group I, 8 in group II and 9 in group III. Conversion rate from laparoscopy to open was 53 % (n=9), surgical site infection rate of 14.8% (n=4) and common bile duct injury occurred one patient in open cholecystectomy group (3.7%). Statistically significant differences between group I and group II were raised total leukocyte count: 10.6±3.05 vs. 7.05±1.8 (P-Value 0.02) and duration of surgery in minutes: 248.75±165 vs. 109±39.7 (P-Value 0.04). The differences between group III and group II were duration of surgery in minutes: 208.75±58 vs. 109±39.7 (P-Value 0.03) and duration of symptoms in days: 3±1.8 vs. 9.8±8.8 (P-Value 0.04). The mean hospital stay in group I was 9.7 days, group II 5.6 days and in group III 10.5 days. Two patients underwent extended cholecystectomy based on clinical suspicion of carcinoma. No mortality was observed in this study population. Duration of surgery was higher in XGC group as compared to controls (NXGC) (203±129 vs.128±4, p-value=0.008) and no statistically significant difference in incidence proportion of operative complication rate were observed among the group (25.9% vs. 14.8%, p-value=0.25. Laparoscopic surgery was introduced in 1994 and 17 patients underwent laparoscopic cholecystectomy and higher conversion rate from laparoscopic to open cholecystectomy was observed in 17 study group (XGC) as compared to 27 Control group (NXGC) 53%vs.3.3% with P-value of < 0.023.CONCLUSION:XGC is a rare entity of cholecystitis and preoperative diagnosis is a challenging task. Difficult dissection was encountered in open as well in laparoscopic cholecystectomy with increased operation time. Laparoscopic cholecystectomy was carried out with high conversion rate to improve the safety of procedure. Per operative clinical suspicion of malignancy was high but no association of XGC was found with gallbladder carcinoma, therefore frozen section is recommended before embarking on radical surgery.

A Rare Association of Hydrops of Gall Bladder with Hepatitis E Infection

Gall bladder distension with acute viral acalculous cholecystitis is an extremely rare event especially with Hepatitis E infection in paediatric cases with a high incidence of perforation, gallbladder necrosis and mortality. We report a four year old male child presenting with fever, vomiting, pain abdomen, mild hepatosplenomegaly and tenderness in right hypochondrium. Laboratory investigations revealed hyperbilirubinemia and elevated liver enzymes, but there was no evidence of bacterial or parasitic infection. Serology for viral hepatitis suggested acute Hepatitis E infection. Ultrasonographically distended inflamed gallbladder without calculous was observed. Finally acute acalculous cholecystitis due to Hepatitis E virus was diagnosed and the child responded to the conservative management. Key words: Acalculous cholecystitis; Hepatitis E; Pericholecystic fluid; Gallbladder thickening.DOI: http://dx.doi.org/10.3126/jnps.v31i3.5362 J Nep Paedtr Soc 2011;31(3): 216-222-223

Acalculous gallbladder distension in a young child due to HAV infection: Diagnostic dilemma

Gall bladder distension with acute viral acalculous cholecystitis is a rare event in pediatric cases with a high incidence of perforation, gallbladder necrosis and mortality. We report a two and a half year old female child presenting with fever, vomiting, pain abdomen, mild hepatosplenomegaly and tenderness in right hypochondrium. Laboratory investigations revealed hyperbilirubinemia and elevated alkaline phosphatase, but there was no evidence of bacterial or parasitic infection. Serology for viral hepatitis suggested acute Hepatitis A infection. Ultrasonographically, distended inflamed gallbladder without calculous was observed. Finally acute acalculous cholecystitis due to Hepatitis A virus was diagnosed and the child responded to the conservative management.

34 Year Old Pregnant Female Presents with Abdominal Pain

Purpose: 34 year old female, gravida 4, para 0, at 16 weeks of gestation presented with abdominal pain for 3 days, epigastric/right upper quadrant, severe, with nausea and vomiting. Patient denied fever, arthralgias, or change in bowel habits. Her past medical history was significant for systemic lupus erythramatosus without active manifestations and antiphospholipid antibody syndrome. She denied any history of smoking, alcohol use, or illicit drug use. Her medications included asprin, enoxaparin, hydroxychloroquine, and prenatal vitamins. She was allergic to sulfa and penicillin. Physical exam revealed elevated blood pressure (150/84 mmhg), tenderness in right hypochondrium with voluntary guarding and a gravid uterus. Lab studies revealed thrombocytopenia, elevated transaminases (7 times above the normal value), LDH and decreased haptoglobin. Urinalysis revealed proteinuria with trace blood. Ultrasound of the abdomen revealed thickened gallbladder wall without gallstones. CT scan of the abdomen revealed densities throughout the liver consistent with hepatic infarctions/necrosis. Our patient was diagnosed with HELLP syndrome with hepatic infarctions/necrosis. Hepatic infarction in pregnancy is a rare condition, with an estimated incidence of 1 in 40,000 to 250,000 pregnancies. The hepatic infarction although rare, usually occurs after the 20th week of pregnancy and usually involves the right lobe of the liver. The diagnosis is established by abdominal ultrasound, CT scanning, MRI or angiography. Hepatic rupture is a dangerous complication that can causes mortality rates as high as 85 percent. Treatment is generally limited to conservative management and delivery of the fetus. Our case is unique in that the patient presented with this clinical syndrome in the 16th week of her pregnancy and her hepatic infarctions included most of her liver and her medical history included antiphospholipid antibody syndrome. Less than 30 such presentations have been reported in our literature search. Our patient had an uncomplicated dilatation and evacuation procedure.[figure1]Figure

34 Year Old Female Presents with Abdominal Pain

Purpose: 34 year old female, gravida 4, para 0, at 16 weeks of gestation presented with abdominal pain for 3 days, epigastric/right upper quadrant, severe, with nausea and vomiting. Patient denied fever, arthralgias, visual disturbances or change in bowel habits. Her past medical history was significant for antiphospholipid antibody syndrome and systemic lupus erythramatosus without active manifestations. She denied any history of smoking, alcohol use, or illicit drug use. Her medications included asprin, enoxaparin, hydroxychloroquine, and prenatal vitamins. She was allergic to sulfa and penicillin. Physical exam revealed elevated blood pressure (150/84 mmhg), tenderness in right hypochondrium with voluntary guarding, hepatomegaly and a gravid uterus. Lab studies revealed thrombocytopenia, elevated transaminases (7 times above the normal value), LDH and decreased haptoglobin. Urinalysis revealed proteinuria with trace blood. Ultrasound of the abdomen revealed thickened gallbladder wall without gallstones. CT scan and subsequent MRI of the abdomen revealed densities throughout the liver consistent with hepatic infarctions/necrosis. Our patient was diagnosed with HELLP syndrome with hepatic infarctions/necrosis. Hepatic infarction in pregnancy is a rare condition, with an estimated incidence of 1 in 40,000 to 250,000 pregnancies. The hepatic infarction although rare, usually occurs after the 20th week of pregnancy and usually involves the right lobe of the liver. The diagnosis is established by abdominal ultrasound, CT scanning, MRI or angiography. Hepatic rupture is a dangerous complication that can causes mortality rates as high as 85 percent. Treatment is generally limited to conservative management and delivery of the fetus. Our case is unique in that the patient presented with this clinical syndrome in the 16th week of her pregnancy and her hepatic infarctions included most of her liver. Our patient had an uncomplicated dilatation and evacuation procedure. [figure 1]Figure 1