Abdominal Upper Quadrant Research Articles

Development of Hepatic Abscesses Following International Travel

A 19 year-old woman presented to the emergency department with a one-week history of progressively worsening right-sided abdominal, shoulder, and rib pain. Her occupational history included service in the navy's culinary department with recent 5-month travel to Oman, Bahrain, Jordan, and Spain. Vital signs were significant for a temperature of 103.1 degrees Fahrenheit and tachycardia to 132. She had exquisite tenderness of the right upper abdominal quadrant with mild guarding. The patient noted recent ingestion of authentic foods from the countries which she visited. She was admitted to the general internal medicine inpatient service. While in the emergency department, right upper quadrant ultrasound was performed. CT of the abdomen and pelvis was later ordered for further characterization of hepatic findings on ultrasound. Empiric therapy with IV metronidazole and ciprofloxacin was initiated. Blood and urine cultures were drawn. Interventional Radiology was consulted for CT-guided aspiration of liver findings on imaging. Initial CBC showed a leukocytosis of 21.5K with 81% neutrophils. Alkaline phosphatase was 146 and INR 1.8. Right upper quadrant imaging demonstrated heterogenous liver parenchyma with multiple cystic lesions in the right hepatic lobe, with the largest measuring 1.3 cm. CT scan of the abdomen confirmed diffusely distributed, peripherallyenhancing cysts in the posterior right hepatic lobe. Extrahepatic biliary ductal prominence was present measuring 4mm in largest diameter. CT-guided aspiration of the largest cystic lesion was performed. Gram stain showed numerous RBCs, few WBCs, and no organisms. Serum serology for Brucella returned positive. Brucellosis is one of the most widespread zoonoses worldwide. Humans may contract the infection through the ingestion of unpasteurized milk, cheese, raw or undercooked meat as well as through the entry of the bacteria through skin lesions, conjunctiva, or by inhalation. The clinical presentation of infection is broad, ranging from asymptomatic to fatal. Gastrointestinal involvement may lead to pancreatitis, cholecystitis, ileitis, colitis, spontaneous peritonitis, splenic or hepatic abscesses, or hepatitis. The take home message for this case demonstrates the importance of recognizing gastrointestinal involvement by Brucella organisms and also acknowledgement of travel history and occupational exposure when presented with new onset abdominal pain.

An Incidentally Discovered Abdominal Mass During Physical Examination

Gastroenterology 2016;151:e16–e17 Question: A 66year-old woman was referred to our hospital for an incidentally discovered abdominal mass during routine physical examination. She had no history of abdominal trauma, liver cirrhosis, or chronic hepatitis virus infection previously, nor did she have of abdominal pain, jaundice, or cholangitis. Physical examination revealed mild tenderness of the right upper abdominal quadrant. Blood test results, including complete blood count, liver function tests, and tumor markers of carbohydrate antigen 19-9, alpha fetoprotein, and carcinoembryonic antigen were all within normal ranges. Computed tomography scan demonstrated a heterogeneous cyst-like mass (5 6 cm) with slightly enhanced projections along the walls in the arterial phase (Figure A), and the mass seemed to be communicated with the common bile duct (Figure B, arrow). The patient underwent an exploratory laparotomy and the tumor was resected completely. The patient was followed for 3 years without evidence of recurrence. What is the diagnosis of this tumor? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

New advantageous tool in single incision laparoscopic cholecystectomy: the needle grasper.

IntroductionDuring single-incision laparoscopic cholecystectomy (SILC), the gallbladder is suspended with stitches, resulting in perforation risk and difficulty in exploration.AimWe used the needle grasper in SILC to hang and manipulate the gallbladder.Material and methodsSixty-five patients (43 female, 22 male) who underwent SILC between December 2013 and December 2014 were analyzed retrospectively for patient demographics, duration of operation, laparotomy or conventional laparoscopy necessity, drain use, complications, and hospital stay periods. To place the SILC port (Covidien, Inc.), the needle grasper was inserted at the right upper abdominal quadrant without an incision to hang and manipulate the gall-bladder.ResultsThe mean age was 47.9 ±13.068 years; the mean body mass index (BMI) was 26.94 ±3.913 kg/m2. ASA scores were 1, 2, and 3. Two patients with high BMI with additional trocar use were excluded. The operations were completed without any additional trocar in 59 patients. The mean operation time was 89 ±22.41 min. Eighteen patients required a drain; all were discharged after drain removal. One patient needed re-hospitalization and percutaneous drainage and was discharged on the 9th day. Fifty-three patients were discharged on the 1st post-operative day. Eleven patients with drains were discharged on the 2nd day, and 1 was discharged on the 7th day. The mean hospital stay period was 1.26 ±0.815 days.ConclusionsThe main difficulty of SILC is to manipulate hand tools because the triangulation principle of laparoscopy use is not possible in SILC. Inserting a needle grasper into the abdominal cavity at the right subcostal area to manipulate the gallbladder helps and does not leave a visible scar.

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.

Incidentally Detected Primary Giant Renal Cystic Enchinococcosis in a Young Patient: An Underestimated Entity?

Echinococcosis is a parasitic infestation caused by Echinococcus granulosus and is an endemic disease in many parts of world. The symptoms and signs depend on the location and size of the cyst. Renal cystic echinococcosis or hydatid cyst (HC) disease of the kidney is extremely rare and constitutes only 2-4% of all cases of hydatid disease (HD). We present a 39-year-old male patient who was referred to our outpatient clinic with cystic right kidney mass that was incidentally diagnosed during hepatobiliary ultrasound for chronic hepatitis B evaluation. Routine blood tests were normal without eosinophilia. Indirect haemagglutination test was negative. Abdominal kidneys, ureters, and bladder X-ray showed an 83×95 mm sized curvilinear calcification in the right upper abdominal quadrant. Abdominal computed tomography scan and magnetic resonance imaging demonstrated a 10x9x10 cm sized cystic mass arising from the middle pole of the right kidney, destructing the whole upper pole and extending into the liver. Daughter vesicles were present in the cystic lesion suggesting renal HD. Right retroperitoneal exploration with flank approach and right radical nephrectomy was performed without any complications. Pathology confirmed HC lesion. Following surgery, albendazole 400 mg per os twice daily for 4 weeks was suggested.

Giant hemangioma in a liver studded with small hemangiomas

CASE SUMMARY A 59-year-old woman presented with complaints of gradual fullness of right upper-abdominal quadrant and an increase in abdominal girth for the past 8 years. More recently she had been experiencing a dull abdominal ache for the immediately preceding 2 months. Her bowel and bladder habits were normal. Her physical examination revealed a distended abdomen but no tenderness. Her vitals were stable. The routine blood and urine tests were unremarkable.

Gastrointestinal quality-of-life after cholecystectomy: indication predicts gastrointestinal symptoms and abdominal pain.

Despite the fact that cholecystectomy is a common surgical procedure, the impact on long-term gastrointestinal quality of life is not fully known. All surgical procedures for gallstone disease performed at Mora County Hospital, Sweden, between 2 January 2002 and 2 January 2005, were registered on a standard database form. In 2007, all patients under the age of 80 years at follow-up were requested to fill in a form containing the Gastrointestinal Quality-of-Life Index (GIQLI) questionnaire and a number of additional questions. The outcome was analysed with respect to age, gender, smoking, surgical technique, and original indication for cholecystectomy. A total of 627 patients (447 women, 180 men) underwent cholecystectomy, including laparoscopic cholecystectomy (N = 524), laparoscopic cholecystectomy converted to open cholecystectomy (N = 43), and open cholecystectomy (N = 60). The mean time between cholecystectomy and follow-up with the questionnaire was 49 months. The participation rate was 79 %. Using multivariate analysis in the form of generalised linear modelling, the original indication for cholecystectomy in combination with gender (p = 0.0042) was found to predict the GIQLI score. Female gender in combination with biliary colic as indication for cholecystectomy correlated with low GIQLI scores. Female gender also correlated with a higher risk for pain in the right upper abdominal quadrant after cholecystectomy (p = 0.028). We found the original indication for cholecystectomy, together with gender, to predict gastrointestinal symptoms and abdominal pain after cholecystectomy. Careful evaluation of symptoms is important before planning elective cholecystectomy.

Beyond acute abdomen…

The authors present the case of male patient, 68years, farmer, autonomous, hypertensive, diabetic, excessive alcohol intake 200g/day for 20years, and mild hepatic steatosis documented on abdominal ultrasound 4months before this episode. Appealed to the emergency department by sudden intense pain in the right shoulder associated with vigorous physical exertion, with subsequent irradiation to the flank and right upper abdominal quadrant. Physical examination highlighted hematoma at the right upper abdominal quadrant and pain on deep palpation without peritoneal reaction.

Massive Subcutaneous Emphysema After Carbon Dioxide Mesotherapy

The authors report the observation of a 43-year-old woman with severe pain on her right upper abdominal quadrant. Differential diagnoses included acute cholecystitis, spontaneous pneumothorax, perforated appendicitis and a recidive of renal calculus. CT-scan showed a huge subdermal gas bubble along her right flank and anterior abdominal wall up to the submammary fold. Only at this point, the patient admitted to have undergone a carboxytherapy procedure on both thighs one day before onset of pain in a paramedical facility. As some of the injection trajects were still patent on CT-scan, she received prophylactic antibiotic coverage. Though there was a complete resorption of gas after 10days, dysesthesias and muscle contracture persisted for 3weeks. To the authors' knowledge this migration and coalescence of injected gas in a single bubble has not been previously reported. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Acute cholecystitis from typhic origin in children

To evaluate the particularities of typhoid cholecystitis in children. This was a 5-year prospective study of typhoid cholecystitis in children under 15 years old at Djougou and Sylvanus Olympio teaching hospital. The diagnosis of typhoid cholecystitis was based on clinical and investigation findings, confirmed by operative findings at cholecystectomy. Six children with typhoid acalculous cholecystitis were treated over a five-year period (4 males and 2 females). Their ages ranged from five to 13 years (median 8.8 years). The mean duration of symptoms was six to 21 days. The clinical signs were fever, abdominal pain, which predominated at the right upper abdominal quadrant, and type II Hackett splenomegaly. The diagnosis was confirmed by a positive Widal's test and Salmonella typhi isolation from the culture in all patients; four patients had ultrasound evidence of acalculous cholecystitis. Open cholecystectomy was successful in the six cases. The operative findings were gangrene (3), perforation (2) and empyema (1). All the patients made an uneventful recovery, and have remained symptom free one and three months on follow-up. Typhoid acalculous cholecystitis is a frequent complication in children. Late presentation and diagnosis is associated with complications. Cholecystectomy in association with antibiotic is the treatment of choice.

Budd-Chiari Syndrome as a Manifestation of Antiphospholipid Antibody Syndrome during Oral Contraceptive Therapy: More to Think About

The association of Budd-Chiari Syndrome (BCS) and Antiphospholipid Antibody Syndrome (APS) has been previously described in literature. We report the case of a 46-year-old woman who was admitted to our Unit of Hepatology for upper abdominal quadrant pain, asthenia and edema of the left upper arm. Her familiar history told about predisposition to Systemic Lupus Erythematosus (SLE) whereas her personal story showed a continuous use of oral contraceptives during the six years preceding diagnosis and the absence of episodes of obstetric complications. At the admission, a Doppler Ultrasound examination showed complete thrombosis of venous axis of the left upper arm and thrombosis of subclavian artery (with the aspect of “subclavian steal syndrome”). Abdominal ultrasonography revealed hepatic lesions (characterized by an abdominal Computed Tomography as ischemic injuries) at seventh and eighth segments and the presence of significant amount of ascites. Abdominal and thoracic Computed Tomography confirmed pleural effusion and pointed out a radiologic pattern of Budd-Chiari Syndrome. To verify the presence of concomitant pericardial effusion, an echocardiogram was performed. It allowed reaching the diagnosis of polyserositis. In order to investigate all potential causes of thrombotic diathesis, specific laboratory tests were performed. Normal level of protein C, S and antithrombin II, absence of JAK-2 mutation and negativity of Ham’s test were observed. Positivity was found for anti-SSA (60 kDa) and for antibodies routinely tested for Antiphospholipid Antibody Syndrome (APS), i.e. Lupus-Anticoagulant, Anticardiolipin and Beta2- Glycoprotein I. After the introduction of oral anticoagulant and diuretics a significant improvement of clinical condition of the patient was reached. To conclude, the exact role of oral contraceptives as triggering factor of an undetected APS need to be emphasize, as well as the potentiality of this disease to evolve in a “ to happen” SLE in patients with positive familiarity for autoimmune diseases.

Obstructive Jaundice: The Kidney Can Do It!

Introduction: Obstructive jaundice is a common clinical problem that gastroenterologists encounter. We report a rare case of obstructive jaundice caused by right renal cyst and hydronephrosis due to obstructive proximal ureteric stone. Case: A 69-year-old woman presented with yellowish discoloration of skin and dark urine for 2 days. Patient was a resident at the rehabilitation center after drainage of septic arthritis of left hip. She had history of coronary artery disease, diabetes mellitus, chronic obstructive pulmonary disease, stroke, dementia and cholecystectomy. On examination she had scleral icterus and mild tenderness in right upper abdominal quadrant. Rest of the examination was unremarkable. Laboratory data on admission was abnormal for total bilirubin 11.1 mg/dL (normal 0.2-1.1), alkaline phosphatase 2,020 IU/L (32-92), AST 207 IU/L (15-41), ALT 171 IU/L (14-54), amylase 700 U/L (24-121), lipase >400 U/L (22-51). A computed tomography (CT) scan of abdomen showed mild common bile duct (CBD) dilatation at 11 mm, cystic structure anterior to the CBD measuring 5.3 × 3.9 cm and 12 mm right proximal ureteric stone with right hydronephrosis and cystic changes within right kidney. Magnetic resonance cholangio-pancreaticography (MRCP) showed no filling defect within biliary tree, enlarged right kidney with multiple cysts and exophytic cyst of 4.4 × 3.3 cm at anterior aspect of right kidney creating a mass effect on second portion of duodenum and pancreatic head. This corresponds to cystic structure seen on CT scan. Urology recommended decompressing cystic structure under radiologic guidance. During course of hospitalization, patient's liver functions started improving before she received any intervention. Upon attempting decompression, her renal cyst appeared to be reduced in size relieving compression on the second part of duodenum with improvement of her liver functions. Patient did not need any procedure. Three months later, her liver functions were within normal limits. With her poor condition, patient denied any further invasive work-up. Discussion: Obstructive jaundice can be caused by extrinsic compression of the biliary system. Extrinsic causes include pancreatic pseudocysts or lymphomas. Renal lesions causing obstruction of the biliary system have been very rarely reported. Giant hydronephrosis and megaureter have been reported to cause obstructive jaundice. We present a rare case of obstructive jaundice caused by right renal cyst with hydronephrosis due to obstructive ureteric stone. Although our case improved spontaneously, drainage procedures should be considered in similar cases.

Complication of gallbladder herniation through the abdominal wall

An 83-year-old woman presented to our hospital complaining of recent onset of right hypochondrial pain, associated with fever and chills. On examination she had a painful, 10-cm subcutaneous, irreducible, tender mass in the right upper abdominal quadrant.

Sister Mary Joseph’s Nodule as the First Sign of Pancreatic Carcinoma

IntroductionMetastasis to the umbilicus from intra-abdominal malignantsolid tumors is not common, occurring mostly in patientswith advanced gastrointestinal and gynecologic carcinomasalthough it may sometimes be the first presentation of anoccult, underlying adenocarcinoma [1–4]. This condition isalso known as Sister Mary Joseph's nodule or sign, namedafter Sister Mary Joseph (1856–1939), the superintendentnurse and surgical assistant of Dr. William Mayo at St.Mary's Hospital in Rochester, Minnesota, USA, who no-ticed the association between umbilical nodules observedduring skin preparation for surgery and advanced intra-abdominal cancer found at surgery [5, 6]. Her name wasaccredited to this clinical feature in 1949 by Sir HamiltonBailey in his book “Physical Signs in Clinical Surgery”.Pancreatic carcinoma usually metastasizes to regionallymph nodes, liver, and peritoneum. However, 10 % ofumbilical metastases originate from a pancreatic carcinoma[7, 8] and sometimes they are the first sign of the disease [9,10]. In this report, we present a patient who had a previouslymesh-repaired umbilical hernia and presented with a SisterMary Joseph's nodule associated with an advanced, meta-static adenocarcinoma of the pancreas before diagnosing theprimary tumor.Case ReportA 64-year-old woman was admitted because of painlessobstructive jaundice of 3-days duration when she noticedyellow-colored scleras and dark-colored urine. Threemonths before presentation she noticed a gradually enlarg-ing, progressively painful and inflamed skin nodule in theumbilicus. She also reported loss of appetite and a 10-kgweight loss over this time period. She had no history of liverdisease and she denied having fever, gastrointestinal com-plaints, or any systemic symptoms. Her past medical historyincluded an umbilical hernia repair by using a prostheticmesh 3 years before.On physical examination the scleras and the skinappeared yellow. An abdominal scar of a midline surgicalincision was present above and below the umbilicus. Awell-circumscribed reddish mass measuring approximately 2 cmin diameter, with a slightly ulcerated surface, hard, andpainful on palpation, and fixed to the underlying tissueswas noted in the umbilicus (Fig. 1). Abdominal examinationrevealed mild tenderness localized in the right upper abdom-inal quadrant and the epigastrium, but no mass was palpa-ble. There were no enlarged cervical, axillary, or inguinallymph nodes.

An unusual case of dysphagia

A 50-year-old homosexual man presented progressive ysphagia, odynophagia, heartburn and weight loss of 5 kg ithin 2 months. The pain was directly related to the intake of olid food, resulting in a bolus feeling. He reported no chronic eartburn or previous history of caustic ingestion. Physical examnation revealed pain in the upper abdominal quadrant without bdominal masses. Laboratory investigations indicated a normal ull blood count and tumour markers. A CT scan showed a focal hickening of the wall of the distal oesophagus. An oesophagogastroduodenoscopy (EGD) was performed and howed an initial stricture with friable mucosa and shallow ulcertions at the distal third of the oesophagus (Fig. 1). No obstacle as observed that prevented the advancement of the instrument. t endoscopic ultrasonography (EUS) scanning, the oesophageal all was thickened up to 7.5 mm with normal stratification and the ubmucosal layer had a heterogeneous structure with a “salt and epper” appearance (Fig. 2A). After injection of a second-generation ontrast agent (Sonovue®), the submucosal layer showed a rapid nd protracted contrast enhancement (Fig. 2B), thus with a postontrast feature typical for an inflammatory condition. Moreover, he muscular layer was normal. Endoscopic biopsy performed at the ulcer sites revealed nclusion bodies suggestive of Cytomegalovirus (CMV) infection. mmune staining showed Cytomegalovirus-positive cells. This pathological finding prompted an HIV test, which proved ositive. Esophagitis is the second most common gastrointestinal anifestation of cytomegalovirus infection after colitis in the mmunocompromised patient. Common endoscopic pathological ndings is well-circumscribed ulcerations. Oesophageal complicaions such as bleeding, tracheo-oesophageal fistula and stricture re uncommon [1].

A case report of bilateral adrenal myelolipoma presenting to a geriatric outpatient clinic

A 76-year-old lady, on routine examination, was noted to have a palpable mass in the left upper abdominal quadrant, which was dull to percussion, descendingwith inspiration andwith a notch on the anterior border suggestive of splenomegaly. She reported an increase in abdominal girth over the preceding months, but complained of no other abdominal, gastrointestinal or urinary symptoms. An abdominal ultrasound revealed a normal sized spleen, with 14.7 cm echogenic left suprarenal mass displacing the spleen superiorly and the normal left kidney inferiorly. No other ultrasonographic features were noted. An intravenous contrast enhanced abdominal CT scan with spiral stacks (7/1.5/5 mm) during breath holding showed an 18.0 8.3 9.3 cm lobulated mass, originating from the left adrenal gland, that displaced the pancreas anteriorly, spleen superiorly and left kidney inferiorly (Fig. 1, Fig. 2). It was composed of material suggestive of adipose tissue with ill defined areas of enhancing tissue within it. A similar but smaller mass was seen in the right adrenal gland, measuring 4.9 cm in diameter. The other intra-abdominal organs were normal, and there was no lymphadenopathy. In view of the CT findings, the radiologist was confident of a diagnosis of bilateral adrenal myelolipomas. Although most lesions of this size are surgically resected [1], because of the confident radiological diagnosis, the lack of A R T I C L E I N F O

Primitive Neuroectodermal Tumor of the Liver: A Case Report

Primary liver sarcomas represent a rare group of neoplasias, with angiosarcoma being the most common histological type. Primitive neuroectodermal tumor (PNET) represents a high malignant neoplasia that usually affects the central nervous system and soft tissues. An 18-year-old male patient was admitted with clinical complains of pain in the right upper abdominal quadrant. The clinical evaluation revealed a solid mass in the right hepatic lobe. On the gross examination of the resected liver specimen, the right lobe of the liver was replaced by a yellow-red solid mass measuring 21 cm in its largest dimension. On the histopathology, a tumor composed of small round blue cells with little cytoplasm and round nuclei was identified. The lesion revealed positive immunoexpression for vimentin and CD99 and negative immunostaining for desmin, CD45, cytokeratin, and neuroblastoma protein, suggesting, then, the diagnosis of PNET. Although it is an unusual tumor, it should be considered in the differential diagnosis of liver masses, especially in young patients.

Coristoma pancreático en la vesícula biliar

Heterotopic pancreas found in the gallbladder. Report of one case We report a 54 years old woman presenting with pain in the right upper abdominal quadrant. An abdominal ultrasound showed multiple gallbladder stones. The patient was operated with the diagnosis of cholelithiasis. During the pathological study of the excised gallbladder a 0.9 cm diameter yellowish nodule was found, that corresponded to heterotopic pancreatic tissue.

Index of Suspicion * Case 1: Abdominal Pain, Vomiting, and Weakness in an Obese Adolescent * Case 2: Bowlegs in a Toddler * Case 3: Cyclical Abdominal Pain and Urinary Symptoms in a Teenage Girl

A 15-year-old girl is hospitalized with right upper quadrant abdominal pain, vomiting, and weakness of 3 days' duration. She has a history of hyperlipidemia, polycystic ovary syndrome (PCOS), metabolic syndrome, and left ovarian cystadenectomy. She has been taking oral contraceptives (OCPs) and metformin for the past 2 years and started spironolactone 8 weeks ago. She experienced menarche at age 12 years and had one menstrual cycle for the whole first year. There is no history of dysmenorrhea or menorrhagia. Her family history is positive for type 2 diabetes mellitus (DM), obesity, and gallstones. On physical examination, her body mass index (BMI) is 28.0 kg/m2 (95th percentile), and she is in mild distress due to pain. Her blood pressure is 128/76 mm Hg (90th percentile for age and height); the remainder of her vital signs are normal. She has acanthosis nigricans and hirsutism. She is at Sexual Maturity Rating 5. She has mild tenderness in the right upper abdominal quadrant, but there is no organomegaly or rigidity. The rest of the physical findings are normal. Laboratory results reveal serum amylase of 660 units/L, lipase of 263 units/L, AST of 868 units/L, ALT of 1,573 units/L, cholesterol of 216 mg/dL (5.6 mmol/L), triglycerides of 181 mg/dL (2.0 mmol/L), high-density lipoprotein (HDL) cholesterol of 33 mg/dL (0.9 mmol/L), and glucose ranging from 120 to 148 mg/dL (6.7 to 8.2 mmol/L). Ultrasonography shows multiple cholesterol gallstones and a thickened gall bladder. Additional investigation reveals the diagnosis. A healthy 2-year-old girl presents to the clinic for evaluation of bowlegs. She was born at term and had a birthweight of 6 lb 11 oz. Her development has been normal, and she eats a regular diet. However, the bowing of her legs has increased progressively since she started walking at 1 year of age. There is …

Intermittent duodenal and bile duct obstruction due to liver hydatid cyst

Hydatid cyst is a parasitic disease due to echinoccocus tapeworms. Cystic echinococcosis is a common finding in parts of the world such as the Mediterranean countries and the Middle East. In Greece, the incidence is as high as 13 per 100,000 per year. As humans accidentally play the role of intermediate hosts in the tapeworm life cycle, they become infected by ingesting tapeworm eggs passed from an infected carnivore. In most cases, the symptoms are non-specific and frequently the condition is left undiagnosed. We report the case of an 86 y.o. woman admitted to the department of general surgery, complaining of right upper abdominal quadrant tenderness, repeated vomiting, nausea and low grade fever. Past history included cholelithiasis and two episodes of acute cholocystitis, one of which had received treatment in another hospital while the other had been successfully addressed in our hospital. In both cases, vomiting was the most prevalent symptom but the hydatid cyst failed to be detected. During cholecystectomy, a hard cystic formation appeared to be hanging from the liver’s edge by a narrow stem covered by Glisson’s capsule. An impression on the surrounding tissue was left at the site of the excised cyst. A month later, a follow-up revealed that the patient continued to have recurrent incidents of vomiting. Laboratory tests showed no pathology but a single contrast abdominal x-ray showed persistent signs of duodenal stenosis.