Upper-quadrant Abdominal Pain Research Articles

Fitz-Hugh-Curtis Syndrome: A Case Report Emphasizing Timely Recognition and Management in Pelvic Inflammatory Disease

Fitz-Hugh-Curtis syndrome (FHCS) is a rare complication of pelvic inflammatory disease (PID), that presents with right upper quadrant abdominal pain, often mimicking hepatic, or biliary conditions. Timely diagnosis is crucial to prevent complications. This case report represents 34 years old female came to ER complaining from right upper quadrant abdominal pain and nausea for one month.

Epstein-Barr in a Patient Presenting with Right Upper Quadrant Pain: A Case Report from the Emergency Department

BackgroundRight upper quadrant abdominal pain and elevated cholestasis blood tests are usually associated with bacterial calculous cholecystitis. However, viral infections, such as Epstein-Barr virus (EBV) can also manifest with a similar clinical picture and is an important differential diagnosis. Case ReportThis case report discusses a young woman presenting to the emergency department with acute right upper quadrant abdominal pain. The initial assessment revealed a positive Murphy's sign, elevated white blood count, and a cholestatic pattern on liver function tests, leading one to suspect bacterial calculous cholecystitis and initiating antibiotic therapy. However, clinical examination also revealed tonsillar exudates and differential white blood cell count revealed monocytosis and lymphocytosis rather than a high neutrophil count. The patient tested positive for EBV. Furthermore, ultrasound and magnetic resonance imaging revealed gallbladder wall edema with no gallstones, leading one to conclude that the clinical manifestation and laboratory results were due to an EBV infection. Antibiotic therapy was ceased and the patient did not require surgical intervention. Why Should an Emergency Physician Be Aware of This?Calculous bacterial cholecystitis usually entails antibiotic therapy and cholecystectomy. It is important to be aware of the differential diagnosis of EBV, as it usually does not require either of these and resolves spontaneously.

FRI239 Oncocytic Adrenocortical Neoplasm Of Uncertain Malignant Potential

Abstract Disclosure: K. Barnett: None. A. Sandhu: None. F. Hasan: None. Introduction: Oncocytic adrenocortical neoplasms are a rare histological subtype of adrenal mass, characterized by their abundant eosinophilic cytoplasm. Like other adrenal masses, they can be functional, or hormone-producing, and present on a spectrum from benign to malignant. Case: Our patient is a 31 year old female with a past medical history of anxiety who presented to the ER for right upper quadrant abdominal pain. She described it as a colicky, aching pain, lasting for several minutes at a time. She could identify no known trigger. A CT abdomen with contrast showed cholelithiasis and a hypodense lesion on the right adrenal gland. Her primary care physician (PCP) ordered a follow-up MRI abdomen with contrast that showed an indeterminate, 2.9 cm x 2 cm mass on the right adrenal gland without evidence of microscopic fat. After consultation with an oncologist, her PCP then recommended a PET scan, which showed that the mass was mildly hypermetabolic. She presented to the endocrinology office for further evaluation shortly thereafter. Though her abdominal pain had subsided, she did endorse a 7 lb weight loss, attributed to decreased appetite from anxiety. Additional review of systems was grossly negative. Hormonal work-up, including DHEA, renin, AM cortisol, ACTH, aldosterone, and plasma metanephrines was normal. CT-guided biopsy was deferred in favor of a repeat CT abdomen with adrenal protocol, which showed the adrenal nodule measured 40 HU on unenhanced images, with an absolute contrast washout of 50%. As this was less than the 60% threshold typically utilized to indicate a lipid-poor adenoma, the nodule was deemed indeterminate. Given the concerning features of the mass: its lipid-poor nature on unenhanced CT, metabolic activity on PET scan, and washout that was below the threshold for an adenoma, adrenalectomy was recommended. She underwent a laparoscopic right adrenalectomy, with final pathology showing oncocytic adrenocortical neoplasm of uncertain malignant potential, based on Lin-Weiss-Bisceglia criteria. She was seen by oncology, and they recommended no adjuvant treatment at this time. A repeat CTAP abdomen with adrenal protocol is planned for 1 year after this procedure. Discussion: Given the rarity of oncocytic adrenocortical neoplasms, their classification into benign, uncertain malignant potential, or malignant using Lin-Weiss-Bisceglia criteria is essential to determining appropriate treatment and surveillance. A recent retrospective cohort study showed oncocytic neoplasms with uncertain malignant potential have favorable outcomes, however, patients require continued radiographic surveillance due to the risk of late recurrence. Reference: Shirali AS, et al. Differences in Clinicopathologic Behavior of Oncocytic Adrenocortical Neoplasms and Conventional Adrenocortical Carcinomas. Ann Surg Oncol. 2022;29(9):5555-5563. doi:10.1245/s10434-022-11626-w Presentation: Friday, June 16, 2023

Uncommon Malpositioned Inserted Biliary Stent Causing Common Bile Duct to Portal Vein Fistula: Case Report

Endoscopic biliary stent is a common practice in recent years. One of the complications might occur is stent malposition. A 31 years old male with obstructive jaundice secondary to gallstone, presented with persistent upper right quadrant abdominal pain immediately after biliary stenting. During evaluation, biliary stent was found in the portal vein, he immediately underwent repair laparoscopic converted to laparotomy due to obscured stent. Intraoperative findings include fistula in the common bile duct (CBD) to portal vein. Malposition of biliary stent is common occurrence. However, only 5% malposition to proximal and <1% cause perforation or fistula. Anatomical variation of extrahepatic biliary system is common and might be a contributing factor. Thus, adequate knowledge of the anatomical variation helps in stent placement and preventing associated complication. We report a rare case of CBD stent malposition to proximal portal vein with fistula.

Cystic lymphangioma of the gall bladder: common disease at uncommon site

BackgroundCystic lymphangiomas are benign vascular malformations of lymphatic differentiation. They usually occur in childhood and are commonly seen in the head and neck region. Lymphangioma of the gallbladder is extremely rare, and only a handful of cases have been reported in the literature.Case presentationA 56-year-old female presented to the outpatient department for evaluation of right upper quadrant abdominal pain which had been bothering her for the past few months. Abdominal ultrasonography revealed an ill-defined septated cystic lesion surrounding the gallbladder (GB) which was initially thought to be a collection. However, contrast-enhanced computed tomography of abdomen showed a well-marginated fluid density lesion in the gall bladder fossa which was insinuating around the gall bladder and was encasing it. No intralesional enhancement was seen after contrast administration. MRI confirmed the well-defined, multiseptated lesion without any solid component in the gall bladder fossa encasing the GB but without any abnormal communication with the biliary tree. Therefore, a final diagnosis of slow flow lymphatic malformation was formulated. The patient underwent exploratory laparotomy, and the mass was resected en bloc with the GB. Histological evaluation was consistent with lymphatic malformation.ConclusionsGB lymphangioma is a rare entity and is difficult to diagnose. While the imaging characteristics are essentially similar to lymphangiomas elsewhere in the body, the location is peculiar and should warrant a thorough evaluation by the means of CT and more importantly MRI.

Case report on splenic abscess with pleural effusion caused by enteric fever

Splenic abscess is an infrequent complication of enteric fever caused by Salmonella typhi. The incidence rate ranges from 0.14-2%. Clinical manifestations are often nonspecific and may be presented as fever with left upper quadrant abdominal pain and a palpable tender mass. Diagnosis is often difficult and splenic abscess management is based on surgical interventions and antibiotic therapy. In this case report we would like to highlight splenic abscess with left reactive pleural effusion as a rare complication of Salmonella typhi infection.

Splenic abscess due to non-operative management of splenic injury: a case report

BackgroundSplenic abscess is a rare disease, with incidence of 0.2–0.7% in previous studies. It often appears with left upper quadrant abdominal pain, fever, chills. Splenic abscess often happens because of hematogenous spreading of infections, endocarditis, angioembolization and some other rare reasons. Treatment relies on one of these two methods: percutaneous drainage or surgery.Case presentationA 68-year-old diabetic Asian female (Asian woman) presented with generalized abdominal pain, low blood pressure, tachycardia, fever, lethargy and elevated level of blood sugar. She had history of conservative therapy in intensive care unit due to blunt abdominal trauma and splenic injury. She had a huge splenic abscess in ultrasonography and computed tomography scan so she went under splenectomy. Our patient had a splenic abscess without performing any intervention like angioembolization.ConclusionImmune compromised patients who are selected for nonoperative management after splenic injury need close follow up and evaluating about abscess formation for at least 2 weeks. Early diagnosis and treatment with two methods including percutaneous drainage or splenectomy should be considered and it depends on patient’s risk factors, vital signs, general conditions and presence or absence of sepsis.

Biliary Ascariasis with Gallbladder Invasion: A Unique Entity

ntestinal Ascariasis is a common helminthic infection in developing countries and in some rare cases, worms migrate to the biliary tract and gall bladder. Extraintestinal biliary ascariasis presents with jaundice, right upper quadrant abdominal pain, and vomiting. Ultrasonography is a useful diagnostic modality. Albendazole and Mebendazole are commonly used anti-helmintic agents for conservative management, whereas endoscopic removal is needed in rare cases.

Point-of-care Ultrasound Identification of Hepatic Abscess in the Emergency Department.

A 92-year-old female with past medical history of hypertension presented to the emergency department with pain in her right shoulder, right flank, and right upper quadrant of her abdomen. Point-of-care ultrasound (POCUS) and computed tomography imaging showed concerns for multiple large hepatic abscesses. Percutaneous drainage removed 240 millileters of purulent fluid that identified Fusobacterium nucleatum, a rare cause of pyogenic liver abscess. Emergency physicians should keep hepatic abscess on their differential for right upper quadrant abdominal pain and can use POCUS for expeditious diagnosis.

Cecal bascule in pregnancy: a case report and review of the literature

A 36-year-old female at 36weeks' gestation presented with right upper quadrant abdominal pain. She had no prior surgeries. Her pregnancy had been uncomplicated up until her presentation. Abdominal ultrasound was negative for cholecystitis or cholelithiasis, and the appendix was not visualized. During the second day of her hospital course, an abdominal magnetic resonance imaging (MRI) was performed revealing dilated small intestine with air-fluid levels and an inverted-appearing, prominent cecum. She was urgently taken to the operating room for cesarean section followed by abdominal exploration. After delivery of the child, a cecal bascule was found, with a severely distended cecum. To our knowledge, this is the first report of a cecal bascule diagnosed by MRI, and the first diagnosis of cecal bascule in a pregnant patient requiring surgical intervention. We discuss the pathophysiology, diagnosis and treatment of cecal bascule and review the current literature of reported cases.

Delayed Cholecystectomy Management for Mirizzi Syndrome.

Mirizzi syndrome is defined as a common hepatic duct obstruction from a cystic duct stone, which results in a severe inflammatory reaction that distorts biliary anatomy and makes surgical intervention challenging. Most case reports describe an open subtotal cholecystectomy as the most common surgical technique with few reports detailing successful laparoscopic interventions. This case involves an 11-year-old African American female who presented with right upper quadrant abdominal pain and imaging consistent with Mirizzi syndrome. She was taken for a laparoscopic cholecystectomy that was quickly aborted due to extensive inflammation. She subsequently underwent endoscopic decompression of her biliary tree by gastroenterology. She returned to the operating room six weeks later for a successful interval cholecystectomy. This case illustrates a unique report of delayed cholecystectomy for management of Mirizzi syndrome, which highlights a potential management strategy that avoids technically difficult laparoscopic cholecystectomy in the acute inflammatory period.

Bone marrow metastasis of breast cancer and chronic lymphocytic leukemia: A coincidence

Objectives. We present an extremely rare case of breast cancer with metastasis to the bone marrow, which was also simultaneously diagnosed with chronic lymphocytic leukemia (CLL). Case Presentation. A 56-year-old female with a history of routine blood transfusions presented with chronic fatigue and recurrent right upper quadrant abdominal pain due to cholecystitis. Additionally, nodules were palpable in both breasts, which were subsequently detected as suspicious calcified lesions on ultrasound. Leukocytosis and bi-cytopenia were found. Cholecystectomy was performed and biopsies from some tissues were conducted. Gall bladder and subcutaneous tissue from the umbilical area showed neoplastic cells suggestive of breast carcinoma. Bone marrow biopsy showed CLL and non-hematopoietic cells identical to the previously detected neoplastic cells. Immunohistochemistry revealed that the breast carcinoma was ER-positive, PR-positive, and HER2negative. Outcome. After a thorough investigation, the bone marrow depression was proven to result from a metastatic bone marrow lesion from breast cancer diagnosed concurrently with CLL. Conclusions. This circumstance obliged clinicians to be more considerate of the diagnostic approach and treatment of patients with neoplasm presenting with cytopenia. It is to avoid underdiagnosis and ensure that every pathology in the bone marrow is investigated and managed accordingly.

Idiosyncratic drug-induced liver injury related to use of novel selective androgen receptor modulator RAD140 (Testalone): a case report

BackgroundRAD140 (Testalone) is a novel selective androgen receptor modulator with very limited data currently available on adverse effects related to this compound. The first-in-human phase 1 trial was recently published and did report a significant proportion of elevated aspartate aminotransferase, alanine transaminase, and total bilirubin among the test subjects. RAD140 may be associated with an idiosyncratic drug-induced liver injury. It is easily purchased online as a workout supplement. Given its ease of use from being an oral formulation, and not requiring a physician’s prescription, its use among the young male population will likely rise. Clinicians should ask about the use of RAD140, and other workout supplements, in young men presenting with acute liver injury.Case presentationWe present the case of a 26-year-old Caucasian male without any significant past medical history who presented with nausea, vomiting, severe right upper quadrant abdominal pain, and jaundice from acute liver injury. Extensive inpatient workup did not reveal a definite cause for his liver injury other than the use of a novel selective androgen receptor modulator called RAD140 (Testalone). He was treated with supportive care and discharged after short hospitalization. He was instructed to stop RAD140, which he reported compliance with, and on 2-month follow-up his liver function panel had normalized without recurrence of any symptoms.ConclusionNovel selective androgen receptor modulators such as RAD140 may be associated with idiosyncratic drug-induced liver injury. Workup of new liver injury in young and middle-aged males should involve asking about use of these novel compounds, for if missed and use continues, it can likely lead to fulminant liver failure or decompensated liver cirrhosis.

A CASE REPORT ON HEPATOGASTRIC FISTULA IN A CASE OF LIVER ABSCESS

Liver abscess is a common cause of febrile illness in India. It usually presents with fever and right upper quadrant abdominal pain. Upper gastrointestinal bleeding is not a commonly described clinical presentation of liver abscess. In liver abscess, upper gastrointestinal bleeding would usually be attributed to nonsteroidal anti-inflammatory druginduced esophagitis, erosive mucosal disease, or duodenal or gastric ulcer, as would be expected in any febrile illness. I present a case report of a patient who presented with febrile illness and upper gastrointestinal bleed due to a ruptured liver abscess perforating into the stomach.

Ameboma mimicking hepatic flexure colon carcinoma: A case report

Introduction and Importance: Ameboma frequently manifests as a segmental and concentric mucosal lesion in the gastrointestinal tract, causing lumen constriction and obstructive symptoms, and can occur as a single or multiple occurrences in the colon. Case Presentation: A 30-year-old woman presented to our hospital’s Department of General Surgery clinic with complaints of right upper quadrant abdominal pain, mild abdominal distension, nausea, vomiting, and constipation for one month. As a result of the investigation, an exploratory laparotomy was performed, a hepatic flexure colon mass was identified, and a right hemicolectomy was performed. An ameboma was found in the pathology report. Clinical Discussion: Ameboma mimics colon carcinoma and other gastrointestinal diseases, such as tuberculosis and Crohn’s disease. As a result of publishing this case, we hope to raise the awareness of clinicians working in endemic regions regarding differential diagnosis. Conclusion: In cases of perforation or obstruction, colorectal amoebiasis requires immediate surgery. Before starting therapy, the patient’s medical history must be analysed and a diagnosis made.

Diagnosis of primary biliary melanoma with distinct imaging features: a case report and literature review

Primary biliary melanoma arises from proliferating melanocytes in the mucosal surface of the bile duct and is extremely rare. Since the vast majority of biliary melanomas represent metastases of cutaneous origin, accurate preoperative diagnosis of melanoma and exclusion of other primary sources are vital in cases involving primary lesions. Although melanomas with pigmented cells have typical signal characteristics, obtaining a non-invasive pre-treatment diagnosis remains difficult, due to their low incidence. Here, the case of a 61-year-old male Asian patient who presented with upper quadrant abdominal pain, swelling and jaundice for 2 weeks, and who was diagnosed with primary biliary melanoma following extensive preoperative blood analyses, computed tomography (CT) and magnetic resonance imaging (MRI), is described. Post-resection immunohistochemistry confirmed the diagnosis and the patient received six chemotherapy cycles of temozolomide and cisplatin, however, progression of multiple liver metastases was observed at the 18-month follow-up CT. The patient continued with pembrolizumab and died 17 months later. The present case of primary biliary melanoma is the first reported diagnosis based on typical MRI features and the exhaustive exclusion of a separate primary origin.

Endoscopic management of a migrated biliary stent in the pleura: a rare complication.

A 65-year-old woman presented with fever, cough, and right upper quadrant abdominal pain. She had undergone endoscopic retrograde cholangiopancreatography (ERCP) 3 weeks earlier for choledocholithiasis, with stent placement. There was a history of attempted stent removal, which failed, at another institute. At presentation, her laboratory parameters were normal, except for white blood cells of 22 570/µL and hemoglobin of 9 g/dL. A computed tomography scan revealed migration of the biliary stent in the pleura ([Fig. 1]).

Bilateral Tubal Pregnancies Presenting 11 Days Apart: A Case Report.

Ectopic pregnancy is the most common cause of maternal mortality in the first trimester. Bilateral tubal pregnancy is the rarest subset with an estimated incidence of one in 725 to 1,580 ectopic pregnancies. Of the cases of bilateral tubal pregnancy reported in the literature, most were associated with the use of assisted reproductive techniques. Here we present the case of a patient, without a prior history of reproductive technology use, who underwent treatment for a tubal pregnancy and was subsequently found to have a second, contralateral tubal pregnancy 11 days later. A 35-year-old female gravida eight para two with a history of left tubal pregnancy and salpingectomy 11 days prior, presented to the emergency department (ED) with two days of left lower and upper quadrant abdominal pain. The patient's last menstrual period had been several months prior. A physical examination revealed left lower quadrant abdominal tenderness, rebound, guarding, and left adnexal tenderness. Her vital signs were unremarkable, and her laboratory studies revealed normal white blood cell and hemoglobin values. Her human chorionic gonadotropin had tripled from her last presentation 11 days prior. Transvaginal ultrasound showed a possible ectopic pregnancy adjacent to the right ovary. She promptly underwent a right salpingectomy. Pathology findings confirmed a tubal pregnancy, and the patient's postoperative course was uneventful. This case highlights the importance of maintaining a high index of suspicion for ectopic pregnancy in all biologically female patients of reproductive age who present to the ED with abdominal pain.

Xanthogranulomatous Cholecystitis: A Rare form of Chronic Cholecystitis

Xanthogranulomatous cholecystitis (XGC) is a rare form of cholecystitis distinguished by the presence of numerous yellow-brown intramural nodules with severe fibrosis and foam cells within the gallbladder wall, which may be misdiagnosed as a Gall Bladder Carcinoma. It is typically diagnosed between the sixth and seventh decades of life, predominantly in females. Clinical signs and symptoms are comparable to those of acute and chronic cholecystitis, making it challenging to distinguish XGC prior to surgery. The case of a 52-year-old man who presented to the emergency department with right upper quadrant abdominal pain for 4 months, radiating into the right shoulder is discussed. Patient was diagnosed to have Chronic Calcular Cholecystitis on Ultrasound. Laparoscopic Cholecystectomy was performed and XGC was diagnosed post-operatively through definitive histopathological examination. Preoperatively and intraoperatively, Xanthogranulomatous Cholecystitis is difficult to diagnose and pathological examination is required for a definitive diagnosis. XGC, which exhibits clinical and radiological signs similar to those of gallbladder tumors, must be included in the differential diagnosis in order to avoid an extensive surgical procedure.

Robotic left hepatectomy with complex reconstruction: When intrahepatic tumor becomes hilar

Background: In this video we present a robotic assisted left hepatectomy with complex biliary reconstruction in a 61 year old female with morbid obesity (BMI 49 kg/m2) and non-alcoholic fatty liver disease. The patient presented with right upper quadrant abdominal pain. Evaluation with axial imaging and ERCP with biopsy confirmed a preoperative diagnosis of a left intrahepatic cholangiocarcinoma. Intraoperative ultrasound demonstrated unexpected tumor extension into the main hepatic ducts necessitating biliary resection and reconstruction. In this video we outline several techniques unique to minimally invasive hepatobiliary surgery that can be utilized to improve exposure and visualization in a patient with a challenging body habitus.