White Stool Research Articles

Case study on viral hepatitis

The majority of such hepatic failure in children worldwide is due to viral hepatitis. This is a case report of an 8-year-old male child who had symptoms like headache, abdominal pain, cough, jaundice, loss of appetite, and white stools. On examination and with routine laboratory tests, the hematological parameters were found to be within normal limits, while the diagnosis of viral hepatitis was established clinically and through ruling out other causes. The child was managed on the lines of supportive and symptomatic pharmacotherapy that included antibiotics, analgesics, ursodeoxycholic acid, vitamin supplementation, and herbal hepato -protective agents. He improved symptomatically through the treatment course and claimed gradual recovery. This case highlights the other end of recognizing and managing a pediatric patient with viral hepatitis early enough.

A case report of carcinoma of the papilla of Vater associated with a hyperplasia-dysplasia-carcinoma sequence by pancreaticobiliary maljunction.

Pancreaticobiliary maljunction (PBM) is a known risk factor for biliary tract cancer. However, its association with carcinoma of the papilla of Vater (PVca) remains unknown. We report a case with PVca that was thought to be caused by the hyperplasia-dysplasia-carcinoma sequence, which is considered a mechanism underlying PBM-induced biliary tract cancer. A 70-year-old woman presented with white stool and had a history of cholecystectomy for the diagnosis of a non-dilated biliary tract with PBM. Esophagogastroduodenoscopy revealed a tumor in the papilla of Vater, and PVca was histologically proven by biopsy. We finally diagnosed her with PVca concurrent with non-biliary dilated PBM (cT1aN0M0, cStage IA, according to the Union for International Cancer Control, 8th edition), and subsequently performed subtotal stomach-preserving pancreaticoduodenectomy. Pathological findings of the resected specimen revealed no adenomas and dysplastic and hyperplastic mucosae in the common channel slightly upstream of the main tumor, suggesting a PBM related carcinogenic pathway with hyperplasia-dysplasia-carcinoma sequence. Immunostaining revealed positivity for CEA. CK7 positivity, CK20 negativity, and MUC2 negativity indicated that this PVca was of the pancreatobiliary type. Genetic mutations were exclusively detected in tumors and not in normal tissues, and bile ducts from formalin-fixed paraffin-embedded samples included mutated-ERBB2 (Mutant allele frequency, 81.95%). Moreover, of the cell-free deoxyribonucleic acid (cfDNA) extracted from liquid biopsy mutated-ERBB2 was considered the circulating-tumor deoxyribonucleic acid (ctDNA) of this tumor. Herein, we report the first case of PVca with PBM potentially caused by a "hyperplasia-dysplasia-carcinoma sequence" detected using immunostaining and next-generation sequencing. Careful follow-up is required if pancreaticobiliary reflux persists, considering the possible development of PVca.

Prevention of white impurities in vaname shrimp (Litopenaeus vannamei) using noni fruit extract (Morinda citrifolia) in semi-intensive shrimp cultivation system

White vanamae shrimp is one of the superior commodities in aquaculture. Currently, the productivity of white vanamae shrimp has not yet reached its production target. So, it is necessary to increase the amount of production on a gradual scale carried out by the community. In shrimp farming activities, disease problems are often encountered. Namely is a white stool, white feces, or White Feces Disease (WFD). The clinical symptoms that arise when shrimp are attacked by White Feces Disease (WFD) are that the shrimp's appetite decreases, the shrimp's intestines change color to white and even look empty due to lack of food intake, white feces floating on the surface of the water, and the shrimp's growth becomes abnormal. This WFD disease can be caused by poor cultivation practices, unhealthy seeds, and poor water quality, causing the emergence of disease microorganisms such as Vibrio sp bacteria. One way to treat this disease is to provide alternative medicine, noni fruit extract. This research consisted of 3 noni extract treatments and consisted of 3 replications, namely Treatment A: 10 mL/L; Treatment B: 15 mL/L; Treatment C: 20 mL/L. The noni dose is given at the specified dose once daily for one month. The survival rate of shrimp increased to 86.7%.

Primary duodenal carcinoma suspected to arise from ectopic gastric mucosa: a case report

BackgroundEctopic gastric mucosa mainly occurs in the duodenal bulb, and its etiology is thought to be congenital straying of gastric tissues. Primary duodenal carcinoma is a rare disease; however, reports of carcinoma arising from ectopic gastric mucosa are extremely rare. We report a case of primary duodenal carcinoma suspected to arise from ectopic gastric mucosa, which discovered as a result of duodenal stenosis.Case presentationThe patient was a 71-year-old man with persistent weight loss and white stools. Enhanced computed tomography showed stenosis of the third portion of the duodenum and main pancreatic duct dilatation. Upper gastrointestinal endoscopy revealed irregularity of the duodenal mucosa from the anorectal side of the papilla of Vater to the stenosis of the third portion. No malignant cells were found by biopsies from the duodenal mucosa. Endoscopic ultrasonography did not detect the tumor in the pancreatic head. The possibility of a pancreatic tumor could not be ruled out based on findings of main pancreatic duct dilatation in the pancreatic head, and the patient had long-term poor oral intake because of duodenal stenosis; thus, surgical treatment was planned. Intraoperative findings showed palpable induration of the third portion of the duodenum and white nodules on the serosal surface. This was diagnosed as primary duodenal carcinoma, and pylorus-preserving pancreatoduodenectomy was performed. Histopathological diagnosis revealed ectopic gastric mucosa in the papilla of Vater and well-differentiated tubular adenocarcinoma invaded the normal duodenal submucosa and extended to the duodenal serosa. No mass lesion was detected in the pancreas, and an intraductal papillary mucinous neoplasm was observed in the branch pancreatic duct. The main pancreatic duct stricture was caused by the duodenal carcinoma invasion.ConclusionsThis case of primary duodenal carcinoma was suspected to arise from ectopic gastric mucosa and review the relevant literature.

Pancreatoblastoma of the pancreatic head with portal tumor embolism in a 2-year-old boy

A 2-year-old boy visited the hospital with a complaint of grayish white stool. A pancreatic tumor was found on investigation. The tumor was located at the head of the pancreas, and the common bile duct was completely occluded by the tumor and surrounding lymph nodes. A tumor embolism in the portal vein was observed. Development of accessory blood circulation associated with tumor embolization in the portal vein was observed. Tumor biopsy and biliary drainage tube placement were performed. The tumor was diagnosed as pancreatoblastoma. Pylorus-preserving pancreaticoduodenectomy was performed after three courses of chemotherapy. For the portal vein tumor plug, the portal vein was opened, and as much of the tumor plug was removed as possible. Anastomosis of the pancreas and small intestine was performed using the pancreatic duct insertion method, and the pancreatic juice was completely discharged from the body. After the operation, it was suspected that there was a small tumor remnant in the portal vein. Postoperative high-dose chemotherapy with peripheral blood stem cell transplantation and proton beam therapy were performed as additional treatments. Currently, the patient has been alive for 7 years without recurrence.

CHOLEDOCAL CYST Pada DEWASA: PERAN ULTRASONOGRAFI

Choledocal cyst (CC) is a rare congenital cystic dilatation of bile duct. The etiology is unknown, and likely multifactorial and it is uncertain whether they are congenital or acquired. Ultrasonography is initial imaging which can be used to evaluate biliary system. We report 43 year old female presented with icteric for 3 months. She had dark-color urine and white stool. She didn’t complain about abdominal pain or palpable mass in her abdomen.We performed ultrasonography and found dilatation of common bile duct for ± 7.4 cm. Gall bladder and another intrahepatic structures were normal. The patient was referred to digestive surgeon in adequate facility. Conclusion: Ultrasonography is initial and non-invasive imaging for viewing biliary system. Early detection and management can prevent morbidity and improve patient’s quality of life.

Cholelithiasis in infants with congenital nephrotic syndrome of the Finnish type.

Congenital nephrotic syndrome of the Finnish type (CNF) caused by NPHS1 mutations is a rare disease. Infants with CNF can develop many complications, but hepatobiliary complications are uncommon. CNF is not reported as a risk factor of cholelithiasis, which is also a rare disease in the pediatric population. We herein present the cases of three infants with CNF diagnosed with gallstones among a total of seven children with CNF who were treated between 2010 and 2020 in our hospital. The gestational ages, birth weights, and ages at CNF diagnosis of cases 1, 2, and 3 were 38, 37, and 38weeks; 2450, 2374, and 3120g; and 25, 3, and 31days of age, respectively. Imaging studies at the time of CNF diagnosis revealed asymptomatic gallstones in each of them. Case 1 patient developed incarcerated choledocholithiasis and presented with vomiting, white stool, and critically prolonged coagulation at 7months of age. The gallstones disappeared at 3months of age in case 2, although they remained in cases 1 and 3 at the last observation. Infants with CNF can develop cholelithiasis and should undergo hepatobiliary ultrasonography at the time of diagnosis. Patients with gallstones should be evaluated for signs of potential gallstone incarceration because of the risk of hemorrhagic complications due to cholestasis with subsequent vitamin K deficiency and treatment with anticoagulation agents.

Case Report: White Colored Stool: An Early Sign of Cystic Fibrosis in Infants

A 2-month-old male infant presented with white colored stools 1 month after birth. There was no jaundice of the skin, mucous membrane, or sclera; his liver was enlarged (4 cm below the ribs), and his liver function tests showed slightly elevated total bilirubin (TB), direct bilirubin (DB), and total bile acid (TBA). An abdominal doppler ultrasound showed no signs of biliary atresia. Genetic testing revealed a CFTR hemizygous mutation site (c.223C>T) in exon 3 and exon 2–3 heterozygous deletion mutation. The infant's stool turned yellow after oral administration of pancreatic tablets. Finally, the infant was diagnosed with cystic fibrosis (CF). Review of literature revealed five children (including the infant in this case study) with CF who presented with white stool. All five children had anemia, four had edema and hypoproteinemia, five had changes in stool color (it was pistachio-green color in two patients, pale colored in one, acholic stool in one, and white stool in one), two had cholestasis, one infant had delayed meconium discharge, and three children had delayed growth and hepatomegaly. Two children had an abnormal sweat test, one had a F508del compound heterozygous mutation, and one had three mutation sites (C.214G>G/A, P.A72T; C.650A>A/G, P.E217G, and C.3406G>G/A, P. A1136T), which was a compound heterozygous mutation. So, CF could be included in the differential diagnosis of infants with white stool. Genetic testing could confirm an early diagnosis of CF. Pancreatic replacement therapy has been shown to be beneficial for improving the digestive function.

Pneumocystis jirovecii pneumonia Suspected Due to Low-Dosage Prednisolone Treatment for Acute Autoimmune Hepatitis: Case Report and Literature Review

(1) Background: Preventative treatment for Pneumocystis jirovecii pneumonia (PCP) has been recommended for patients receiving ≥20 mg/day prednisolone. We describe a patient who developed PCP while receiving a dose of 15 mg/day prednisolone, and consider criteria for the initiation of preventative therapy for PCP in patients with autoimmune hepatitis (AIH) treated with prednisolone.(2) Case Report: A 71-year-old woman initially possessed dark-colored urine, white stool, and decreased appetite, which indicated hepatic dysfunction. Further comprehensive investigation suggested a diagnosis of acute hepatitis with probable autoimmune etiology. Treatment was initiated at 60 mg/day prednisolone. Following a positive response by the patient, the dose was gradually reduced to 15 mg/day. Seventy days after the start of prednisolone treatment, respiratory symptoms appeared, and PCP was diagnosed following examination of bronchoalveolar lavage samples. The patient responded positively to treatment with sulfamethoxazole/trimethoprim combination therapy.(3) Conclusions: Preventative therapy for PCP may be indicated for AIH patients treated with steroids with (1) a dose of prednisolone of 12–15 mg/day or more, (2) a CD4+ lymphocyte count of 200–250/mm3 or less, or (3) a total lymphocyte count of 600/mm3 or less.

Diagnosis of Pancreatic Cancer: Can Biopsy Misguide?

Pancreatic cancer remains the second leading cause of cancer related mortality in United States with 48,960 new cases and 40,560 deaths in 2015, with a 5 year survival rate of 7.2%. Due to its retroperitoneal location and insidious course, diagnosis of pancreatic cancer remains elusive. Case Presentation: 76 y/o male with past medical history of hypertension, diabetes and hypothyroidism presented with decreased appetite, 60 pound weight loss, fatigue and pale white stools for a year. Laboratory workup revealed AST and ALT ˜ 200 IU/L, ALP > 1200 IU/L, CEA - 9.9 ng/mL, CA-125 of 81.6 U/mL and CA 19-9 of 12131 U/mL. CT abdomen showed extrahepatic and intrahepatic ductal dilatation, narrowing of common bile duct, soft tissue density in the pancreatic head. (figure 1). EUS revealed a 3x2 cm heterogenous mass in pancreatic head encasing bile duct. FNA of the mass was suggestive of benign cellular elements. Repeat EUS-FNA of the mass was also negative for malignancy. During ERCP, sphincterotomy was performed with multiple biopsies of papilla, which were also negative for malignancy. PET scan was also negative for uptake anywhere (figure 2) Due to multiple co-morbidities he was managed supportively and external biliary drain was placed. Autopsy revealed poorly differentiated pancreatic cystadenocarcinoma with signet ring cells and mucinous infiltration involving pancreatic head and body. (figure 3).Figure 1Figure 2Figure 3Discussion: Algorithm for imaging diagnosis of pancreatic carcinoma includes a multi-detector computed tomography (MDCT), MRCP, or fine-needle aspiration using EUS. MDCT has >96% sensitivity for predicting the resectability of pancreatic cancer, however misses small metastases. EUS produces high resolution images of the pancreas and is useful for tumours < 3 cm. EUS-guided FNA is > 90% sensitive in detecting pancreatic malignancy. In our case despite two EUS- FNA attempts, we were unable to get a tissue diagnosis, which highlights potential fallacies. The necessity of obtaining a cytological or tissue diagnosis of pancreatic cancer prior to surgery remains controversial. However in unresectable cases and where palliation is to be considered, pathological proof of malignancy is required for determining neo-adjuvant chemotherapy. This case highlights the fact that despite many advances we still have long strides to make in techniques for diagnosis of pancreatic cancer, to help institute timely management.

Pancreatitis in adult with acute lymphoblastic leukemia using L-asparaginase and simvastatin: case report and systematic review

Context: Acute pancreatitis is a inflammatory process of the pancreas. It can be caused by gallstones, metabolic disorders, associated or not with alcohol abuse, or medication. Case Report: A 38-year-old man was admitted to the hospital because of worsening of nausea, abdominal pain, dizziness and white stool. Patient was diagnosed with severe acute pancreatitis. After six days of hospitalization, patient progressed into hypotension and severe bradycardia, and died. The patient used simvastatin chronically, and was in treat with L-asparaginase, both drugs related to the occurence of acute pancreatitis separately. Naranjo´s probability scale of adverse drug reaction established the causality between these medications and acute pancreatitis as probable. However, due to the absence of reports of causality, the acute pancreatitis is associated with to the use of L-asparaginase with possible drug interactions with simvastatin. Conclusion: It is very important to monitor patients treated with L-asparaginase, through careful observation of clinical signs and laboratory follow-up, as well as verification of other medications in use. The AP may have different levels of severity, being indispensable the quick diagnosis and early treatment

Late-Onset Invasive Group B Streptococcal Infection with Serotype VIII in a Neonate Having Congenital Biliary Atresia

A female newborn was admitted to our department 15 days after birth for insufficient sucking and jaundice. The patient's blood and urine cultures were both positive for group B streptococcal (GBS) infection. A maternal vaginal sample at 35 weeks' gestation was negative for GBS in culture-based microbiologic screening. The patient recovered shortly after receiving systemic antibiotic therapy. On the basis of clinical evidence of white stool and progressive jaundice, we suspected that the newborn had complications related to congenital biliary atresia (CBA); surgery was performed. Isolates from the mother's vaginal sample obtained when the patient was 25 days old, along with neonatal blood, revealed identical patterns (serotype VIII and sequence type 1) of GBS capsular and multilocus sequence typing, suggestive of maternal transmission. Molecular epidemiologic examination may be useful to clarify the transmission route and etiology; culture-based microbiologic screening appears to have limitations for detecting the route of transmission.

Transaminase in rotavirus gastroenteritis

Children infected with rotavirus often show increased levels of transaminase, and symptoms are characterized by white stool, similar to biliary atresia. Rotavirus infections are also sporadically accompanied with convulsions, encephalopathy and Reye syndrome. The aim of the present study was therefore to investigate transaminase and interleukin (IL)-6 levels in rotavirus infection, in order to better understand their clinical significance. Results of liver function tests, mainly the elevation of transaminase and IL-6 in rotavirus gastroenteritis with or without convulsions, were evaluated. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were high in 23 of 26 samples (88.5%), and in three of 26 samples (11.5%), respectively. No significant differences in liver function tests could be found between the groups with or without convulsions. Three patients whose direct bilirubin levels were above the upper normal limit were all classified into the group without convulsions. Spearman's correlation coefficient was 0.89 between increasing AST levels and IL-6 levels. Rotavirus infection is occasionally accompanied with hepatitis, but only in a mild form, and does not correlate with neurological complications. High levels of transaminase might reflect high IL-6.

Problem of a rare anomalous hepatic artery during whipple procedure

Sir, Anatomical variation of the Hepatic Artery (HA) is seen in 20.4% of liver donors. The common variations include a replaced or an accessory right HA originating from the superior mesenteric artery (6.67%) and a replaced or an accessory left HA originating from the left gastric artery (6.41%).[1] A 46-year-old male patient presented with painless and progressive jaundice of 1 month's duration, with severe generalized itching and white stools. Clinically, he was deeply jaundiced, with serum bilirubin of 26mg% and elevated alkaline phosphatase. The whole biliary tree was seen to be dilated on Ultrasonography (USG). Side-viewing endoscopic biopsy from an ulcer at the ampulla was reported as adenocarcinoma. There was no metastasis on evaluation. While doing the classical Whipple procedure the HA was dissected free in the normal location in front of and left of the portal vein. While dissecting toward the gastroduodenal artery, a much bigger vessel was seen crossing the portal vein anteriorly. The main artery was seen to the right of the portal vein, crossing in front of the portal vein at the superior border of the pancreatic neck and dividing into the gastroduodenal and the common HA, which further divided into the right and left HA [Figures ​[Figures11 and ​and2].2]. There was no HA arising from the celiac trunk. As the artery lay in front of the portal vein, along the line of the pancreatic neck transection, the chance of injury was high. The main trunk and the artery beyond the gastroduodenal were protected and an uneventful Whipple procedure was done. Figure 1 Hepatic artery before gastroduodenal disconnection. (1) Portal vein, (2) Abrrant hepatic artery Figure 2 Hepatic artery after division of the gastroduodenal artery. (1) Portal vein, (2) Main pancreatic duct with tube inside, (3) Aberrant hepatic artery, (4) Ligated gastro-duodenal artery, (5) Common hepatic artery, (6) Liver, (7) Left hepatic artery 8 Right ... The arterial system of the liver in humans presents wide variability and knowledge of the different variations is important when operating in this region.[2] In a cadaveric dissection, a similar anatomical variation has been reported, with a gastrosplenic and hepatomesenteric trunk, and with the HA having a similar course to that found in our case[3]; we, of course, could not dissect till the origin of the artery in our live patient. In another cadaveric dissection, two anomalous HAs were described; one of these was similar to the HA seen in the present case, which can be classified as type VI of Adachi's classification and type IV of Morita's classification.[4] Ours is the first report of such an anomaly in a live jaundiced patient. Such cases require careful dissection and ligature of the gastroduodenal artery, with care being taken to preserve the common hepatic trunk.

Hepatotoxicity induced by cyproterone acetate: A report of three cases

Cyproterone acetate (CPA) is a steroidal synthetic progestagen and anti-androgenic compound widely administered in prostate cancer which has been evidentially correlated with a severe hepatotoxic potency. Three male patients aged 78-83 years are presented, in whom severe hepatotoxic reactions emerged after CPA administration. Patients were treated with CPA at the doses of 200-300 mg/d for malignant prostate disease for 3-12 mo prior to the acute manifestation of the hepatic disease. Clinical features compatible with mixed hepatocellular and cholestatic liver disease including jaundice, white stools and dark urine, manifested in all three cases whereas encephalopathy and ascites were present in two of the patients. Other primary causes of hepatotoxicity (alcohol consumption and viral hepatitis) were also verified in two cases, and in those patients biopsy findings revealed the presence of cirrhotic lesions in liver parenchyma. Discontinuation of the therapeutic agent led to the amelioration of the clinical profile in all the patients whereas a patient died 40 d after hospital admission due to sepsis, despite acute liver disease improvement. The current article highlights the hepatotoxic potency of a widely administered therapeutic agent and illustrates the importance of clinical surveillance especially in patients with previous hepatic diseases. Three relevant cases are reported and a review of the published literature is made.

仮性小児コレラのウイルス学的研究 (第1報)

Infantile diarrhoea with white stool occurs every winter from November to March in Sendai. The virus isolation was attempted from 26 cases of this diseases occured from November 1965 to February 1966. Employing human embryonic kidney fibroblasts, cytomegalovirus (CMV) was isolated from the throat swabs of 6 cases of 17 (35.3%). Then CF antibody against the isolated strain of CMV in paired sera obtained from the patients was titrated. However, significant rise of CF antibody was demonstrated only in 2 cases of 19 and the CF antibody was detected even in the acute sera obtained from 10 cases of 19. The CF antibody against the same virus in sera obtained from the healthy infants was also titrated in the comparative manner. The CF antibody was found in 46.4% of them on summer 1965, in 35.3% on autumn before the occurrence of the disease, in 31.5% on winter during the epidemic of the disease and 47.4% on next spring after the epidemic, while demonstrated in 61.3% of the patients.Thus CMV may be or may not be the etiological agent of this disease, although the seroepidemiological results that CMV seemed to be spread in the winter during the epidemic of the disease, taken together the high ratio of CMV isolation from the patients, suggested the posibility that CMV may be the cause of this disease.

ANOMALIES OF THE BILE DUCTS

Congenital anomalies of the bile ducts, although not extremely rare, are sufficiently so to make the following cases of interest. Case1.—A 15 year old girl was admitted to the New York Post-Graduate Medical School and Hospital on March 11, 1938, because of jaundice. Ten years previously she was studied in this hospital for dysentery. The cause was not discovered. This was followed by a celiac syndrome. Two years later she was readmitted with convulsions. These ceased with general treatment. The child did fairly well in spite of occasional attacks of diarrhea, which persisted for about four years. At the time of her last admission no blood had been present in the stools for six years. One year previously she had jaundice, with white stools, dark urine and moderate digestive disturbance. The attack subsided in two months. About six months before admission jaundice appeared again and persisted, varying in intensity