Challenges in treatment of a patient suffering from neuroendocrine tumor G1 of the hilar bile duct: a case report

Background Neuroendocrine tumors (NETs) arise from neuroendocrine cells and are extremely rare in the biliary tract. Currently, there are no guidelines for the diagnosis and treatment of biliary NETs. We presented a case with NETs G1 of the hilar bile duct and the challenges for her treatment. Case presentation A 24-year-old woman was presented to our department with painless jaundice and pruritus, and the preoperative diagnosis was Bismuth type II hilar cholangiocarcinoma. She underwent Roux-en-Y hepaticojejunostomy with excision of the extrahepatic biliary tree and radical lymphadenectomy. Unexpectedly, postoperative pathological and immunohistochemical examination indicated a perihilar bile duct NETs G1 with the microscopic invasion of the resected right hepatic duct. Then the patient received 3 cycles of adjuvant chemotherapy (Gemcitabine and tegafur-gimeracil-oteracil potassium capsule). At present, this patient has been following up for 24 months without recurrence or disease progression. Conclusion We know little of biliary NETs because of its rarity. There are currently no guidelines for the diagnosis and treatment of biliary NETs. We reported a case of perihilar bile duct NETs G1 with R1 resection, as far as we know this is the first report. More information about biliary NETs should be registered.

Leptospirosis: A Rare Cause of Acute Hepatitis

Leptospirosis is a zoonotic infection caused by the pathogenic Leptospira interrogans. Humans acquire the infection either through direct contact with the urine of infected animals, commonly rats or indirect contact of contaminated water or soil. It is a rare cause of acute hepatitis in the UK with fewer than 100 reported cases a year and hence diagnosis is commonly delayed. A 51-year-old fit Caucasian gentleman was admitted with a one-week history of painless jaundice, dark urine and pale-coloured stools. This was associated with feeling unwell, anorexia, nausea and intermittent epigastric discomfort. He binges on alcohol on a weekend. He works as a telephone engineer which occasionally exposes him to sewage water. On clinical examination, he was icteric with mild right hypochondriac tenderness. Liver biopsy was performed and histologically it was suggestive of leptospirosis. He was started on a five-day course of intravenous ceftriaxone followed by two days course of oral doxycycline. His IgM leptospirosis result finally came back as positive. Due to the rarity of leptospirosis in the UK, the serological testing of leptospirosis is only performed in the Rare and Imported Pathogens Laboratory in Porton Down, Salisbury leading to a delay in getting the result. The patient underwent an invasive procedure which can be avoided if the leptospirosis serology was ordered early and result available quickly. Fortunately, the patient made a full recovery after two months. Leptospirosis should be considered in an individual with acute hepatitis and a history of exposure to sewage.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S22

A Prospective Study of Evaluation and Management of Obstructive Jaundice in a Tertiary Care Hospital, North Coastal Andhra Pradesh

BACKGROUND Obstructive jaundice is defined as a condition occurring due to block in pathway between the site of conjugation of bile in liver cells and entry of bile into duodenum through the ampulla. This block may be intraheptic or extraheptic in the duct. Evaluation and management of obstructive jaundice is a challenging task to the surgeon owing the varied etiology and wide management option. Common bile duct (CBD) varies in length from 5 to 15 cm with average diameter of 6 mm. CBD can be divided in to four portions: supra duodenal, retro duodenal, intra duodenal and intramural portion. The purpose of this study was to evaluate the pattern of aetiology of obstructive jaundice in these parts and compare the clinical and laboratory presentations with obstructive jaundice between benign and malignant cases. METHODS This is a prospective analytical study. Patients with obstructive jaundice who attended the outpatient department of Surgery, GITAM Institute of Medical Sciences and Research, Visakhapatnam over a period of 24 months from November 2017 to October 2019 were admitted and taken up for the study. A total of 60 cases were studied. RESULTS Abdominal pain was a presenting symptom in 48 patients (80 %). Ninety five percent of patients of benign and 50 % of patients of malignant aetiology presented with this symptom. P value was found to be statistically significant for this symptom. This means that jaundice with pain in abdomen is more common in benign conditions while malignant conditions cause painless jaundice. CONCLUSIONS Malignant obstructive jaundice is most commonly seen in males while benign conditions are more common in females. Benign conditions causing obstructive jaundice is most common under 40 years of age while malignant obstructive jaundice is commonly seen between 50 and 60 years of age. KEYWORDS Cholestasis, Extraheptic, Obstructive Jaundice

Inflammatory Myofibroblastic Tumor of the Porta Hepatis: A Case Report

A 43-year-old man presented with painless jaundice. Imaging revealed a porta hepatis mass compressing the common bile duct. Endoscopic biopsy was negative for malignancy. Complete surgical resection was performed. Pathological assessment showed IGg4 negative inflammatory myofibroblastic tumor.

Focal Autoimmune Pancreatitis: A Simple Flow Chart for a Challenging Diagnosis

Autoimmune pancreatitis is a chronic fibroinflammatory autoimmune mediated disease of the pancreas. Clinically, obstructive painless jaundice and upper abdominal pain are the main symptoms. Focal AIP is characterized by segmental involvement of pancreatic parenchyma and it is often radiologically represented by a pancreatic mass. In these cases, the diagnosis can be very challenging, since it may be easily confused with pancreatic cancer. Therefore, we suggest a combined approach of imaging tests as the diagnostic workup. EUS study combined with CEUS and elastography, if available, increases the accuracy of the method to rule out cancer. Moreover, the lesion should always be sampled under EUS guidance to obtain a cyto/histological diagnosis. The diagnostic workup should also include the use of diagnostic clinical criteria (extrapancreatic lesions, steroid response) and laboratory findings (CA 19.9 and IgG4 evaluations).