EP.FRI.86 Spontaneous haemoperitoneum due to acute hemorrhagic pancreatitis in a child: A Case report

Introduction Hemoperitoneum resulting from acute pancreatitis (AP) is rare. It is more commonly associated with chronic pancreatitis. Seldom, it has been associated with paediatric population. Here we report a case of spontaneous hemoperitoneum due to acute hemorrhagic pancreatitis in a child presented with the clinical features suggestive of acute appendicitis. Presentation of the case A 9-year old girl presented with abdominal pain and clinical features consistent with perforated appendicitis, underwent diagnostic laparoscopy. This revealed hemoperitoneum due to acute hemorrhagic pancreatitis with fat saponification in the omentum around the splenic flexure. She was stable postoperatively and was transferred to a tertiary paediatric unit for further management. Discussion The incidence of paediatric AP is increasing at 1/10,000 children per year. The definition of paediatric AP is based on the Atlanta criteria in adults. Biliary condition, systemic illness, and medications remain the main causes of AP in children. Intravenous fluid therapy with crystalloids remains the mainstay of treatment. Conclusion A high index of suspicion is required to reach the diagnosis as symptoms are commonly comprised of abdominal pain, irritability, nausea, vomiting, and epigastric pain. USS is the investigation of choice. Majority of the patient recovers completely with a recurrence reported only on 15-35% of the cases. Key Statement Inclusion of amylase or lipase to be considered in the routine workup if there is a suspicion of an alternate diagnosis. Diagnostic laparoscopy remains a viable option for patients presented with features of peritonism to establish a diagnosis.

486 Spontaneous haemoperitoneum due to acute hemorrhagic pancreatitis in a child: A Case report

Introduction Hemoperitoneum resulting from acute pancreatitis (AP) is rare. It is more commonly associated with chronic pancreatitis. Seldom, it has been associated with paediatric population. Here we report a case of spontaneous hemoperitoneum due to acute hemorrhagic pancreatitis in a child presented with the clinical features suggestive of acute appendicitis. Presentation of the case A- 9-year-old girl presented with abdominal pain and clinical features consistent with perforated appendicitis, underwent diagnostic laparoscopy. This revealed hemoperitoneum due to acute hemorrhagic pancreatitis with fat saponification in the omentum around the splenic flexure. She was stable postoperatively and was transferred to a tertiary paediatric unit for further management. Discussion The incidence of paediatric AP is increasing at 1/10,000 children per year. The definition of paediatric AP is based on the Atlanta criteria in adults. Biliary condition, systemic illness, and medications remain the main causes of AP in children. Intravenous fluid therapy with crystalloids remains the mainstay of treatment. Conclusions A high index of suspicion is required to reach the diagnosis as symptoms are commonly comprised of abdominal pain, irritability, nausea, vomiting, and epigastric pain. USS is the investigation of choice. Majority of the patient recovers completely with a recurrence reported only on 15-35% of the cases. Key Statement Inclusion of amylase or lipase to be considered in the routine workup if there is a suspicion of an alternate diagnosis. Diagnostic laparoscopy remains a viable option for patients presented with features of peritonism to establish a diagnosis.

Lemur Loris Digestive Tract Pathologies (Dissection Study)

A necropsy study of the Lemur Lori was carried out. Physiologically, Lemurs have a very sensitive gastrointestinal tract. Therefore, these animals almost keep the lead in the incidence of pathologies of the oral cavity, stomach, and intestines. The study was carried out in the dissection room of the Veterinary Medicine Faculty of the Altai State Agrarian University. The object was the animal corpse of a Lemur Loris: animal species: monkey; gender: female; age: 1.5 years; breed: Loris; the owner is a private zoo; provisional diagnosis: not known. The following methods were used: history taking; postmortem examination according to Shor’s method with a description of the results obtained; photographing; analysis of the data obtained with the help of fact-finding. As a result of the postmortem examination, the following changes were recorded: pulmonary edema, acute congestive hyperemia and emphysema; acute expansion of the right atrium and ventricle of the heart; acute catarrhal-hemorrhagic esophagitis and gastroenteritis; acute hemorrhagic pancreatitis; acute serous-hemorrhagic lymphadenitis of the mesenteric lymph nodes; liver and kidneys fatty degeneration; cyanosis of the conjunctiva, tunica mucosa of the mouth; obesity. Thus, death occurred as a result of pulmonary arrest (pulmonary edema), which was the result of autointoxication (inflammatory processes in the stomach, intestines, pancreas). The cause of autointoxication is a long-term and major violation of the norms of feeding and maintenance, stress, and presumably a drug that was administered to the animal, namely, an incorrect dose or individual intolerance of its constituent components.

Pancreatic Polypeptide-Secreting Tumour of the Proximal Pancreas (PPoma)—Ultra Rare Pancreatic Tumour: Clinically Malign, Histologically Benign

Background and objectives: Here we report a rare case of a pancreatic polypeptide-secreting tumour (PPoma) discovered by accident during an autopsy. These PPomas occur in less than 2% of all pancreatic neoplasms and are almost exclusively silent, i.e., they are non-functional. Symptoms arising from PPoma are due to its compression of surrounding tissue. Materials and methods: The autopsy was performed on a 68-year-old male diagnosed with multiple endocrine neoplasm type 1 (MEN1) due to the patient’s sudden death. Results: A solitary, densely fibrotic, pink-brown tumour, 18 mm in size tumorous mass, was localised in the head of the pancreas. Microscopically, the tumour had a glandular structure with a tubuloacinar arrangement of the cells. Immunohistochemically, we detected strong PP (pancreatic polypeptide) intracytoplasmic activity and negative glucagon activity. The PPoma was located in the head of the pancreas, likely resulting in the obstruction of the main pancreatic and common bile duct. Conclusions: To the best of our knowledge, this is the first report suggesting the association of PPomas with MEN1. Also, the PPoma could be the cause of acute hemorrhagic pancreatitis due to its location.

Porphyria Cutanea Tarda Associated With Acute Hemorrhagic Pancreatitis

Porphyria cutanea tarda (PCT) is a condition of dysregulated heme synthesis that leads to accumulation of photosensitizing precursors with resultant fragility and blistering of the skin. It can be hereditary or acquired and has been known to be associated with hepatic C virus, alcohol, HIV, and estrogen. In this article, we report an unusual presentation of PCT associated with acute hemorrhagic pancreatitis in a 57-year-old man. He presented initially to a community hospital with acute onset of epigastric abdominal pain and new-onset ascites. Lipase was elevated. Diagnostic paracentesis was grossly bloody. He was then transferred to our institution for concern for acute hemorrhagic pancreatitis. On arrival, physical examination demonstrated vesicles and bullae with erythematous bases, in different stages of healing seen over the dorsal aspects of both hands with scaling, scarring, and hypopigmentation and hyperpigmentation of the skin. Laboratory evaluation and skin biopsy confirmed the diagnosis of PCT. Search for an underlying etiology failed to reveal typical predisposing factors. This report illustrates that acute hemorrhagic pancreatitis may be an underlying etiology for PCT.

Sudden Death Due to Acute Pancreatitis

Acute pancreatitis can present as sudden, expected death and, therefore, fall under the jurisdiction of the medical examiner/coroner (ME/C). Although its etiologies are varied, alcohol abuse, trauma, and drugs are important to consider in the forensic setting. It is therefore important for the forensic pathologist to have an understanding of these and other etiologies, to have a functional knowledge of the pancreatic anatomy and physiology, and to be able to diagnose acute pancreatitis and distinguish it from postmortem artifact. This review will highlight the forensic aspects of acute pancreatitis, with particular focus on acute hemorrhagic pancreatitis. This will include an overview of the developmental anatomy and normal physiology of the pancreas, the various causes of pancreatitis that may result in deaths coming to the attention of the ME/C, the underlying pathophysiology of the disease, the postmortem diagnosis of acute pancreatitis, and ancillary studies that support the diagnosis. Acad Forensic Pathol. 2018 8(2): 239-255