Pancreatic cyst-solid mass: tuberculosis

Question: A 29-year-old Chinese male was admitted to our department with a history of right upper quadrant pain for two months, anorexia, weight loss about 5 kg and without fever. The pain radiated to the back and it got worst lately. He didn’t have a history of tuberculosis. The sclera was mild icteric. Laboratory test results showed total bilirubin level increased to 58 umol/L (normal level <28 umol/L) and tumor markers were normal. Chest X-ray was normal. Abdominal contrastenhanced CT showed a 25 x 30 mm cyst-solid mass in the head of pancreas (Figure1. A) and the lesion was mild enhancement in arterial phase. Pancreatic tumor was considered. Endoscopic ultrasonography confirmed the mass with uneven echo in the pancreatic head and the boundary of the mass was not clear (Figure1. B). The lesion may invade the portal vein. As the patient was young and the operation was very traumatic, the patient refused surgery unless the lesion was proved to be a tumor.

When hematochezia becomes a red herring

An 81-year-old male patient presented on the emergency ward for hematochezia, without any other complaints. Rectosigmoidoscopy showed a predominant patchy inflammation of the mucosa with several bluish blebs (submucosal hemorrhage) and small ulcerations. (Figure 1A). Subsequent elective colonoscopy (1) revealed multiple submucosal hematomas and mucosal lacerations throughout the entire colon in between normal mucosa. During the procedure spontaneous mucosal tears occurred. (Figure 1B). Multiple biopsies were taken.

Unusual cause of low abdominal pain

A 53-year-old woman, G2P2, was referred to the outpatient clinic because of chronic abdominal pain. Abdominal examination revealed tenderness in the right lower quadrant without peritoneal signs and blood analysis was normal. To exclude slow transit constipation a pellet study was performed: plain abdominal radio-graphy showed the presence of all ingested pellets and an abnormal, slightly lateralized and angulated position of the intrauterine device, a levonorgestrel intrauterine system called Mirena® which was placed five years earlier (figure 1). Subsequently an abdominal computed tomography was executed.

The role of extracorporeal shock wave lithotripsy in the treatment of chronic pancreatitis

Pain is the most frequent symptom in chronic pancreatitis (CP) and has an important impact on quality of life. One of its major pathophysiological mechanisms is ductal hypertension, caused by main pancreatic duct stones and/or strictures. In this article, we focus on extracorporeal shock wave lithotripsy (ESWL) as a treatment for main pancreatic duct stones, which have been reported in >50% of CP patients. ESWL uses acoustic pulses to generate compressive stress on the stones, resulting in their gradual fragmentation. In patients with radiopaque obstructive main pancreatic duct (MPD) stones larger than 5 mm, located in the pancreas head or body, ESWL improves ductal clearance, thereby relieving pain and improving quality of life. In case of insufficient ductal clearance or the presence of an MPD stricture, ESWL can be followed by endoscopic retrograde cholangiopancreatography (ERCP) to increase success rate. Alternatively, direct pancreaticoscopy with intracorporeal lithotripsy or surgery can be performed

Gastric adenocarcinoma with enteroblastic differentiation: an unexpected cause of upper gastrointestinal bleeding

A 78-year-old male with previous medical history of hypertension, dyslipidemia, benign prostatic hyperplasia and colectomy for colon adenocarcinoma 16 years earlier presented to emergency department with melena for approximately 2 weeks. He denied hematemesis or hematochezia. He also denied other symptoms including abdominal pain, nausea, vomiting, fever, anorexia or weight loss. Usual medications included silodosin, simvastatin, losartan, hydrochlorothiazide, pantoprazole and midazolam. He denied recent intake of iron supplements or non-steroidal anti-inflammatory drugs. Physical examination was unremarkable except for pale skin. Laboratory studies revealed the presence of anemia (hemoglobin level: 7.1 g/dL). Leukocyte and platelet counts, liver tests, renal function, electrolyte levels, C-reactive protein and coagulation studies were all normal. Upper digestive endoscopy revealed red blood and blood clots in gastric lumen and a polypoid lesion with a diameter of approximately 20 mm located at the greater curvature of the proximal body with active oozing hemorrhage (Figure 1). Bleeding was successfully controlled with injection of diluted epinephrine at the base of the polyp and the patient was admitted in intermediate care unit for close monitoring. During the following days,

How skin and liver can lead to diagnosis

A 73-year-old woman was referred by her hematologist for cholestasis of unknown origin. She was recently diagnosed with chronic myelomonocytic leukemia grade 0 in a context of fatigue, night sweats, weight loss and monocytosis. A PET-CT showed hepatosplenomegaly and multiple centimetric adenopathy. The diagnosis was confirmed by a bone marrow aspiration and biopsy. Interestingly, the evolution of the patient is marked by the appearance of cholestasis and an erythematous firm skin nodule of the right forearm. The skin lesion was biopsied to rule out a cutaneous localization of the patient’s known hemopathy.

Rectal plasmablastic lymphoma in Ebstein Barr virus positive and human immunodeficiency virus negative subject after external radiation therapy for prostatic cancer

Plasmablastic lymphoma (PBL) represents a rare and aggressive subtype of diffuse large B cells lymphoma (DLBCL) most associated with the human immunodeficiency virus (HIV). Prognosis remains poor despite various treatment approaches. We describe an evolution at six months of HIV negative PBL and Ebstein Barr virus (EBV) positive PBL with chemotherapy. Role of radiotherapy is still unclear.

Worldwide prevalence, genotype distribution and management of hepatitis C

Hepatitis C virus (HCV) is one of the leading causes of chronic liver disease, cirrhosis, and hepatocellular carcinoma, resulting in major global public health concerns. The HCV infection is unevenly distributed worldwide, with variations in prevalence across and within countries. The studies on molecular epidemiology conducted in several countries provide an essential supplement for a comprehensive knowledge of HCV epidemiology, genotypes, and subtypes, along with providing information on the impact of current and earlier migratory flows. HCV is phylogenetically classified into 8 major genotypes and 57 subtypes. HCV genotype and subtype distribution differ according to geographic origin and transmission risk category. Unless people with HCV infection are detected and treated appropriately, the number of deaths due to the disease will continue to increase. In 2015, 1.75 million new viral infections were mostly due to unsafe healthcare procedures and drug use injections. In the same year, access to direct-acting antivirals was challenging and varied in developing and developed countries, affecting HCV cure rates based on their availability. The World Health Assembly, in 2016, approved a global strategy to achieve the elimination of the HCV public health threat by 2030 (by reducing new infections by 90% and deaths by 65%). Globally, countries are implementing policies and measures to eliminate HCV risk based on their distribution of genotypes and prevalence.

Gastrointestinal tract involvement in hepatocellular carcinoma: two cases illustrating duodenal and oesophageal invasion

We present here two hepatocellular carcinoma (HCC) patients with gastrointestinal tract involvement (GITI). Hemorrhage due to duodenal involvement was the inaugural event of the HCC for the first patient. Dysphagia due to HCC recurrence in the oesophagus four years after left hepatectomy was the call symptom for the second. As incidence of HCC increases, and overall survival improves, incidence of GITI in HCC patients is expected to increase.

An unusual recurrent ileocolonic injury

Potassium binders (Kayexalate® and Sorbisterit®) are commonly used to treat hyperkaliemia. They are made of sodium or calcium polystyrene sulfonate. Their use is associated with multiple adverse effects including ileocolonic (or more rarely upper digestive tract) injuries which can lead to necrosis or perforations. This side effect is mostly seen in patients with chronic kidney disease or constipation. It presents with abdominal pain, diarrhea or hematochezia. The diagnosis is made when the histo-logical analysis of samples from the erythematous or ulcerated digestive wall finds polystyrene sulfonate crystals embedded in the mucosa. This diagnosis can be suspected by taking a careful initial drug inventory, if the clinician is aware of this rare but serious adverse effect. The lack of specificity of clinical symptoms and endoscopic lesions makes this inventory even more essential. Treatment is mainly supportive and requires cessation of the drug, while surgery is inevitable in the most severe cases.