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The operation was completed with a double suction drainage.
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In the immediate postoperative period, the patient developed hemodynamic collapse requiring the introduction of dobutamine.
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After 48 hours of hemodynamic support, the blood pressure stabilized and dobutamine was stopped.
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Histological study concluded in multinodular colloid goiter.
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The patient was discharged from the hospital after 20 days in good health.
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A 36 year old female farmer gravida 5 para 4 at 27 weeks gestation presented to our facility.
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Her main complaint was a 3 month history of epigastric abdominal pain, which was gradual in onset, dull and persistent.
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Pain had gradually worsened over the months with no known relieving or aggravating factors but with intermittent radiation to the chest.
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There was a history of significant weight loss but no associated early satiety, jaundice, fever, itch or spontaneous bleeding.
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No history of blood transfusion and patient was on her routine hematinic from the antenatal clinic (ANC).
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She is not a known diabetic, Hypertensive and has no known chronic illness.
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Patient did not know her Hepatitis status.
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Denied to taking any alcohol or smoking.
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There were no cardiorespiratory nor urogenital symptoms.
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She did not store grains at home and had no known contact with chemicals or ionizing radiation.
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Clinical signs on examination included wasting, mild pallor, a tinge of jaundice but well hydrated, afebrile and no palpable lymphnodes.
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She had palmer erythema but no clubbing and parotid enlargement.
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Respiratory, cardiovascular and neurological examinations were unremarkable.
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Abdomen was grossly distended with distorted contour in the upper half and visibly distended anterior abdominal wall veins draining away from the umbilicus.
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Liver was enlarged 12cm below the costal margin with a span of 17cm.
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The liver was hard, nodular with irregular edge, mild tendernes and had a bruit on auscultation.
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The spleen was not palpable but with demonstrable mild ascites and bipedal eodema up to the mid shin.
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Symphysio fundal height was 26 cm, with longitudinal lie and breech presentation.
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Fetal heart rate was 134 bpm and regular.
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Rectal and vaginal examination were unremarkable.
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[ 0, 0, 0, 1, 0, 1, 0 ]
Initial diagnosis of hepatocellular Carcinoma in pregnancy was made.
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Laboratory assesment revealed HB-10.3g/dl, WBC 10200 cells/dl; Neutrophils 59.3%, lymphocytes 26.1%, Monocytes 10.1% and Eosinophils 2.7%.
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Platelets 350000/ul.
[ "Platelets", "350000/ul", "." ]
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[ 0, 0, 0 ]
[ "CUI_LESS", "CUI_LESS", "CUI_LESS" ]
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Normal bilirubin but GGT and AST were raised (4 times upper limit).
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Total protein and albumin were low, 44g/L and 29g/L respectively with INR-1.3.HBsAg was positive, HBeAg negative with HBV DNA level of 126869 IU/ml \(Viral load).
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VDRL positive but TPHA not done.
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Alphafeto protein (AFP) >50000KU/L.
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She tested negative to HIV and HCV.
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Abdominal ultrasound showed a heterogeneous coarse liver with multiple hypoechoic lessions.
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The liver measured 17.2cm and there was mild ascites.
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Pelvic scan revealed a 27 week, 3 day old fetus, with active fetal movements.
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A revised diagnosis of hepatocellular carcinoma on a cirrhotic liver with decompensation in pregnancy was made.
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She was managed with analgesia, furosemide, spironolactone and lamivudine added for prevention of mother to child trasmission of the hepatitis B infection.
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The plan was to allow pregnancy to continue to at least 32 completed weeks to improve the chance of neonatal survival.
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However because of the progressive unbearable abdominal pain, pregnancy was terminated at 30 weeks 3days by successful induction of labour.
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The outcome was a fresh stillbirth weight 1.2kg.
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Pain was markedly reduced post delivery and was discharged home after 5 days.
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She was booked for a follow up visit at the gastrointestinal clinic.
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She was seen at the clinic at 2 weeks and four weeks post discharge but was lost to follow up afterwards.
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A 21-year-old male was referred to the gastroenterology clinic for incidental findings of severe chronic pancreatitis on cross-sectional imaging but no associated symptoms of pancreatitis.
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He had presented to the emergency department for abdominal pain consistent with prior episodes of renal colic.
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Computed tomography scan confirmed the presence of renal calculi that passed with conservative management.
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An incidental finding on the imaging showed marked pancreatic atrophy with multiple sub-centimeter calcifications consistent with severe chronic pancreatitis.
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Remarkably, he did not report having any symptoms associated with pancreatic insufficiency including epigastric pain, vomiting, steatorrhea and weight loss.
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He denied having any prior episodes of acute pancreatitis and had no history of alcohol use.
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His laboratory tests were all within normal range, including complete blood count, liver function tests, amylase and lipase.
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His family history was significant as his father had an isolated episode of pancreatitis which required abdominal surgery.
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Magnetic resonance cholangiopancreatography (MRCP) showed severe parenchymal atrophy and pancreatic ductal stones with ductal dilation to 9mm.
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Due to his young age and atypical presentation, he was referred for genetic testing and counselling.
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He underwent genetic testing for various genes known to cause hereditary pancreatitis: CASR, CFTR, CTRC, PRSS1, SPINK1.
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He tested positive for homozygous variant of SPINK1 (N34S) mutation.
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Reflex testing of at-risk relatives confirmed that both of his parents were heterozygous carriers of the same SPINK1 (N34S) mutation and a review of their extended pedigree revealed that they were distant cousins.
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Given his asymptomatic clinical course, he remains under close follow-up without requiring any specific treatment for pancreatic insufficiency.
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Due to the severity of pancreatitis noted on imaging and long expected lifespan, he was counselled about the increased risk of pancreatic malignancy and is undergoing regular cross-sectional imaging for the detection and prevention of cancer.
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We present a case of a 77-year-old Caucasian woman with obstructive jaundice.
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Laboratory tests revealed that she had elevated bilirubin and liver enzyme levels.
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A computed tomographic scan showed a homogeneous 5 × 3-cm mass obstructing the common bile duct.
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The results of brush cytology were consistent with a bile duct villous papilloma.
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However, on the basis of the tumor's radiological features, a preliminary diagnosis of extrahepatic bile duct malignant tumor was made.
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After discussion among the multidisciplinary team, a surgical resection of the bile duct tumor was performed.
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Histopathological examination confirmed a villous adenoma.
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The patient's postoperative course was uneventful.
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We report a case of a 63-year-old woman with a minute ampullary carcinoid tumor that was 7 mm in diameter, but was associated with 2 peripancreatic lymph node metastases.
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Mild elevation of liver enzymes was found at her regular medical check-up.
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Computed tomography (CT) revealed a markedly dilated common bile duct (CBD) and two enlarged peripancreatic lymph nodes.
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Endoscopy showed that the ampulla was slightly enlarged by a submucosal tumor.
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The biopsy specimen revealed tumor cells that showed monotonous proliferation suggestive of a carcinoid tumor.
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She underwent a pylorus-preserving whipple resection with lymph node dissection.
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The resected lesion was a small submucosal tumor (7 mm in diameter) at the ampulla, with metastasis to 2 peripancreatic lymph nodes, and it was diagnosed as a malignant carcinoid tumor.
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A 77-year-old Tunisian woman was hospitalized because of massive painful ascites.
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Her family history did not include any autoimmune disease.
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She denied a history of hepatitis, jaundice or alcohol use.
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She had a history of diabetes, hypertension treated by glinide and calcium blocker.
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She was explored 4 years prior to admission for exudative pleuritis of the right lung without any established diagnosis after multiple explorations including thoracoscopy with biopsies.
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On admission, blood pressure was 150/70 mmHg, her rate was 80 /mn and body temperature was 37°C.
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The physical examination showed only abdominal distension related to the important ascites without collateral venous circulation.
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She had no skin lesions, lymphadenopathy, or hepatosplenomegaly and lower extremities showed no edema.
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Laboratory investigations showed: leucopenia with white blood cell count = 3100/mm3, lymphopenia = 840/mm3, hemoglobin = 10.5g/dL ; low serum albumin level = 29g/L, 47;-globulin = 19g/L. blood glucose levels = 180 mg/dl and hemoglobin A1c = 8.6 %.
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Urine analysis showed trace protein (0.03g/24h).
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Platelet count, activated partial thromboplastin time, liver function tests, blood urea nitrogen, serum creatinine, erythrocyte sediment rate and total cholesterol were within normal limits.
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Tests for HBsAg and HCV were negative.
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Abdominal ultrasonography showed ascitic fluid without any sign of bowel loop thickening or enteritis.
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Neither lymphadenopathy nor liver abnormality was present.
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A chest X-ray film disclosed bilateral pleural effusion.
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Ascitic obtained by aspiration contained 170 cells mm3 (67% lymphocytes), 46g/L protein, but no malignant cells.
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Cultures for bacteria and mycobacteria gave no growth.
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Tuberculosis investigation including initial tuberculin skin test and the research of Koch bacilli in sputum and urine were negative.
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Echocardiogram and electrocardiogram were normal.
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Computed tomographic scan showed massive ascites, no dysmorphic liver, and a mild bilateral pleural effusion.
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Pelvic examination was normal.
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Oesogastroduodenoscopy showed hiatal hernia without oesophageal varices.
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An exploratory laparoscopy was performed, revealing a large amount of ascite, a normal liver appearance, and no granulations suggesting tuberculosis or peritoneal carcinosis.
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Histological examination of the peritoneum showed non specific chronic inflammation.
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Systemic lupus erythematosus was suspected based on pleuritis, lymphopenia and leucopenia.
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An additional serologic survey revealed markedly elevated anti-nuclear antibody (ANA) titer of 1/1600 and a significantly elevated titer of antibody to double-stranded DNA (83 IU/mL ; normal < 30 IU/mL).
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