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Volume 68 - 2005 - Fasc.4 - Case reports

Non-operative management of endoscopic iatrogenic haemobilia: case report and review of literature

Haemobilia denotes an abnormal communication between a vessel of the splanchnic circulation and the biliary system. Patients typically presents with the triad of abdominal pain, upper gastrointestinal haemorrhage, and jaundice. Common causes for haemobilia are iatrogenic causes secondary to hepatobiliary system instrumentation and trauma. Management of patients with haemodynamic significant haemobilia is aimed at stopping bleed- ing, maintaining continuous flow of biliary system, and cure of the underlying aetiology. Iatrogenic haemobilia after ERCP poly- ethylene biliary endoprosthesis placement is extremely uncom- mon. Herein we present a case of iatrogenic haemobilia triggered by biliary endoprosthesis placement and was successfully man- aged by non-operative treatment. The management algorithm for a rational approach to haemobilia is discussed (Acta gastroenterol. belg., 2005, 68, 428-431).


Development of sarcoidosis during interferon alpha 2b and ribavirin combina- tion therapy for chronic hepatitis C- A case report and review of the literature

Sarcoidosis is a chronic granulomatous multisystemic disorder of unknown aetiology. Although interferon gamma has been impli- cated in the pathogenesis of sarcoidosis, only a few cases of sar- coidosis associated with interferon alpha therapy have been reported. We report a case with chronic hepatitis C (CHC) who developed sarcoidosis after the treatment by interferon alpha and ribavirin. The combination therapy of interferon alpha and ribavirin was given to a 50-year-old female with CHC who had not responded to a previous treatment by interferon alpha. She has been admitted with non-productive cough, dyspnoea and fever 11 months after the initiation of combination therapy. Chest x-ray and thorax com- puted tomography revealed bilateral hilar masses and nodular infiltrations in the lung parenchyma. Pulmonary function test showed a mild restriction. Biopsy of mediastinal lymphadenopa- thy revealed noncaseating granuloma. She was diagnosed to have pulmonary sarcoidosis at stage II, and the combination treatment was discontinued. Her symptoms regressed after inhaler steroid treatment. Six months after the diagnosis of sarcoidosis, the patient was asymptomatic and a complete sustained response to hepatitis C was achieved. During the three years of follow-up, both pulmonary sarcoidosis and hepatitis C have not recurred. We sug- gest that sarcoidosis may develop in chronic hepatitis C patients during interferon alpha and/or ribavirin treatment, and diagnos- tic tests for this adverse effect should be performed during the fol- low-ups (Acta gastroenterol. belg., 2005, 68, 432-434).


Tertiary syphilis presenting as hepatic bull's eye lesions

We report a rare case of tertiary syphilis (hepatic gummata, asymptomatic neurosyphilis and iridocyclitis) in a 47 year old female patient. Our patient suffered from a troubled sight, pain in the right hypochondrium, one enlarged submandibular lymph node, an elevated sedimentation rate, disturbed liver tests and two hepatic lesions upon abdominal computed tomography. The diag- nosis was based upon a liver biopsy and a positive Treponema Pallidum haemagglutination test. The patient was treated with doxycyclin. After treatment the sedimentation rate and liver tests normalised and the hepatic lesions disappeared leaving a small 'scar' on CT-scan ; at the end she still complained of a decreased sight. We conclude that syphilitic gummata of the liver have a favourable prognosis when the diagnosis is made early. One has to differentiate with hepatic abscesses, primary tumours and metas- tases (Acta gastroenterol. belg., 2005, 68, 435-439).


Gallbladder adenosquamous cell carcinoma: Report of two Cases

Adenocarcinoma is the usual histological presentation of the very rare gallbladder carcinoma. Adenosquamous cell carcinoma accounts for less than 3.5% of gallbladder carcinomas, and is characterised by invasive growth, a reduced tendency for lymph node metastasis, an increased tendency for hepatic infiltration or liver metastasis, and a poorer prognosis than adenocarcinoma. We present two cases. The first patient presented to our institution with increased bilirubin levels and dilated intra- and extrahepatic bile ducts. Adenosquamous carcinoma of the gallbladder was diag- nosed on the post-operative pathological specimen. After surgery, bilirubin levels decreased, but hepatic metastases occurred that did not respond to conventional chemotherapy. The second patient was admitted to our hospital with jaundice and abdominal pain. Abdominal computed tomography (CT) imaging showed marked thickening of the gallbladder with direct extension of a mass into the left liver lobe. Cytology specimens obtained with an endoscop- ic retrograde cholangiopancreatography (ERCP) procedure revealed a malignant epithelial tumour. The patient underwent surgery but the tumour was incompletely resected. A regimen of oral UFT (Tegafur + uracil) chemotherapy was begun. Serum bilirubin levels increased due to occlusion in the surgical area 15 weeks after the start of chemotherapy (Acta gastroenterol. belg., 2005, 68, 440-442).


Recurrent colonic Dieulafoy's lesion associated with bizarre vascular malforma- tions and abnormal Von Willebrand factor

Colonic Dieulafoy's lesion is an unusual source of massive lower gastrointestinal haemorrhage. It is characterized by severe bleed- ing from a minute submucosal arteriole that bleeds through a punctuate erosion in an otherwise normal mucosa. We describe an elderly man who presented recurrent rectal bleeding from a Dieulafoy's lesion in the sigmoid colon associated with bizarre colonic vascular malformations and an abnormal von Willebrand Factor. He was successfully treated by endoclips application. The clinicopathologic features of this unusual association are discussed and suggestions are made for diagnosis and management (Acta gastroenterol. belg., 2005, 68, 443-445).