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Volume 80 - 2017 - Fasc.3 - Clinical images

Ischemic proctosigmoiditis mimmicking a colorectal tumor

A 91-year-old woman, with a medical history of atrial fibrillation, dyslipidaemia and arterial hypertension, presented to the emergency department due to constipation, abdominal pain and rectal bleeding. The physical examination was remarkable for mild abdominal tenderness. The vital signs were stable. Laboratory tests showed anaemia (hemoglobin 10.1 g/ dL) and elevated CRP (73mg/dL) without leukocytosis. Abdominal computed tomography (CT) scan showed a concentric and irregular thickening of the rectosigmoid transition with densification of the adjacent fat, and a proximal dilated bowel segment, suggestive of a neoplasia (Fig. 1).


A case of worsening jaundice in a critically ill patient

A 58-year-old male was admitted to the hospital with right upper quadrant (RUQ) pain and fever of four days duration. On admission, patient was febrile and hypotensive with RUQ tenderness. Lab work showed leukocytosis, abnormal liver function test (LFTs) (see table) and Escherichia coli bacteremia. His initial imaging showed emphysematous cholecystitis and mildly dilated common bile duct (CBD) and underwent emergent percutaneous cholecystostomy. An ERCP was performed due to concerns of potential concomitant cholangitis which demonstrated a normal intra and extrahepatic biliary system with no filling defects (Fig. 1a) and a plastic biliary stent was placed successfully. Subsequently, the patient underwent open cholecystectomy on the next day and was complicated by intra operative bleeding likely secondary to disseminated intravascular coagulation requiring massive transfusion and continuous use of three vasopressors. Post-operatively, the patient's LFTs increased abruptly suggestive of shock liver and then improved gradually (see table). His hepatitis serologies and immunoglobulin levels were unremarkable. His postoperative course was complicated by dry gangrene involving both the feet and hand and underwent bilateral below knee amputation.


Transient tracheo-bronquial aspiration of capsule endoscope

An 81 year-old man with personal history of Alzheimer's disease and under antiplatelet drugs therapy presented with melena and no other symptoms. No source of bleeding was obtained at conventional upper and lower gastrointestinal endoscopy. Thus, video capsule endoscopy was indicated. Although the patient had not history of swallowing disorders and/or dysphagia, the ingestion of the capsule endoscope precipitated self-limited coughing. When capsule endoscope was reviewed the device was located at the tracheo-bronquial system (B-C) for 17 seconds. No symptoms were observed during this period. Afterwards, capsule endo- scopy migrated spontaneously to the oro-pharyngeal cavity (A-D) and continued across the gastrointestinal tract until cecum was reached.


Extremely rare cause of acute abdomen in a child

A 5-year-old boy presented to our emergency department because of sudden onset of abdominal pain and nausea that begun two days before admission. The pain was located at whole right hemiabdomen, especially periumbilically and in the upper right quadrant. The patient had no past medical history. The patient was conscious, his blood pressure of 115/75 mmHg, pulse 84 beats/min, and body temperature 36.6°C. On physical examination palpable mass in the epigastrium and right upper quadrant was found. The patient had direct and rebound tenderness on the right side, especially in right upper quadrant accompanied with abdominal distension. The white blood cell count was 12.40x109/l and C reactive protein level was 26.6 mg/l. All other laboratory examinations showed normal values. Abdominal ultrasonography revealed the presence of a giant cyst in whole right hemiabdomen and measuring 12.6 x 10.0 cm. Findings prompted a subsequent CT scan of abdomen (Fig. 1).