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Volume 80 - 2017 - Fasc.1 - Case reports

Liver disease late in pregnancy without pre-eclampsia

We describe the case of a first twin pregnancy in a 27 year old patient, who experienced acute onset epigastric and right upper quadrant pain at a gestational age of 32 weeks and 2 days. She was diagnosed with acute liver and renal failure and possible disseminated intravascular coagulopathy (DIC) syndrome without pre-eclampsia. Early labor induction was mandatory to save both mother and foetuses. In this overview we describe the differential diagnosis of severe pregnancy related liver injury in the third trimester of pregnancy without pre-eclampsia. (Acta gastroenterol. belg., 2017, 80, 53-57).


A rare cause of acute pancreatitis: Hantavirus infection

Hantaviruses cause potentially fatal two different systemic infectious diseases in humans named as hemorrhagic fever with renal syndrome (HFRS) and Hantavirus pulmonary syndrome. The clinical features of HFRS are hemorrhage, fever, thrombocytopenia and acute renal insufficiency frequently observed. HFRS shows distinctive clinical manifestations throughout from acute influenza- like febrile illness to shock. Although a large portion of HRFS patients present with a complaint of abdominal pain, acute pancreatitis is a rare complication of HFRS. No specific treatment protocol has been described for HRFS and supportive treatment is the basic approach. The rate of success enhanced with early diagnosis and intensive care support. Clinicians should be alert to the HFRS in patients with acute pancreatitis associated with systemic viral infection. We describe a case with HFRS who has presented with acute kidney injury, thrombocytopenia and acute pancreatitis. The patient was treated by supportive management successfully. (Acta gastroenterol. belg., 2017, 80, 59-61).


Unsuccessful transjugular intrahepatic portosystemic shunt for a patient with right heart failure and portal hypertension

A 60-year-old women with a history of congenital pulmonary valve stenosis developed right heart failure, cardiac cirrhosis and end-stage renal disease requiring renal replacement therapy. Cirrhosis was complicated by portal hypertension, resulting in intractable gastro-intestinal bleedings despite optimal treatment with beta-blockers and endoscopic band ligation. Because of fears for worsening right heart failure, a decision for placement of a transjugular intrahepatic portosystemic shunt (TIPS) was initially turned down. However, as intractable bleeding problems persisted and caused heavy transfusion needs, TIPS was ultimately performed as a rescue procedure. Although TIPS successfully reduced the hepatic venous pressure gradient from 16 mmHg to 4 mmHg, portal pressure remained high at 14 mmHg because of persisting right heart failure with elevated central venous pressure. Hepatic encephalopathy soon developed after TIPS placement and culminated in multi-organ failure after another episode of gastro-intestinal bleeding. At this point, the family of the patient decided to withdraw care and the patient died subsequently. This case illustrates how important it is to diagnose and optimally treat right heart failure before cardiac cirrhosis with its impending complications emerges. Although TIPS may effectively treat complications of portal hypertension in the context of cirrhosis, persisting right heart failure may abrogate its beneficial effects. (Acta gastroenterol. belg., 2017, 80, 63-66).


Rectal red blood loss in a healthy toddler is not always a juvenile polyp

Aim Heterotopic gastric mucosa is a well-known congenital anomaly in Meckel's diverticula and duplication cysts. Solitary heterotopic gastric mucosa in the rectum is a rare and frequently overlooked abnormality. Starting from a patient history, the lit- erature is searched and all cases reported over the past 20 years are reviewed and compared to a summary of the older cases. Differences between adult and childhood presentation are outlined and our patient is compared with prior reported cases. Case A 3-year-old girl presented with recurrent rectal blood loss caused by heterotopic gastric mucosa without duplication cyst. She was endoscopically treated with two-stage endoscopic surgical dis- section (ESD). Up to now, rectal heterotopic gastric mucosa has been reported in 34 adults and 24 children, including this patient. There is an overall male dominance (69%). Presenting complaints in children were recurrent fresh blood loss per anum (96%), pain (46%), perineal ulcers (25%), diarrhoea (8%) and one patient had an ano-cutaneous fistula. Endoscopy revealed a mucosal elevation with a slightly different aspect (33%), a polyp (42%) and a solitary ulcer (25%). Endoscopy in adults reveals more frequently polyps compared to children. Treatment in childhood is mainly surgical where adults are more frequently treated with endoscopic tech- niques. Conclusion In a child with recurrent rectal bleeding in good general health, it is important to withhold heterotopic gastric mucosa in the differential diagnosis and take sufficient biopsies during endoscopy. (Acta gastroenterol. belg., 2017, 80, 67-70).


Management of hypertriglyceridemia induced acute pancreatitis and therapeutic plasmapheresis : Report of nine cases and review of literature

Hypertriglyceridemia is one of the rare causes of the acute pancreatitis. The prevalance of hypertriglyceridemia has increased recently due to the changing eating habits, sedentary lifestyle, alcohol consumption, obesity and concomitant diabetes mellitus. Therefore, the frequency of the acute pancreatitis due to hypertriglyceridemia may increase in coming years. Diagnosis of the acute pancreatitis by hypertriglyceridemia can be overlooked easily and may be very severe if untreated accurately on time. In addition to the standard management of pancreatitis, specific treatment for hypertriglyceridemia that is insulin, heparin and anti- hypertriglyceridemic drugs are used. Therapeutic plasmapheresis is the last treatment option and seems the most effective one in this subject through developing device and membrane technologies when we review the current literature. Not only triglycerides but also proinflammatory cytokines and adhesion molecules that play an active role in pathogenesis are removed by plasmapheresis. SO. the effectiveness of treatment appears promising. However, the exact pathophysiology of hypertriglyceridemia-induced pancreatitis could not be fully understood and the majority of published experience comes from the case reports and the benefit of randomized clinical trials is not available. Therefore, there are no data about what are the exact indications and when we start therapeutic plasmapheresis in literature. This manuscript describes our hospital experience with treatment options and analyzes reports published recently about plasmapheresis as a treatment modality for hypertriglyceridemia induced acute pancreatitis. (Acta gastroenterol. belg., 2017, 80, 71-74).