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Volume 83 - 2020 - Fasc.4 - Clinical images

Membranous colitis: a potentially bone-deep diagnosis

A 44-year-old patient, with a history of cutaneous mastocytosis, was referred to our center following chronic attacks of diarrhea and epigastric pain. A previous colonoscopy was regarded as macroscopically normal. However, a new colonoscopy, performed at the time of acute complaints, revealed diffuse loss of vascular pattern in the transverse and sigmoid colon, with sloughing white membranes (Figure 1-left). Histological evaluation showed moderately active erosive colitis and increased numbers of eosinophilic granulocytes (Figure 1-right).


A rare cause of high liver stiffness

A 71-year-old man with a past medical history of arterial hypertension was referred to our outpatient clinic for a suspected liver disease, based on biochemical and radiological findings. He was poorly symptomatic with discrete weight loss due to reduced appetite. Physical examination revealed a good general condition, hepatosplenomegaly, overweight (BMI 27) and enhanced waist circumference. Biochemical examination showed pancytopenia (hemoglobin 11,4 g/dL [13.3-16.7 g/dL], white cells count 3870/μL [4-10x103/μL], platelets count 38000/μL[150-350x103/μL]) and cholestasis (gGT 147 U/L [<60U/L], alkaline phosphatase 152 U/L [40-130 U/L], total bilirubin 2.1 mg/dL [<1.2mg/dL]). ALT and AST levels were normal. The usual liver biochemical etiology tests were negative unless elevated type M immunoglobulins and an antinuclear antibody titer of 1/160. Doppler-abdominal ultrasonography showed a heterogeneous liver (Figure 1A), large splenomegaly (Figure 1B) and several enlarged lymph nodes. Liver vascularization was normal. Differential diagnosis included a chronic liver disease (seronegative primary biliary cholangitis, fatty liver disease or cardiac liver disease) and a hematological disorder infiltrating the liver. Median liver elasticity (E), evaluated by transient elastography (TE), was compatible with cirrhosis (22.8 kPa) while controlled attenuation parameter (CAP) evaluation suggested slight steatosis (Figure 1C). What do you recommend?


Cholecystoduodenal fistula with gastric outlet obstruction

A 68-year-old man with a history of a gallbladder stone for many years suffered acute right upper quadrant pain and was admitted to the emergency room. Computed tomography of the abdomen showed a very high-density shadow in the gallbladder (Fig. 1A). His symptoms were relieved after receiving antibiotics and spasmolytic treatment, but he refused to accept further cholecystectomy. Five months later, the patient presented with a 2-week history of postprandial nausea and vomiting. Physical examination found abdominal splashing sound. Computed tomography revealed a large dense shadow in the duodenum, while the gallbladder appeared atrophic with pneumatosis (Fig. 1B). What could the patient’s diagnosis be?