Volume 82 - 2019 - Fasc.1 - Clinical images
An atypical endoscopic diagnosis
A 57-year old man presented to the emergency department with intermittent right lower quadrant pain for the previous two days. No fever on admission. Physical examination revealed discomfort in the right lower quadrant. Abdominal ultrasound revealed thickening of cecum wall with slightly increased diameter of appendix base.
Laboratory results show slightly elevated C-reactive protein (CRP 36 mg/dL) and normal leukocyte count (10 000/µL). Liver enzymes, kidney function and electrolytes were normal.
Abdominal CT scan was performed and revealed oedematous thickening of cecum wall and local lymphadenopathy. The tip of the appendix appeared normal (Fig. 1).
Patient was admitted and observed. To rule out neoplasm or inflammatory bowel disease a total colonoscopy and ileoscopy were performed two days after admission. These revealed an inflammatory cecum with faecal impacted base of the appendix, surrounded by pus (Fig. 2 Panel A). With the use of endoscopic biopsy forceps, the piece of faeces was removed (Fig.2 Panel B).
A rare presentation of a gallbladder mass
A 47-year-old female presented with complaints of abdominal pain for last 3 months and fever for last 2 weeks. She gave history of fever with occasional chills and rigors. There was no history of jaundice, nausea, vomiting, hematemesis, melena, significant anorexia or weight loss. She had been operated for extradural meningioma 2 years back. Her vitals were stable at presentation. General physical examination revealed pallor. Abdominal examination revealed tenderness in right hypochondrium and presence of globular lump, extending 4 cm below right costal margin. Liver function tests showed hypoalbuminemia (albumin-2.8g/ dL) and raised alkaline phosphatase (ALP-372 IU; normal-100-250)). Her coagulogram and renal function tests were within normal limits. CECT of the abdomen revealed a large low-attenuation mass involving segments IV and V of liver (Figure 1a). The gallbladder was only partly visualized in neck and proximal body and showed continuity with the lesions. An upper gastrointestinal endoscopy (UGIE) was done (Figure 1b). What is your diagnosis?
Acute pancreatitis and obesity: where is the problem?
A 33-year-old male patient presented at the emergency department for an acute abdominal pain. He is non- smoker and non-alcoholic. In his past history, we note a class I obesity (weight: 118 kg, height: 185 cm, body mass index 34.5) treated by the placement in another institution of an intragastric balloon (single balloon) filled with 600 mL of methylene blue-mixed saline 3 months ago. The balloon was well tolerated except some signs of reflux treated by pantoprazole 20 mg per day. He had a regular check up by his physician and a total weight loss of 19.5 kg after 3 months. He presented to the emergency department for an acute continuous epigastric pain radiating to the back started brutally 6 hours ago without fever, chills, diarrhea nor vomiting. The pain was not decreasing after taking 1g of paracetamol.
Clinical examination reveals an epigastric pain on palpation without any sign of peritonitis and negative Murphy sign, stable vital signs except sinus tachycardia (110/min). Laboratory findings included a minor inflammation (C-reactive protein 45 mg/L) with normal hepatic tests and an increase in lipase values (434 mU/ mL, 7 times upper normal value). Triglyceride and calcium levels were normal. An abdominal ultrasound showed no stone in the gallbladder.
An abdominal computed tomography scan was performed (Figure 1A-B). What is your diagnosis and strategy for the patient?
