Volume 84 - 2021 - Fasc.4 - Clinical images
Pancreatic cyst-solid mass: tuberculosis
Question: A 29-year-old Chinese male was admitted
to our department with a history of right upper quadrant
pain for two months, anorexia, weight loss about 5 kg
and without fever. The pain radiated to the back and it
got worst lately. He didn’t have a history of tuberculosis.
The sclera was mild icteric. Laboratory test results
showed total bilirubin level increased to 58 umol/L
(normal level <28 umol/L) and tumor markers were
normal. Chest X-ray was normal. Abdominal contrastenhanced
CT showed a 25 x 30 mm cyst-solid mass in
the head of pancreas (Figure1. A) and the lesion was
mild enhancement in arterial phase. Pancreatic tumor
was considered. Endoscopic ultrasonography confirmed
the mass with uneven echo in the pancreatic head and
the boundary of the mass was not clear (Figure1. B). The
lesion may invade the portal vein. As the patient was
young and the operation was very traumatic, the patient
refused surgery unless the lesion was proved to be a
tumor.
How skin and liver can lead to diagnosis
A 73-year-old woman was referred by her hematologist
for cholestasis of unknown origin. She was recently
diagnosed with chronic myelomonocytic leukemia grade
0 in a context of fatigue, night sweats, weight loss and
monocytosis. A PET-CT showed hepatosplenomegaly
and multiple centimetric adenopathy. The diagnosis was
confirmed by a bone marrow aspiration and biopsy.
Interestingly, the evolution of the patient is marked
by the appearance of cholestasis and an erythematous
firm skin nodule of the right forearm. The skin lesion
was biopsied to rule out a cutaneous localization of
the patient’s known hemopathy.
When hematochezia becomes a red herring
An 81-year-old male patient presented on the
emergency ward for hematochezia, without any other
complaints. Rectosigmoidoscopy showed a predominant
patchy inflammation of the mucosa with several bluish
blebs (submucosal hemorrhage) and small ulcerations.
(Figure 1A). Subsequent elective colonoscopy (1)
revealed multiple submucosal hematomas and mucosal
lacerations throughout the entire colon in between normal
mucosa. During the procedure spontaneous mucosal tears
occurred. (Figure 1B). Multiple biopsies were taken.
Unusual cause of low abdominal pain
A 53-year-old woman, G2P2, was referred to the outpatient clinic because of chronic abdominal pain. Abdominal examination revealed tenderness in the right lower quadrant without peritoneal signs and blood analysis was normal. To exclude slow transit constipation a pellet study was performed: plain abdominal radio-graphy showed the presence of all ingested pellets and an abnormal, slightly lateralized and angulated position of the intrauterine device, a levonorgestrel intrauterine system called Mirena® which was placed five years earlier (figure 1). Subsequently an abdominal computed tomography was executed.
