Pancreatolithiasis: Does Management Depend on Clinical Manifestations?

BACKGROUND Pancreatic calculi (PC) or pancreatolithiasis refers to the presence of stones in the main pancreatic duct (MPD), side branches, or parenchyma of the pancreas. It is highly associated with chronic pancreatitis (CP), and is present in 50-90% of those patients. The stone formation can be attributed to a diversity of factors, all of them leading to obstruction in the duct, hypertension of its distal part, increased intraductal and parenchymal pressure, and inflammation, causing the standard symptom, epigastric pain. Immediate restoration of pancreatic secretion flow is of utmost importance and can be achieved with both endoscopic and surgical techniques. Endoscopic techniques include endoscopic retrograde cholangiopancreatography (ERCP) combined, if possible, with extracorporeal shock wave lithotripsy (ESWL), while surgical techniques consist of drainage and resection procedures. The choice of treatment for PC depends on the location, size, and number of stones, and the existence of other complications. CASE REPORT We present 2 cases that were diagnosed with PC, in which clinical symptoms, laboratory results, and imaging examinations were different, suggesting the variety of manifestations pancreatolithiasis can cause. Each patient was treated differently, according to their clinical situation and the presence or absence of complications. Both patients were discharged and fully recovered. CONCLUSIONS The management of pancreatolithiasis can be demanding in some cases, mostly when there are complications. The purpose of this case report is to indicate the importance of personalized treatment for each patient, as different approaches to the same medical condition should be easily identified and successfully treated.

Gastrointestinal Imaging Findings in the Era of COVID-19: A Pictorial Review.

The potentially fatal COVID-19 pandemic has been associated with a largespectrum of clinical presentations. Beyond the classical pulmonary manifestations, gastrointestinal tract-related symptoms suchas nausea, diarrhea, abdominal distention and pain have been observed in patients, as a consequence of the binding of SARS-CoV-19 to Angiotensin-converting Enzyme 2 (ACE2) receptors in the gastrointestinal (GI) tract. The early recognition ofspecific imaging features, including hepatobiliary involvement, pancreatic involvement, development of solid organ infarcts, ischemic bowel changes and vascular occlusion, plays a key role through the course of the disease. Also, suspicious symptoms, especially in critically ill patients with clinical and biochemical markers of hypovolemia, necessitate timely imaging for bleeding complications. The aim of this pictorial review is to illustrate the spectrum of the GIimaging findings in patients with COVID-19. Awareness of diagnostic imaging hallmarks is crucial to optimize the management of these patients.

Synchronous Pancreatic Ductal Adenocarcinoma in the Head and Tail, a Double Trouble: A Case Report and Literature Review.

Synchronous primary pancreatic ductal adenocarcinoma (PDAC) is very rare and can be formed either through multicentric carcinogenesis or intrapancreatic metastasis. We report the case of an 80-year-old man with a history of type 2 diabetes mellitus who presented with abdominal pain and weight loss. Laboratory tests showed elevated levels of blood glucose and CA 19-9, and Computed Tomography revealed two hypoenhancing lesions in the head and tail of the pancreas. Endoscopic ultrasound, which is the imaging method of choice for pancreatic cancer, was performed with a fine needle biopsy, and the cytological analysis diagnosed PDAC in both lesions. The patient underwent total pancreatectomy, and pathologic evaluation revealed synchronous primary PDAC with moderate to poor differentiation in the head and tail in the setting of IPMN (intraductal papillary mucinous neoplasia) and chronic pancreatitis. After his recovery from postoperative pulmonary embolism, the patient was discharged home with sufficient glycemic control. Multifocal PDAC occurs more often when precursor lesions, such as IPMN, pre-exist. The optimal treatment for multiple lesions spread all over the pancreas is total pancreatectomy. Diabetes mellitus is a serious complication of total pancreatectomy (new-onset or type 3c), but overall, long-term survival has been significantly improved.

Massive subgaleal hematoma in a 62-year-old man treated with apixaban as a consequence of mild head trauma.

Subgaleal hematoma, accumulation of blood in the loose areolar tissue of the subgaleal space of the skull, is considered the most catastrophic complication of instrumental delivery. It is a rare finding in older ages, usually associated with coagulation disorders, severe head trauma leading to skull base fractures and accidental or abusive hair pulling. Complications include periorbital necrotising fasciitis, permanent blindness, infections and, in extreme rare cases, airway obstruction. Most cases of subgaleal hematoma resolve spontaneously, without the need of aspiration or drainage.We present here the case of a 62-year-old male on anticoagulant therapy with apixaban for chronic atrial fibrillation, who came to the emergency department after a car accident suffering from mild head trauma. The patient was complaining of a diffuse headache and physical examination showed a large ecchymosis and edema on the frontal area of the head. His neurological examination was unremarkable. Full-body computed tomography (CT) revealed a fracture of the third right rib. Twelve hours after admission, due to an excessive decrease of hematocrit, a second CT was performed. Although the images didn't show intracranial hemorrhage or skull base fractures, a large and diffuse hematoma of the subaponeurotic space was observed and the diagnosis of subgaleal hematoma was confirmed.Massive subgaleal hematoma after mild head trauma is rather infrequent. Early diagnosis improves outcomes and can avert serious complications. Therapeutic strategy should be based on the severity of each case. In our case, conservative treatment appeared to be a valid alternative to surgery, as hematoma resolved spontaneously within 10 days. It is noteworthy that the use of anticoagulation is the only evident factor that could have been the precipitating factor for the development of the hematoma in our patient.

Impact of Bevacizumab Versus Erlotinib on Tumor Metrics in Patients With Previously Untreated Advanced Non-small Cell Lung Cancer: A Study by the Hellenic Cooperative Oncology Group.

BACKGROUND: The mechanism of action of bevacizumab and erlotinib is quite different in the treatment of advanced non-small cell lung cancer (NSCLC). This study sought to compare the two targeted therapies in terms of sequential tumor response metrics. PATIENTS AND METHODS: Parameters of radiological tumor response evaluation were assessed at baseline and periodically in 58 patients receiving either bevacizumab plus platinum-based chemotherapy (N=25) or erlotinib (N=33). RESULTS: Bevacizumab-treated patients had lower longest diameter at best response compared to the erlotinib group (p=0.011). The longest diameter, tumor volume and density significantly decreased from baseline to best response for the entire cohort and bevacizumab-treated patients; no difference was found in the erlotinib group. CONCLUSION: Treatment with bevacizumab substantially improved tumor metrics between baseline and each cycle of treatment, as well as between baseline and best response, in patients with advanced NSCLC.

The challenging diagnosis and treatment of duodenal diverticulum perforation: a report of two cases.

BACKGROUND: The duodenum is a common site for diverticulum formation. Most of the duodenal diverticula are asymptomatic, incidental findings. Perforation is a rare but potentially lethal complication of duodenal diverticular disease. Surgery remains the mainstay of treatment for perforated duodenal diverticula. In recent years, a few cases were successfully managed either conservatively or with endoscopy. CASE PRESENTATION: We present two cases of female patients treated in our department for duodenal diverticulum perforation. The first case was treated surgically with a diverticulectomy. The second case was managed conservatively with bowel rest and intravenous antibiotics. Both patients had an uncomplicated postoperative course and were discharged home. CONCLUSIONS: Both surgical and conservative treatments are viable options for a perforated duodenal diverticulum in selected patients. Patients with a contained duodenal diverticular perforation can be managed conservatively at the outset. Possibly, the introduction of a classification system for duodenal diverticulum perforation may help clinicians in making essential therapeutic decisions.

Acute Partial Brown-Séquard Syndrome Secondary to Intraforaminal Disc Prolapse and Spinal Cord Infarction.

We report the case of a 45-year-old female who presented with acute left abdominal pain and subsequently developed a left partial Brown-Séquard syndrome. Spinal fluid, inflammatory and prothrombotic tests were unremarkable. Magnetic resonance showed a left intraforaminal disc prolapse at the T9-T10 level and a hyperintense lesion on T2-weighted images in the left postero-lateral cord at the T8-T9 level with restricted diffusion on DWI imaging. A diagnosis of spinal cord infarction due to compromise of the left T8 thoracic radicular artery was made. The patient was managed conservatively and at the 3 months follow-up, she was ambulant and able to walk small distances without a walker.