Diagnostic Challenge in Heterotopic Pancreas in the Ampulla of Vater with Obstructive Jaundice - A Case Report and Literature Review.

Heterotopic pancreas is a rare congenital abnormality. The most common location is the stomach, duodenum and proximal jejunum. Rare locations are represented by the ampulla of Vater, esophagus, ileum, Meckel diverticulum, biliary tract, mesentery and spleen. We present the case of a 49 year old patient investigated for obstructive jaundice and diagnosed with an ampullar heterotopy of pancreas parenchyma, initially considered to be a malignant tumor. A Whipple pancreatoduodenectomy was performed with good postoperative evolution, the serum levels of bilirubin being normal after the first postoperative week.

Gastrointestinal stromal tumors of the colon and rectum.

Gastrointestinal stromal tumors (GISTs) are rare neoplasms, colorectal location being met in less than 5% of cases. Knowledge about this site related particularities are limited. The aim of this study is to present our experience with colorectal GISTs between 2005 and 2018 from the clinical, morphological, and immunohistochemical perspectives, with emphasis on prognostic factors. From a total of 203 gastrointestinal stromal tumors registered, 12 were colorectal (6%). The number of colonic tumors surpassed that of the rectum (9 : 3) and on the right side were registered more cases than on the left side (6/3). 9 were primary tumors and 3 were recurrences. Men and women were represented equally and the age range was between 22 and 76. Tumor dimensions varied between 0.5 and 14 cm. Microscopically, spindle cell type was dominant. Mitotic rate was variable between 1 and 115/50HPFs. Accordingly, for primary tumors progression risks were assigned (low risk: 2 cases, intermediate risk: 3 cases and high risk: 4 cases). All GISTs were CD117 and DOG1 positive. Four of the patients died of the disease.

[Difficulties in diagnosis and surgical treatment of the angiodysplasia of the gastrointestinal tract]. / Dificultati de diagnostic si tratament chirurgical în angiodisplaziile tractului gastrointestinal.

BACKGROUND: Angiodysplasia (AD) of the gastrointestinal (GI) tract is a rare cause of surgical GI bleeding. It frequently poses difficult problems in diagnosis and treatment. The purpose of this study is to find answers to these problems for a better management of the AD patients. MATERIALS: From 1982 to 2006 a total of 75 patients suffering of AD of the GI tract were operated in our center. They represent about 3.6% of total patients operated for GI bleeding in the same period. The age of the patients was between 9 and 81 years old, with two peaks: one between 21 and 40 years old and the other between 51 and 70 years old. The localisation of the lesions was: righ colon +/- ileum 31 patients (41.33%), stomach 13 patients (17.33%), jejunum 6 patients (8%), descendent colon +/- sigmoid 5 patients (6.66%), rectum 4 patients (5.33%), pan-colonic 4 patients (5.33%), sigmoid colon 2 patients (2.66%), cecum + transverse colon 2 patients (2.66%), ileum 2 patients (2.66%), sigmoid colon + jejunum 1 patient (1.33%), cecum + sigmoid colon 1 patient (1.33%), cecum +/- sigmoid colon + jejunum 1 patient (1.33%), jejunum + ileum 1 patient (1.33%), pan-colonic + rectum 1 patient (1.33%). According to Moore classifications 29 patients were type 1 (38%) and 45 patients were type 2 (60%). In one patient AD was associated with Crohn disease (type 4 Fowler). RESULTS: The main symptom in AD was repetitive GI bleeding, of various amplitude, often obscure in origin, the patients having many hospital entries. The medical examination that give us the best help was selective angiography which was positive in 34 of 40 patients (85%). Upper and lower endoscopy were give to 50 surgical patients, being diagnostic in 32 (64%). Histopathologic examinations confirm the diagnosis of AD in all cases, without using injection techniques. All patients were operated for symptomatic AD. Other 11 patients non included in this study were find to have angiodysplastic lesions on operatory specimens for other diseases. The main indications for operative in AD were: continuing digestive hemorrhage of growing amplitude with detected source (54 patients = 72%), inefficient endoscopic and angiographic hemostasis (8 patients = 10.66%) and patients with massive bleeding without any preoperative evaluation (13 patients = 17%). Intraoperative exploration produced little information because of the mucosal and submucosal localisation of the lesions. Operative panendoscopy was the most rewarding investigation. Various types of resections were practiced depending on the site(s) known or presumed of the lesions. Perioperative morbidity was 23% (21 patients), rebleeding being in 4 patients (5.33%). Perioperative mortality was 12% (9 patients) a consequence of advanced age, comorbid conditions and frequent extreme emergency of the operations. CONCLUSIONS: Although rare as a cause of surgical digestive bleeding, AD poses often difficult problems of diagnosis and treatment. In patients with GI bleeding, without evident cause, multiple investigated, especially elderly but not always, we must think of an AD.

The evaluation of interstitial Cajal cells distribution in non-tumoral colon disorders.

Interstitial cells of Cajal (ICC) are pacemakers that generate electric waves recorded from the gut and are important for intestinal motility. The aim of the study was to evaluate the distribution of interstitial cells of Cajal in colon specimens from patients with idiopathic chronic pseudo-obstruction and other non-tumoral colon disorders as compared with samples from normal colon. The distribution pattern of ICC in the normal and pathological human colon was evaluated by immunohistochemistry using antibodies for CD117, CD34, and S-100. In two cases with intestinal chronic idiopathic pseudo-obstruction we found a diffuse or focal reducing number of Cajal cells, the loss of immunoreactivity for CD117 being correlated with loss of immunoreactivity for CD34 marker. Our study revealed that the number of interstitial cells of Cajal also decrease in colonic diverticular disease and Crohn disease (p<0.05), whereas the number of enteric neurones appears to be normal. These findings might explain some of the large bowel motor abnormalities known to occur in these disorders. Interstitial Cajal cells may play an important role in pathogenesis and staining for CD117 on transmural intestinal surgical biopsies could allow a more extensive diagnosis in evaluation of chronic intestinal pseudo-obstruction.

An unusual etiology of viral hepatitis in three renal transplant recipients with normal graft function.

Liver impairment in renal transplant recipients is not a common complication and is associated, in most cases, with viral infections (HBV, HCV, HVD, HGV) or drug hepatotoxicity (Cyclosporin, Azathioprine, statins). Cytomegalovirus (CMV) infection is common, with 50 to 80% of the adult population being seropositive for CMV antibodies. In immunocompetent individuals, primary infection is usually asymptomatic or associated with minor illness. CMV remains latent after primary infection. In immunocompromised patients, as in renal transplant recipients or transplant recipients of other solid organ or bone marrow, the virus can cause serious disease. This could be the result of newly acquired infection or reactivation of the latent virus. One of the organs involved in CMV disease is the liver. The subjects of this report are renal transplant recipients with liver impairment due to CMV induced acute hepatitis.

Acute pancreatitis, acute hepatitis and acute renal failure favourably resolved in two renal transplant recipients.

Renal transplantation is often associated with severe complications. Except for acute rejection, infections and toxicity of immunosuppressive treatment are the most frequent problems observed after transplantation. Infections with hepatic viruses (HBV, HDV, HCV, HGV) and cytomegalic virus (CMV) are the main infectious complications after renal transplantation. Cyclosporine toxicity is not unusual for a patient with renal transplantation and is even more frequent for patients with hepatic impairment due to viral infections. The subjects of this report are two renal transplant recipients with acute pancreatitis, severe hepatitis and acute renal failure on graft, receiving immunosuppressive therapy for maintaining renal graft function

Atypical primary tuberculosis mimicking an advanced penile cancer. Can we rely on preoperative assessment?

Tuberculosis of penis is a very rare clinical entity. There are isolated reports of its presentation as a subcutaneous nodule with or without superficial ulcers and can be interpreted as advanced penile cancer. We present a case of penile tuberculosis that presented in our Center with a bulky penoscrotal formation treated in other center for the suspicion of Fournier gangrene.

Pathological characteristics and clinical specifications in gastroenteropancreatic neuroendocrine tumors: a study of 68 cases.

INTRODUCTION: Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) represent a group of tumors, having their origin in cells of diffuse endocrine system, with particular clinical course, diagnosis and treatment. PATIENTS AND METHODS: In our study, were included 68 patients with neuroendocrine digestive tumors admitted, diagnosed and treated in Fundeni Clinical Institute, Bucharest, in the last ten years--2000-2010 (retrospective study). RESULTS: Thirty-three (49%) patients were males, 35 (51%) females, and the main age was 58.9 years. In 62 (90.3%) cases was possible to find the primary tumor. The examined tumors had different localizations: pancreas--32 (47.04%) cases (head--17 (24.99%) cases, and body and tail--15 (22.05%) cases), stomach--7 (10.29%) cases, small intestine--7 (10.29%) cases, 6 (8.82%) cases--unknown primary site (diagnosis was established on metastases), right colon--6 (8.82%) cases, liver--6 (8.82%) cases, rectum--2 (2.94%) cases, and retroperitoneum--2 (2.94%) cases. Microscopic examination revealed 59 (86.8%) malignant tumors and 9 (13.2%) benign tumors. Using WHO 2000 Classification, 28 cases of malignant tumors were well-differentiated neuroendocrine carcinomas, and 31 cases were poor differentiated neuroendocrine carcinomas. From malignant cases, 25 (42.3%) have distant metastases and 15 (25.9%) lymph node metastases. CONCLUSIONS: Cases of gastroenteropancreatic neuroendocrine tumors included in our study had clinical and histopathological features in correspondence with data from literature--slight predominance in women, predominance in 5th and 6th decades of life, the most frequent localizations were at pancreatic level--both head and body and tail, but the rarest were in colon and retroperitoneum. Most of the cases studied, were malignant tumors, from these more than a half were poor differentiated, and a quarter of them having lymph node or distant metastases.

Prolonged treatment with interferon alpha and peginterferon induces rheumatoid arthritis syndrome and erythema nodosum.

The antiviral treatment of chronic C hepatitis has improved significantly over the past decade with the introduction of interferons (IFNs), and more recently, pegylated IFNs. Up to two-thirds of all patients treated with pegylated IFN combined with ribavirin can now achieve viral eradication if treated according to current guidelines. Despite this success rate, hematological, immunological, rheumatological and dermatological side effects have been reported in chronic hepatitis C patients treated with IFN-alpha. The subjects of this report are two young females with chronic hepatitis C, who developed rheumatoid syndrome and/or erythema nodosum during antiviral treatment with IFN-alpha or pegylated IFN combined with ribavirin.