Misdiagnosis of pancreatic tuberculosis as a pancreatic cystic neoplasm - A case report.

Pancreatic tuberculosis is an extremely rare condition. Its non-specific clinical and radiological findings resemble pancreatic malignancy. Here, we report a case of pancreatic tuberculosis that presented with abdominal pain and dyspeptic symptoms for 2 months and was misdiagnosed as a pancreatic cystic neoplasm. Abdominal magnetic resonance imaging showed a well-demarcated exophytic lesion with multiple T2 high signals small cystic areas in the anterior superior part of the head of the pancreas measuring 23 × 20 × 28 mm. This patient has undergone laparotomy and excision of the pancreatic mass. Histological examination revealed granulomatous inflammation of a lymph node with caseation, which was pathognomonic of tuberculosis. She was treated for tuberculosis for 6 months and has become symptom free. The diagnosis of pancreatic tuberculosis could be misleading and should be considered when dealing with pancreatic masses in countries with high incidence.

Solid pseudopapillary neoplasm of the pancreas with multiple liver metastases successfully managed with staged resection.

Due to the rarity of the disease, there are no guidelines or consensus for the management of solid pseudopapillary neoplasm of the pancreas with liver metastasis. We describe a patient with solid pseudopapillary neoplasm of the pancreas with multiple liver metastases who was successfully managed with staged resection. A previously healthy 50-year-old female presented to the clinic with dull epigastric pain. The contrast-enhanced computed tomography showed a well-defined cystic lesion at the distal body and tail of the pancreas with multiple liver deposits. A core needle liver biopsy was suspicious of a hepatic epithelioid hemangioendothelioma. A distal pancreatectomy with splenectomy and a left hemi-hepatectomy were performed with a subsequent staged right posterior sectionectomy to address the inadequate future liver remnant. The final histology with immunohistochemistry revealed a pancreatic solid pseudopapillary neoplasm. The patient had satisfactory surgical and oncological outcomes with no recurrence. As these are slow growing tumours, appropriately spaced staged liver resection was feasible to allow hypertrophy of the liver remnant and physiological recovery of the patient. The discrepancy in the histology and cross-sectional imaging led to a pre-operative diagnostic dilemma, and the final diagnosis was reached after surgical resection. Thus, resectable metastatic solid pseudopapillary neoplasm of the pancreas may be offered a primary curative radical surgery before considering other treatment modalities.

Intestinal obstruction due to small bowel herniation through foramen of Winslow: a case report.

BACKGROUND: Intestinal obstruction due to internal herniation of the bowel is a rare clinical entity which is often overlooked in the differential diagnosis of patients with abdominal pain who have no previous history of abdominal surgery. Several sites of bowel internal herniation have been described, amongst which internal herniation through the foramen of Winslow accounts for about 8% of cases. These patients present with nonspecific abdominal pain associated with symptoms of gastroesophageal reflux disease, and hence the diagnosis is often overlooked. The usual symptoms of intestinal obstruction can be delayed, which results in a delay in diagnosis and gangrene of the herniated bowel segment. Abdominal radiographs and computed tomography are helpful in the diagnosis. Open reduction is the management of choice; however, laparoscopic reduction has also been attempted, with good results. CASE PRESENTATION: We report a case of a middle-aged Sri Lankan man who presented with features of gastroesophageal reflux disease, developed features of intestinal obstruction and was found to have a gangrenous small bowel loop which had herniated through the foramen of Winslow. Following needle aspiration and reduction of the herniated small bowel loop, the gangrenous part of the small bowel was resected and an ileoileal anastomosis performed. The large foramen of Winslow was partially closed with interrupted stitches. The patient made an uneventful recovery. CONCLUSION: Since delayed diagnosis of bowel obstruction is detrimental, it is of utmost importance to diagnose it early. Because internal herniation of the small bowel through the foramen of Winslow presents with nonspecific symptoms including features of gastroesophageal reflux disease, as documented in several cases worldwide and also presented by our patient, there should be a high degree of suspicion of internal herniation of the bowel causing bowel obstruction and low threshold for extensive investigation of patients presenting with symptoms of gastroesophageal reflux disease which does not resolve with usual medication.

An International Group of Hepatopancreaticobiliary Surgeons Respond to the COVID-19 Pandemic.

An informal workgroup of 9 hepatopancreaticobiliary (HPB) surgeons from 6 different countries on 4 continents shifted the focus of their quarterly tumor board discussions to their responses to the current COVID-19 pandemic. Just as they had discussing HPB cases, they share their experiences and ideas in dealing with the outbreak that faced their hospitals and communities. Their efforts to improve care proved that professionalism in surgery, like the global pandemic, has no boundaries.

Prediction of colorectal cancer risk among adults in a lower middle-income country.

BACKGROUND: Globally, colorectal cancer (CRC) is ranked as the third most common cancer in men and the second in women. Use of a simple, validated risk prediction tool will offer a low-cost mechanism to identify the high-risk individuals for CRC. This will increase efficient use of limited resources and early identification of patients. The aim of our study was to develop and validate a risk prediction model for developing CRC for Sri Lankan adults. METHODS: The risk predictors were based on the risk factors identified through a logistic regression model along with expert opinion. A case control design utilizing 65 CRC new cases and 65 hospital controls aged 30 years or more was used to assess the criterion validity and reliability of the model. The information was obtained using an interviewer administered questionnaire based on the risk prediction model. RESULTS: The developed model consisted of eight predictors with an area under the curve (AUC) of 0.849 (95% CI: 0.8 to 0.9, P<0.001). It has a sensitivity of 76.9%, specificity of 83.1%, positive predictive value (PPV) of 82.0%, negative predictive value (NPV) of 79.3%. Positive and negative likelihood ratios are 4.6 and 0.3. Test re-test reliability revealed a Kappa coefficient of 0.88. CONCLUSIONS: The model developed to predict the risk of CRC among adults aged 30 years and above was proven to be valid and reliable and it is an effective tool to be used as the first step to identify the high-risk population who should be referred for colonoscopy examination.

"Appropriateness of colonoscopy according to EPAGE II in a low resource setting: a cross sectional study from Sri Lanka".

BACKGROUND: Due to finite resources, the clinical decision to subject a patient to colonoscopy needs to be based on the evidence, regardless of its availability, affordability and safety. This study assessed the appropriateness of colonoscopies conducted in selected study settings in Sri Lanka. In the absence of local guidelines, audit was based on European Panel on Appropriateness of Gastrointestinal Endoscopy II (EPAGE II) criteria. METHODS: This cross-sectional study assessed consecutive patients who underwent colonoscopy between June to August 2015 at four main hospitals in Sri Lanka. Interviewer administered questionnaire and secondary data were collected by trained health staff. Indications were assessed according to EPAGE II criteria. RESULTS: Out of 325 patients, male female proportions were 57.2 and 42.8%. Mean (SD) age was 54.9 (12.1) years. Colonoscopies were appropriate in 61.2% (95% CI 55.8-66.3), uncertain in 28.6% (95% CI 23.9-33.7) and inappropriate in 10.2% (95% CI 7.3-13.9). Colonoscopy to evaluate abdominal pain has highest percentage of inappropriateness of 10.0%. However, 9.5% of these colonoscopies revealed Colo-Rectal Cancer (CRC), reflecting differences in the profile of local CRC patients. Colonoscopies with appropriate or uncertain indications are three times more likely to have a relevant finding than inappropriate indications (42.5% vs. 18.2%; OR 3.32, 95% CI 1.33-8.3; P = 0.008). CONCLUSIONS: Majority of colonoscopies are appropriate. However, it cannot be neglected that every one in ten patients undergo inappropriate colonoscopy. Proportion of inappropriateness was highest for the indication of chronic abdominal pain, of which, 9.5% of patients were diagnosed with CRC. This may reflect the different profile of local CRC patients in terms of symptom manifestation and other characteristics. In conclusion, the authors recommend formulation of national guidelines for colonoscopy indications based on current best evidence and local patient profile. Use of such prepared local guidelines will improve the efficient use of finite resources.

Worsening cholestasis and possible cefuroxime-induced liver injury following "successful" therapeutic endoscopic retrograde cholangiopancreatography for a distal common bile duct stone: a case report.

BACKGROUND: Cefuroxime very rarely causes drug-induced liver injury. We present a case of a patient with paradoxical worsening of jaundice caused by cefuroxime-induced cholestasis following therapeutic endoscopic retrograde cholangiopancreatography for a distal common bile duct stone. CASE PRESENTATION: A 51-year-old, previously healthy Sri Lankan man presented to our hospital with obstructive jaundice caused by a distal common bile duct stone. Endoscopic retrograde cholangiopancreatography with stone extraction, common bile duct clearance, and stenting failed to improve the cholestasis, with paradoxical worsening of his jaundice. A liver biopsy revealed features of drug-induced intrahepatic cholestasis. Although his case was complicated by an episode of cholangitis, the patient made a complete recovery in 4 months with supportive treatment and withdrawal of the offending drug. CONCLUSIONS: This case highlights a very rare drug-induced liver injury caused by cefuroxime as well as our approach to treating a patient with paradoxical worsening of jaundice after therapeutic endoscopic retrograde cholangiopancreatography.

Episodic biliary obstruction due to an intrahepatic biliary cystadenoma: a case report.

INTRODUCTION: Biliary cystadenoma is a rare, benign neoplasm of the bile ducts with malignant potential. Symptoms, predominantly right hypochondrial pain and the feeling of a lump or fullness are usually due to the mass effect. Jaundice is rare. This is the fifth reported patient with an intrahepatic biliary cystadenoma giving rise to episodic biliary obstruction, which is usually caused by choledocholithiasis or periampullary carcinoma. Considering the mean age of previous similar patients (53.5, standard deviation 14.6 years), the early age of presentation is very unusual in our patient. CASE PRESENTATION: A 25-year-old Asian woman presented with right hypochondrial pain and episodic biliary obstruction. Contrast enhanced computed tomography revealed a cystic mass in segment 4B and protruding into and along the left hepatic duct. Laparotomy confirmed the contrast enhanced computed tomography findings and histology revealed an intrahepatic mucinous biliary cystadenoma. CONCLUSION: Biliary cystadenoma should be considered as a differential diagnosis in patients with cystic liver lesions who present with episodic biliary obstruction. Due to the reported malignant potential, radical surgery such as wide local excision of the lesion or hepatic resection is needed to minimize the risk of local recurrence.