Usefulness of scheduled follow-up CT in discharged patients with acute pancreatitis.

BACKGROUND AND AIM: Follow-up computed tomography (CT) in patients with acute pancreatitis has been advocated but rarely studied. The aim of this study was to determine whether follow-up CT for acute pancreatitis might be helpful in establishing the prognosis or complications, and in determining a selected subgroup of patients for whom computed tomography could be beneficial. METHODS: Between January 2010 and December 2012, patients with acute pancreatitis who underwent follow-up CT in the outpatient department between one and three months after discharge were retrospectively enrolled. Events discovered on follow-up CT were defined as newly developed or increased pancreatic collection such as pseudocyst or walled off necrosis, and diagnosis of pancreatic cancer. RESULTS: Ultimately, 106 asymptomatic patients were enrolled (mean age 50.24 ± 16, 74.5% male, 31.1% moderately severe and severe acute pancreatitis). The median duration of follow-up CT was 69 (31-90) days. On follow-up CT, 23 patients showed events (2 pancreatic cancer, 21 increasing or developed pancreatic collections). In multivariate analysis, the predictive factors for events on follow-up CT were CTSI ≥3 (OR 4.46, CI 1.08-18.43, p = 0.039) and BISAP ≥ 2 (OR 4.83, CI 1.08-21.55, p = 0.039). CONCLUSIONS: Follow-up CT within three months after discharge may be helpful for acute pancreatitis patients with CTSI ≥ 3 points or BISAP score ≥ 2 points.

[Portal-splenic-mesenteric venous thrombosis in a patients with protein S deficiency due to novel PROS1 gene mutation].

Protein S (PS), a vitamin K-dependent glycoprotein, performs an important role in the anticoagulation cascade as a cofactor of protein C. Because of the presence of a pseudogene and two different forms of PS in the plasma, protein S deficiency (PSD) is one of the most difficult thrombophilias to study and a rare blood disorder associated with an increased risk of thrombosis. We describe a unusual case of previously healthy 37-year-old man diagnosed with portal-splenic-mesenteric vein thrombosis secondary to PSD. The patient was admitted to the hospital due to continuous nonspecific abdominal pain and nausea. Abdominal computed tomography revealed acute venous thrombosis from inferior mesenteric vein to left portal vein via splenic vein, and laboratory test revealed decreased PS antigen level and PS functional activity. Conventional polymerase chain reaction and direct DNA sequencing analysis of the PROS1 gene demonstrated duplication of the 166th base in exon 2 resulting in frame-shift mutation (p.Arg56Lysfs*10) which is the first description of the new PROS1 gene mutation to our knowledge. Results from other studies suggest that the inherited PSD due to a PROS1 gene mutation may cause venous thrombosis in a healthy young man without any known predisposing factor.

[Cytomegalovirus induced gastric ulcer as a principal manifestation in the initial stage of hodgkins disease].

Cytomegalovirus (CMV) is an important cause of opportunistic infection in immunocompromised patients. CMV infection occurs as a result of the cell-mediated immunity change in lymphoma patients. Although CMV can cause ulceration anywhere in the gastrointestinal (GI) tract in immunocompromised patients, only a few case reports about CMV GI infection in malignant lymphoma have been documented in literature. Furthermore, it was rare that CMV gastric ulcer with massive bleeding presented as an initial manifestation in a patient who has been not diagnosed lymphoma. We report a case of CMV induced gastric ulcer as an initial manifestation in patient with Hodgkins disease.

[A case of left paraduodenal hernia combined with acute small bowel obstruction].

Paraduodenal hernias are rare congenital malrotational anomalies of midgut that arise in the potential spaces and folds of the posterior parietal peritoneum adjacent to the ligament of Treitz and can lead to intestinal obstruction. Also, they have shown several presentation patterns, such as asymptomatic, chronic intermittent abdominal pain, and acute severe abdominal pain. If symptomatic hernias with strangulation are untreated, according to the previous reports, they lead to overall mortality exceeding 50%. We report a case of the left paraduodenal hernia combined with small bowel obstruction from the patient who had no history of surgery before and developed abdominal pain after drinking of alcohol heavily. Abdominal CT scan showed sac-like mass of clustered in the left upper quadrant. The patient underwent the surgery of the bowel reduction and adhesiolysis and got uneventful recovery.

[A case of hepatocellular carcinoma invading the gallbladder misdiagnosed as a primary gallbladder carcinoma].

Extrahepatic metastasis of hepatocellular carcinoma (HCC) is occasionally seen in the lung, bone, adrenal gland, and lymph nodes. It is well known that HCC sometimes invades the biliary system. Since there is no peritoneum between the gallbladder and the liver fossa, a gallbladder cancer easily invades the liver; however, HCC seldom invades the gallbladder because it rarely destroys the muscle layer or the collagen fibers of the gallbladder wall. Routes of gallbladder metastasis of HCC include direct invasion, extension to the biliary system, and invasion of the adjacent hepatic vascular system. Some cases of gallbladder metastasis of HCC without direct invasion have been reported. We report here a case of HCC that directly invaded the gallbladder, and that resembled gallbladder carcinoma invading the liver.

[A case of actinomycosis of gallbladder presenting as acute cholecystitis].

Actinomycosis is a chronic suppurative and granulomatous disease, characterized by the formation of abscess, draining sinuses, abundant granulation, and dense fibrous tissue. Actinomycosis of the gallbladder is extremely rare. We report a case of an 56-years old man who abruptly presented with right upper quadrant abdominal pain. Abdominal CT showed that the gallbladder had 2 cm sized stone and an edematous thick wall. Our preoperative diagnosis was acute calculous cholecystitis. After the management of acute cholecystitis, laparoscopic cholecystectomy was performed but converted to open surgery due to severe adhesion to liver and greater omentum. Partial cholecystectomy was performed. Histologic section of the gallbladder showed sulfur granule with gram-positive branching bacilli compatible with actinomyces. After cholecystectomy, the patient received intravenous penicillin G for 2 weeks, followed by oral penicillin for 3 months.