Primary small intestine angiosarcoma mimicking Crohn's disease.

A man in his 40s presented to an emergency department after experiencing worsening abdominal pain for 2 days. Contrast-enhanced CT of the abdomen and pelvis revealed circumferential mural thickening and luminal narrowing of the distal ileum and upstream dilatation of the small intestine, indicating small intestine obstruction. This prompted emergency laparotomy, where two lesions in the distal ileum were identified as the source of his bowel obstruction and resected. Immunohistochemistry of the resected segment revealed a primary small intestine angiosarcoma acting positively for vascular markers ERG and CD31. A subsequent positron emission tomography (PET) scan revealed positive mediastinal metastatic lymphadenopathy without organ metastases.Following his surgery, the patient recovered well and was promptly referred to an oncology unit at a specialised health centre for further treatment. Primary small intestine angiosarcoma is a rare entity in which patients present with non-specific symptoms requiring prompt tissue diagnosis to facilitate multidisciplinary management.

What features on intraoperative cholangiogram predict endoscopic retrograde cholangiopancreatography outcome in patients post cholecystectomy?

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure performed to remove bile duct stones. Intraoperative cholangiography (IOC) is often performed at the time of cholecystectomy to determine the presence of intraductal stones. However, many of the ERCP procedures performed for this indication fail to find any intraductal stones. Given that ERCP carries significant patient morbidity, we investigated whether there are features on IOC that can guide ERCP patient selection. METHODS: A retrospective analysis of 152 patients who had an IOC filing defect and a subsequent ERCP was performed. RESULTS: Small single stones greater than or equal to 4.5 mm on IOC can be used to predict the presence of stones on a subsequent ERCP. Furthermore, ERCPs performed for single filling defects smaller than 4.5 mm are more likely to be negative if performed later rather than earlier, suggesting that small stones can pass over time. We show that 80% of these stones will pass by 11 days after the IOC. CONCLUSION: Single small stones on IOC should be given adequate time to pass into the intestine. Imaging should be performed to determine if the stone has passed into the intestine after day 11 prior to performing a therapeutic ERCP.

Usefulness of early post-operative liver function test monitoring after laparoscopic common bile duct exploration.

BACKGROUND: This study examines the usefulness of early post-operative liver function test (LFT) monitoring in predicting retained choledocholithiasis after laparoscopic common bile duct exploration (LCBDE). METHODS: Data on patients who had LCBDE over a 3-year period were collected retrospectively. Patients who had ongoing choledocholithiasis after unsuccessful LCBDE were considered for the test group and patients who had successful LCBDE were considered for the control group. Preoperative, day 1 post-operative and day 2 post-operative alkaline phosphatase (ALP), gamma glutamyl transferase (GGT), alanine transaminase (ALT) and bilirubin levels were recorded. Proportions of patients who had worsening LFTs were analysed in each group. RESULTS: Proportions of patient who had worsening LFTs on day 1 were not statistically different between two groups and they were statistically equal on equivalence testing (two one-sided tests). On day 2, proportions of patient were again not statistically different. Bilirubin and ALT were statistically equivalent (P = 0.022 and P = 0.025 respectively) but GGT and ALP failed to achieve statistical equivalence (P = 0.062 and P = 0.138 respectively) on day 2. Twelve patients with normal appearing final intraoperative cholangiogram needed reintervention due to retained choledocholithiasis diagnosed subsequently. LFTs progressively improved despite presence of choledocholithiasis in eight of these 12 patients (75%) and only four were diagnosed by worsening post-operative LFTs during index admission. CONCLUSION: LFTs in the early post-operative period are not useful in determining which patients require biliary imaging or intervention after an apparently successful LCBDE.

Interventional management of necrotizing pancreatitis: an Australian experience.

BACKGROUND: The interventional management of necrotizing pancreatitis has evolved from early open surgery to delayed endoscopic or percutaneous intervention. However, few studies have directly compared the three treatment modalities. We aim to compare the outcomes of patients who had endoscopic, percutaneous or surgical interventions for necrotizing pancreatitis at our institution. METHODS: This is a retrospective cohort study of patients who had interventions for necrotizing pancreatitis at our institution from 2005 to 2014. Primary outcome was length of stay (LOS); secondary outcomes were complication rate and number of procedures required for resolution of necrosis. RESULTS: Thirty patients were included. Mortality rate was 13% (four patients). Median LOS and time to intervention was 88 and 28 days, respectively. There were no significant differences in the computed tomography severity indices and 48-h C-reactive protein levels among the three groups. Initial endoscopic intervention was associated with a median LOS of 62 days compared with 101 days in the percutaneous group and 91 days in the surgical group (P = 0.04). There were higher rates of pancreatic fistulae (40%) (P = 0.012) and new onset diabetes (30%) (P = 0.046) in the surgical group. Median number of procedures was similar among the three groups. Median LOS for patients with delayed intervention (fourth to sixth week of pancreatitis) was 66 days, compared with 137 days in patients with early intervention (first to third week) and 104 days in patients with late intervention (seventh week onwards) (P ≤ 0.001). CONCLUSION: A delayed, endoscopy first approach appears to be a reasonable strategy as it is associated with decreased LOS and low complication rate.

Effect of contrast injection into the biliary tract during intraoperative cholangiogram on postoperative liver function tests.

INTRODUCTION: Postoperative abnormal liver function tests (LFT) following laparoscopic cholecystectomy (LC) could present a substantial clinical dilemma due to suspicion of missed choledocholithiasis or more serious complications such as bile duct injury. We noted that LFT were more likely to be abnormal when an intraoperative cholangiogram (IOC) had been performed. This study aims to examine if contrast injection into the biliary tract during IOC is associated with deranged LFT. METHODS: Data on all LC performed in a tertiary referral hospital network over a period of 30 months were collected retrospectively, and two groups were identified depending on successful performance of an IOC. Identical inclusion and exclusion criteria were applied to both groups to identify eligible patients. Alkaline phosphatase, gamma-glutamyl transferase (GGT), alanine transaminase (ALT), and bilirubin levels were recorded, and the mean difference between preoperative and postoperative values was analyzed. RESULTS: There were 177 eligible patients: 147 patients in the LC with IOC test group (IOC group) and 30 patients in the LC without IOC control group (NO IOC group). Demographics and preoperative mean LFT were not significantly different between groups. In the IOC group, the mean ALT difference (43 ± 57, P =< 0.001) and GGT difference (34 ± 66, P =< 0.001) were significantly higher than in the NO IOC group (ALT [19 ± 25], GGT [7 ± 20]). The mean alkaline phosphatase difference (IOC [9 ± 47], NO IOC [-2 ± 14], P = 0.214) and mean bilirubin difference (IOC [-2 ± 9], NO IOC [-1 ± 8], P = 0.911) were not significantly different. CONCLUSION: The performance of an IOC is associated with elevated GGT and ALT but does not affect alkaline phosphatase and bilirubin concentrations.

Young strokes in Sri Lanka: an unsolved problem.

Stroke in young adults is more common in India and Sri Lanka and the reasons for this are not well understood. The current study was conducted to elucidate the risk factors and radiologic features in young people (age < 45 years) with ischemic stroke. Sociodemographic data, stroke risk factor information, and laboratory investigations were recorded in 41 cases with first-ever ischemic stroke. Most common risk factors for stroke in the 15- to 45-year-old age group were: hypertension, 8 (21%); family history of stroke, 7 (18%); transient ischemic attack, 6 (16%); hyperlipidemia, 3 (8.0%); and diabetes, two (5%). Age group younger than 15 years included 3 girls and one had a mass attached to the posterior mitral valve leaflet. Our observations underscore the importance of the presence of hypertension, family history of stroke, and transient ischemic attack in young adults and thus to adopt preventative strategies.