Autoimmune hepatitis (AIH) is a chronic hepatitis of unknown etiology, which is characterized by the body's own immune cells attacking the liver cells. This results in inflammation, leading to scarring of the liver and ultimately cirrhosis. Diagnosis is made with a combination of laboratory and histological findings. Lab findings, include a striking elevation in amino transferase levels (as compared to bilirubin and alkaline phosphatase ALP), along with increased immunoglobulin G (IgG)/gamma globulin and the specific serological markers (ASMA/ANA/ALKM-1). We present a case of a 25-year-old male with a history of Type 1 AIH who presented with complaints of sharp abdominal pain in the right upper quadrant with distension, fever, chills, nausea, constipation and one episode of melena. The patient’s blood work revealed only a modest elevation in serum transaminases and normal gamma globulin levels. He was diagnosed with spontaneous bacterial peritonitis (SBP) and showed evidence of cirrhosis, with a Model for End Stage Liver Disease (MELD) score of 11. A repeat liver biopsy at this time revealed pathological changes suggestive of AIH. This patient’s case of autoimmune hepatitis is unique for several reasons, mainly because his liver enzymes were only minimally elevated at a time when his liver biopsy showed signs of active disease. One of the hallmark features of AIH are very high transaminases and elevated globulin, both of which this patient did not have. The case highlights the importance of diagnosing and treating AIH early in the course of the disease. This raises the question as to whether or not all cases of AIH are associated with a gross elevation of amino transferases. It emphasizes on the fact that chronic liver diseases can also present only with mildly elevated or even normal transaminases.
Inflammatory bowel disease (IBD) represents a group of disorders that involve chronic inflammation of the digestive tract. These disorders usually present with various symptoms such as abdominal pain, vomiting, diarrhea and rectal bleeding, especially during a flare-up. There is an increased risk of venous thromboembolism during the flare-up and patients usually present with pulmonary embolism or deep vein thrombosis. Rarely, it can present with neurological symptoms due to a cerebrovascular event from thromboembolization. In this case report, we present a 38-year-old female with a seven-year history of IBD who developed acute encephalopathy during her IBD flare-up. Imaging studies of her brain revealed a large cerebral venous thrombosis (CVT) associated with intraparenchymal hemorrhage and surrounding vasogenic edema in the left temporal lobe extending to the parietal lobe. This finding of venous thrombosis was suspected to be from a hypercoagulable state associated with IBD flare-up.
Local inflammatory processes in the gastric mucosa are followed by extensive immune cell infiltration, resulting in chronic active gastritis characterized by a marked infiltration of T(h)1 cytokine-producing CD4+ and CD8+T-cells Objective. To investigate the correlation between CD4+/CD8+ T-cells in gastric mucosa with endoscopic appearance in chronic gastritis with or without H.pylori infection. Prospective, cross sectional study is performed in a chronic dyspepsia population in July-November 2009 at Dr. Sardjito General Hospital Yogyakarta, Indonesia. The update Sydney system was used to analyze the gastroscopy appearance. Biopsy specimens were stained with HE-stain and IHC-stain. Data were analyzed by t-test, Mann-Whitney and Spearman correlation test. Number of 88 consecutive subjects are enrolled the study (50% male; 50% female), age 46±15 years; 25% H.pylori positive. The expression of CD4+ and CD8+ were higher in H.pylori negative subjects, but only the CD4+ was significant (P=0.011). A significant correlation was found between CD4+ and CD8+ in both subjects (r(Hp+)=0.62 and r(Hp-)=0.68; P<0.05). The expression of CD4+ and CD8+ in H.pylori positive showed a significant correlation with gastric lesions (r(CD4+)=-0.60; r(CD8+)=-0.42 ; P<0.05), only erosion showed a significant difference in both subjects. A positive correlation was found between CD4+ and CD8+ infiltration in both subjects with or without H.pylori infection, and a negative correlation was only found between gastric lesion with CD4+ and CD8+ infiltration in H.pylori subject.
Autoimmune hepatitis (AIH) usually exists as a single entity but rarely occurs in combination with either primary sclerosing cholangitis (PSC) or primary biliary cirrhosis (PBC) as a part of an overlap syndrome. Each of these overlap syndromes has its own characteristic features. We report on a case of autoimmune hepatitis with subsequent development of primary sclerosing cholangitis and ulcerative colitis. Identification of patients with overlap syndrome is important as they typically have a poorer response to steroid therapy, enter remission less frequently and fail therapy more commonly.
Menetrier’s disease, a hyperproliferative protein losing gastropathy, is a rare disorder of the gastric foveolar mucosa with a characteristic endoscopic and histopathologic appearance. Menetrier’s disease usually is a disease of adult men; however, it has also been described in children. The etiology of Menetrier’s disease is largely unknown. Increased signaling by transforming growth factor-α and infection with H. pylori (H.pylori gastritis) have been implicated. The association of Menetrier’s disease with cytomegalovirus infection has been reported in over sixty cases in pediatric patients; however, this association has been rarely reported in adults and interestingly all of the latter have been males. We report a case of 22-year old, immunocompetent female with clinical, endoscopic and histopathologic findings of Menetrier’s disease that demonstrated cytomegalovirus by DNA in-situ hybridization. This case hence adds to the extremely rare occurrence of Menetrier’s disease associated with CMV in an adult and to our knowledge is the first report of such a case in an adult female.
Bleeding disorders presenting as acute abdomen mimicking intra abdomen emergency is a well established entity. Surgery with a mistaken diagnosis can be disastrous. We report a case, presented to the department as acute abdomen proved to be retroperitoneal hematoma, referred to us as retroperitoneal abscess. Careful evaluation and review of the old records proved that he had von Willie brand disease. He was successfully managed conservatively only with FFP.
Background: Managing acute mesenteric ischaemia continues to be a nightmare for the surgeon and a calamity for the patient. Literature on the subject is fragmented and is devoid of uniformity with authors describing their personal experiences. Aim: To identify and evaluate factors which affect outcome in patients suffering from acute mesenteric ischaemia. Materials and methods: Retrospective study of all the records of patients diagnosed as acute mesenteric ischaemia at surgery managed in a single surgical unit of an urban civic hospital in India. Results: Delayed presentation associated with co morbidities, delayed surgical intervention due to hemodynamic instability, extensive gangrene of the bowel requiring resection of significant lengths of the bowel and post operative complications involving the cardiopulmonary system are associated with poor outcomes. Conclusion: Identification of co morbid conditions, early diagnosis by CT after hemodynamic stabilisation, prompt surgery followed by close postoperative monitoring can help lower the morbidity and high mortality.
The cystic artery can have variable origin, the right cystic artery being the most common. In addition, its course can also follow diverse paths often in close proximity to the common bile duct. This report presents a course of the cystic artery encountered during open cholecystectomy that has not been reported prviously in the literature. The cystic artery was unusually long and crossing across the middle of the gall bladder giving it a pseudobilobed appearance. This rare variant is reported to enhance knowledge on spectrum of cystic artery anomalies
Crohn’s disease (CD) and its treatments have several associations with hepatobiliary disorders, including gallstone disease, portal vein thrombosis, and idiosyncratic drug toxicities. However, hepatocellular carcinoma (HCC) has rarely been described. It is unusual to diagnose HCC in a non-cirrhotic liver; this occurs less than 15% of the time [1]. In this case report, we describe a 50-year-old male with longstanding CD treated with azathioprine (AZA). He presented with loose stools and weight loss. Laboratory evaluation identified mildly elevated hepatocellular liver tests. An abdominal CT showed a new, 15 cm heterogeneous tumor and surgical resection revealed a moderately differentiated HCC. Trichrome staining of the non-tumoral parenchyma did not show fibrosis. Eight out of ten case reports of HCC in patients with CD cite the use of AZA. Prior studies show that AZA increases hepatocyte turnover. CD, itself, is a chronic inflammatory condition that has been shown to alter the gut-liver axis. Therefore, we believe that the complex interplay between our patient’s AZA use and his CD led to the development of HCC in the absence of liver fibrosis.
Background: Fecal occult blood testing (FOBT) is commonly utilized as a screening modality for colon cancer. However, the effect of concurrent use of antithrombotics, including anticoagulation agents (warfarin, enoxaparin) and antiplatelet agents (aspirin, clopidogrel, NSAIDs, COX-2 inhibitors), on the yield of FOBT has not been well established. Therefore, a meta-analysis was performed to evaluate the effect of antithrombotics on the yield of FOBT. Methods: Multiple databases were searched (July 2012). Studies examining the use of antithrombotics (aspirin, clopidogrel, NSAIDs, COX-2 inhibitors, warfarin, enoxaparin) versus no antithrombotics in patients with positive FOBT were included. Metaanalysis for the effect of antithrombotics or no antithrombotics for FOBT was performed by calculating pooled estimates of colonoscopy findings and detection of neoplasia, any adenoma, advanced adenoma, or colon cancer by odds ratio (OR) with fixed and random effects model. RevMan 5.1 was utilized for statistical analysis. Results: Eight studies (N=2,800) met the inclusion criteria. No statistically significant differences were noted between FOBT with or without antithrombotics for colon cancer (OR 0.87; 95% CI: 0.69-1.11, p=0.26), advanced adenoma (OR 0.92; 95% CI: 0.62-1.37, p=0.70), colonoscopy findings (OR 0.76; 95% CI: 0.42-1.37, p=0.37), neoplasia (OR 0.87; 95% CI: 0.65-1.18, p=0.38), or any adenoma (OR 0.89; 95% CI: 0.67-1.20, p=0.45). Conclusion: Among patients with positive FOBT, findings on colonoscopy do not appear to be affected by whether or not patients are taking antithrombotics. Abbreviations: FOBT, fecal occult blood test; CRC, colorectal cancer; NSAIDs, nonsteroidal anti-inflammatory drugs; OR, odds ratio; CI, confidence interval.
The authors present the case of a 49-year-old man who presented with massive hematochezia and hemodynamic instability, caused by an actively bleeding diffuse non-Hodgkin large B-cell lymphoma of the duodenum.Endoscopic haemostasis was successfully attained with BICAP thermocoagulation using a 10Fr probe at 20W. Later, the patient underwent an elective cephalic duodenopancreatectomy and adjuvant chemo-radiotherapy. To our knowledge, this is the first report on the literature of the use of BICAP probe in the setting of acutely bleeding lymphoma of the small bowel.
Primary hydatid disease of the pancreas is a rare entity. We report an 18 year old female who presented with complaints of pain abdomen, vomiting and constipation for two months. Radiological investigations suggested it to be a case of hydatid cyst of the tail of the pancreas. Although distal pancreatectomy is treatment of choice but removal of the endocyst was done. Histopathology also confirmed the diagnosis.
Massive gastrointestinal bleeding from the small intestine un common, It is usually a complication advanced local small bowel pathology or vascular abnormalities. Parasitc infections causing gastrointestinal bleeding is usually a feature of large bowel prasitc infestations. Small parasitic infestation can cause chronic anemia rather than acute bleeding. This is a report of massive small intestinal bleeding cause by Trichuris trichiura infection. The patient had dramatic response to the treatment with Albendazole for 6 days.
A 7 years old child presented with a history of be fall from a height(10 ft approx). The child had ingested a large meal in the hour preceding the injury. He complained of generalized pain in the the abdomen. He was haemodynamically stable. Abdominal examination was unremarkable initially but soon child developed abdominal distension & generalized tenderness. X ray abdomen(erect) showed gas under diaphragm. Ultrasound abdomen did not show any solid organ injury. At laparotomy the only injury found was a complete tear of the greater curvature of stomach. The tear was sutured and the patient made an uneventful recovery.
Although 50%-65% of metastatic gallbladder tumors come form malignant melanoma, clinically diagnosed cases are very rare. We are reporting such a symptomatic case of metastatic melanoma in the gall bladder occurring in a 40-year-old man.
BACKGROUNDGastric diverticula are infrequent anatomic abnormalities that are usually asymptomatic.AIMWe report a case of large gastric diverticulum and discuss diagnostic and therapeutic challenges.CASE REPORTA 63-year-old man was admitted with vague epigastric discomfort. Physical examination and laboratory investigations were normal. Endoscopy revealed an erosive gastropathy and a pouch arising from the posterior aspect of the greater curve, 8 cm from the hiatus. Barium meal confirmed the presence of a 5 cm diameter diverticulum arising from the gastric fundus.CONCLUSIONCareful examination of the whole stomach at gastroscopy is recommended for not missing a diverticulum.
Per cutaneous endoscopic gastrostomy (PEG) is one of the most common procedures performed by the gastroenterologist for various indications. The procedure is associated with complications which may be minor or major; though the better part is minor yet a high incidence of morbidity is linked to them. This review article illustrates the complications associated with PEG and various methods to prevent and manage the complications.
