Background Situs inversus totalis is a rare anatomical variation of both the thoracic and the abdominal organs. Common bile duct strictures can be caused by malignant and benign diseases as well. 7–18% of the latter ones are 'malignant masquerade’ cases, as pre-operative differentiation is difficult. Case presentation We present the case of a 68y male patient with known situs inversus totalis and a recent onset of obstructive jaundice caused by a malignant behaving common bile duct stricture. Technically difficult endoscopic retrograde cholangiopancreatography, brush cytology, magnetic resonance cholangiopancreatography, endoscopic ultrasound, and percutaneous transhepatic drainage with stent implantation were performed for proper diagnosis. Cholecystectomy, common bile duct resection with hilar lymphadenectomy, and hepatico-jejunostomy have been performed following multidisciplinary consultation. The final histology report did not confirm any clear malignancy, the patient is doing well. Conclusion In situs inversus patients, both diagnostic and therapeutic procedures can lead to various difficulties. Benign biliary strictures are frequently misdiagnosed preoperatively as cholangiocellular carcinoma. Surgery is usually unavoidable, involving a significant risk of complications. The co-existence of these two difficult diagnostic and therapeutic features made our case challenging.

Background and aims The last decade gave clear evidence that hyper/hypoglycemia and glucose variability are associated with increased mortality in critically ill patients. Continuous glucose monitor (CGM) is a new device in paediatric critical care units (PICU) with clear advantages in glucose monitoring. The aim of our study was to survey the incidence of glucose regulation disorders in our PICU and specify the association between the PRISM III score and the glycemic variability [mean amplitude of glycemic action (MAGE)]. Methods We evaluated 22 children: mean age: 1.3 years, mean length of PICU stay: 18 days; 20/22 patients were on invasive mechanical ventilation; 6/22 needed vasoactive agent therapy. CGM duration: 1–12 days. Interstitial glucose level was monitored by Guardian® REAL Time CGM (Medtronic®). Reference glucose values were obtained from blood gas analyzer or point-of-care glucose analyzer. We used Spearman correlation to evaluate the association between PRISM III and the MAGE. Results Hypo- and hyperglycemia (CGM glucose < 55 mg/dl / CGM glucose > 180 mg/dl) were detected in 4.6% and 2.5% of measurements, respectively. The mean MAGE (meaningful excursion >45 mg/dl) and PRISM III were 78 mg/dl and 19. We found a significant correlation between PRISM III and MAGE (r = 0,55; p < 0.05). Pearson’s correlation coefficient (0.82) and Clarke Error Grid analysis (96% clinical accuracy) proved a good reliability of the CGM. Conclusions Glucose homeostasis disorders are frequent in the PICU; hypoglycemia being more commonly detected. Increased PRISM III score contributes significantly to the elevation of glucose variability.

Background and aims: The glycemic stability is of great importance during critical care, because both hyper- and hypoglycemia are associated with increased mortality. The continuous subcutaneous glucose monitoring system (CGM) was developed for diabetic patients, however, it has a potential role in critical care. Aims: The aim of our study was to evaluate the accuracy of CGM in pediatric patients needing intensive care. Methods: Clinical data: n=38, mean age (range): 1.3(0–18) years; gender: 10 females; length of PICU stay: 21(1–80) days; 32/38 patients needed mechanical ventilation; 11/38 needed vasoactive therapy. Subcutaneous glucose level was monitored by Guardian® REAL Time (Medtronic). Reference glucose values were obtained by GEM Premier 3000 blood gas analyzer (Instrumentation Laboratory) or point-of-care glucose analyzer (DCONT Ideal, 77 Elektronika). Calibration was performed at least twice a day. Approved by the IRB. Results: A total of 4199 hours of CGM recordings were analyzed. Calibration was performed 555 times. 225 blood gas recordings were archived without calibration. Pearson’s correlation coefficient was 0.83. Based on the Clarke Error Grid analysis, the clinical accuracy was 96% (zone A+B). None of the glucose pairs fell in field C or E. Bland Altman analysis: the mean difference between reference and CGM glucose levels was 2.4 mg/dL, (SD: 22 mg/dL). In 48 cases the differences were over the 2SD, in five cases over 80 mg/dL. Conclusions: We conclude that CGM is a reliable tool for glucose monitoring in pediatric intensive care, however, the diagnostic use of CGM may be restricted by possible incoherence of subcutaneous and intravascular glucose levels.