Andrzej Smereczyński

Nodular regenerative liver hyperplasia as a complication of azathioprine-containing immunosuppressive treatment for Crohn’s disease

Nodular regenerative liver hyperplasia (NRH) is a very rare but potentially severe complication of thiopurine-containing immunosuppressive therapy for autoimmune disorders, organ transplantation, and/or oncological treatment. Here we report a case of a 40-year-old female patient with Crohn’s disease and genetic hypercoagulability disorder—factor V Leiden, who in the course of azathioprine immunosuppressive treatment for inflammatory bowel disease developed NRH, which was clinically manifested by thrombocytopenia and delicate hepato-splenomegaly. Moreover, her endoscopic examination of upper gastrointestinal tract demonstrated esophageal varices. Genetic analysis revealed heterozygous genotype (*1/*3A) of thiopurine S-methyltransferase (TPMT), a key enzyme of thiopurines’ metabolism, which results in lower activity of TPMT enzyme, thereby making our patient more susceptible to azathioprine-related hepato and myelotoxicity development. Treatment was started with the immediate cessation of azathioprine therapy, and administration of propranolol as primary prophylaxis for bleeding from esophageal varices. Currently (3 years after diagnosis) remission of Crohn’s disease is achieved, however, progression of features of portal hypertension is observed. Propranolol administration is continued and the patient is constantly monitored in our Department. Our Case Study highlights the clinical difficulties and challenges associated with diagnosing of azathioprine-induced NRH, as well as, supports previous observations that hypercoagulability disorders and abnormal TPMT activity may contribute to NRH development.

Sonographic imaging of Spigelian hernias.

The aim of the work was to present clinical material referring to rarely occurring abdominal cavity hernias in semilunar line – Spigelian hernias diagnosed with the help of ultrasound. Material and methods In the period from 1995 to 2001 785 anterior abdominal wall hernias were diagnosed including 11 Spigelian hernias (1.4%) diagnosed in 10 patients (7 women and 3 men) aged from 38 to 65 years old (average age 48). Eight patients complained of spastic pain in abdomen, in 5 of them it was accompanied by bloating and sometimes loud peristalsis. All the patients had been observing the mentioned symptoms from 2 to 5 years. Each of them had had colonoscopy and abdominal cavity ultrasound examination performed, some of them even three times. In 3 women with uterine fibroid the uterus was removed which did not eliminate the symptoms. The ultrasound examination of the abdominal integument was performed mainly with the use of linear transducers of the frequency of 7–12 MHz; in obese patients also convex transducers were used (3,5–6 MHz). Each examination of abdominal integument included the assessment of the following areas: linea alba from xiphoid process to pubic symphysis including umbilicus, both semilunar lines from costal margins to pubic bones, and also inguinal areas. Moreover, all types of postoperative scars were examined. Each hernia was assessed in terms of size (the greatest dimension), hernia sac contents, width of the ring and reducibility under the compression of the transducer. Moreover, cough test and Valsalvas maneuver were performed. Generally, the examination was performed in a standing position. Results In 9 patients hernias were localized unilaterally, in one patient bilaterally. In 7 cases the hernia sac contained small bowel, in 2 cases the preperitoneal and omental fat, and in 2 cases preperitoneal fat only. Eight patients presenting with clinical symptoms underwent operative repair. Conclusion Ultrasound examination is beneficial in confirming the diagnosis of Spigelian hernias especially in terms of proper, therapeutic decision-making.

Pulmonary Benign Metastasizing Leiomyoma from the Uterine Leiomyoma: A Case Report

Summary Background Benign metastasizing leiomyoma (BML) is a rare condition described as multiple well-differentiated leiomyomas at sites distant from the uterus. Apart from lungs it has also been reported in lymph nodes, heart, brain, bone, skin, eye and spinal cord. We present a case of pulmonary benign metastasizing leiomyoma in a female patient admitted to our hospital with suspicion of left adnexal tumor. Case Report A 45-year-old woman was referred to our hospital with suspicion of left adnexal tumor. The control transvaginal ultrasound examination performed at admission to the Gynecological Department excluded adnexal neoplasm. However, a large amount of fluid within the Douglas pouch raised the oncological concern. The patient underwent myomectomy in 2005. In the same year she was diagnosed with multiple lung nodules and underwent pulmonary wedge resection with the diagnosis of pulmonary benign metastasizing leiomyoma being stated. The decision of reevaluation of the specimen, control CT and puncture of the Douglas pouch fluid was made. Computed tomography performed at the Department of Diagnostic Imaging and Interventional Radiology of the Pomeranian Medical University Hospital revealed multiple, bilateral nodules. The microscopic examination of the samples confirmed the initial diagnosis of benign metastasizing leiomyoma with no evidence of neoplastic cells within the fluid. Conclusions Pulmonary benign metastasizing leiomyoma is a rare entity. However, it should be always taken into consideration in women with a previous or coincident history of uterine leiomyoma, especially when no evidence of other malignancy is present.

Intra-abdominal fat. Part III. Neoplasms lesions of the adipose tissue.

This article focuses on various cancerous lesions that are found beyond organs in the intra-abdominal fat and can be visualized with ultrasonography. These lesions are divided into five groups. The first group includes primary benign tumors containing adipocytes, such as lipoma, lipoblastoma, hibernoma and other lesions with an adipose tissue component, such as myolipoma, angiomyolipoma, myelolipoma and teratoma. The second group comprises primary malignant adipocytecontaining tumors, including liposarcoma and immature teratoma. The third group contains primary benign tumors without an adipocyte component that are located in intra-abdominal fat. This is a numerous group of lesions represented by cystic and solid tumors. The fourth group encompasses primary malignant tumors without an adipocyte component that are located in intra-abdominal fat. These are rare lesions associated mainly with sarcomas: fibrosarcoma, malignant fibrous histiocytoma, hemangiopericytoma and leiomyosarcoma. An epithelioid tumor at this site is mesothelioma. The last but not least group includes secondary malignant tumors without an adipocyte component located in intra-abdominal fat. This is the most numerous group with prevailing carcinoma foci. For each of these groups, the authors present ultrasound features of individual lesions and discuss their differential diagnosis. In the vast majority of cases, the material for cytological and histological analysis can be obtained during ultrasound-guided procedures. This is the advantage of this imaging modality.

Mediastinal Pancreatic Pseudocysts

Mediastinal pseudocysts are a rare complication of acute pancreatitis. Lack of uniform treatment standards makes the management of this condition a clinical challenge. We report the case of a 43-year-old patient who presented with a left pleural effusion. Pleural fluid revealed a high amylase concentration consistent with a pancreaticopleural fistula. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a disruption of the pancreatic duct with free outflow of contrast medium into the thoracic cavity. A pancreatic stent was placed. The second day after the ERCP, the patient developed septic shock and was admitted to the intensive care unit. Computed tomography (CT) revealed mediastinal pseudocysts and bilateral pleural effusions. After bilateral drainage of the pleural cavities, the patient improved clinically, and a follow-up CT scan showed that the fluid collection and pseudocysts had resolved. We discuss the optimal strategies for diagnosing and treating patients with pancreatic thoracic pseudocysts and fistulas, as well as review the management of these conditions.

Mesenteric changes in an ultrasound examination can facilitate the diagnosis of neuroendocrine tumors of the small intestine

Neuroendocrine tumors make up an interesting pathology of a variable clinical picture, prognosis, localization, endocrine activity and degree of malignancy. Aim The aim of this paper is to assess whether ultrasonography can be helpful in diagnosing neuroendocrine tumors in the small intestine by analyzing changes in the mesentery. Material and methods From 1996 to 2013, we encountered 17 patients (9 women and 8 men at the mean age of 57) with a neuroendocrine tumor in the small intestine. The diagnosis was confirmed in all patients by pathomorphological examinations. All retrospectively analyzed patients (n =17) had an abdominal US examination conducted in accordance with the previously mentioned protocol. Results Primary neuroendocrine tumors were visualized ultrasonography in 13 of 17 patients (76.5%). In the remaining 4 patients, tumors in the small bowel were diagnosed in CT enteroclysis (n = 3) and conventional enteroclysis (n = 1). Somatostatin receptor scintigraphy and CT enteroclysis supplemented the ultrasound result by providing information about the stage of the disease in 7 cases. In most of the 17 patients with a neuroendocrine tumor diagnosed by ultrasound (n = 11, 64.7%), changes in the mesentery were prevailing pathological signs that raised suspicion and, consequently, helped localize the primary lesion. The hypoechoic mesenteric lymph nodes were the greatest (9–18 mm), well-circumscribed, and the largest of them showed signs of vascularization. The size of hypoechoic lesions in the mesentery ranged from 25 to 53 mm. These lesions showed moderate blood flow. All of them were single, usually poorly circumscribed; two lesions showed slight calcifications. Conclusions In an abdominal US examination, 2/3 of patients with neuroendocrine tumors in the small bowel manifest secondary lesions in the mesentery which are easier to visualize than the primary focus. 30% of them are manifested as hypoechoic masses. The detection of such lesions should prompt the search for the primary focus in the small intestine.

Ultrasound of selected pathologies of the small intestine.

Intestines, especially the small bowel, are rarely subject to US assessment due to the presence of gases and chyme. The aim of this paper was to analyze ultrasound images in selected pathologies of the small intestine in adults, including the aspects of differential diagnosis. Material and methods In 2001–2012, abdominal ultrasound examinations were conducted in 176 patients with the following small bowel diseases: Crohns disease (n=35), small bowel obstruction (n=35), yersiniosis (n=28), infectious diarrhea (n=26), bacterial overgrowth syndrome (n=25), coeliac disease (n=15) and small bowel ischemia (n=12). During examinations patients were fasting and no other particular preparations were needed. Convex transducers of 3.5–6 MHz and linear ones of 7–12 MHz were used. The assessment of the small intestine in four abdominal quadrants constituted an integral element of the examination. The following features of the small bowel ultrasound presentation were subject to analysis: thickness and perfusion of the walls, presence of thickened folds in the jejunum, reduction of their number, presence of fluid and gas contents in the intestine, its peristaltic activity, jejunization of the ileum and enteroenteric intussusception. Furthermore, the size of the mesenteric lymph nodes and the width of the superior mesenteric artery were determined and the peritoneal cavity was evaluated in terms of the presence of free fluid. Results Statistically significant differences were obtained between the thickness of the small intestine in Crohns disease or in ischemic conditions and the thickness in the remaining analyzed pathological entities. Small bowel obstruction was manifested by the presence of distended loops due to gas and fluid as well as by severe peristaltic contractions occurring periodically. In the course of ischemic disease, the intestinal walls were thickened without the signs of increased perfusion and in the majority of cases intestinal stenosis was observed. Fluid in the intestine was detected in all patients with coeliac disease, gas in 86.7% of patients, thickening of the folds in the jejunum in 86.7%, their reduction in 80%, increased (enhanced) peristalsis in 93.3% and jejunization in 40%. In 80% of coeliac disease cases, the intestine showed the features of hyperemia on color Doppler examination and in 53.3% of patients the dilated lumen of the superior mesenteric artery was detected. Enlarged mesenteric lymph nodes were visualized in 73.3% of the subjects, enteroenteric intussusception in 33.3% and free fluid in the peritoneal cavity in 60%. Conclusions Small bowel obstruction is manifested by the presence of evidently dilated intestinal loops filled with gas and fluid and periodical severe deepened peristalsis. Ischemic changes and Crohns disease are characterized by the presence of fragmentarily thickened intestinal walls and intestinal stenosis. Moreover, in Crohns disease, increased wall perfusion and mesenteric adenomegaly is encountered. Coeliac disease is manifested by: increased amount of fluid mainly in the jejunum, thickened and hyperemic jejunal walls, increased peristalsis; hypertrophied mucosal folds – often their number is reduced, jejunization and transient enteroenteric intussusception; ultrasound changes that require the differentiation with small intestinal bacterial overgrowth syndrome and, to a lesser degree, with infectious diarrhea.

Is a fatty pancreas a banal lesion

So far, a fatty pancreas has been related to obesity and the ageing processes in the body. The current list of pathogenetic factors of the condition is clearly extended with genetically conditioned diseases (cystic fibrosis, Shwachman-Diamond syndrome and Johanson-Blizzard syndrome), pancreatitis, especially hereditary and obstructive, metabolic and hormonal disorders (hypertriglyceridemia, hypercholesterolemia, hyperinsulinemia and hypercortisolemia), alcohol overuse, taking some medicines (especially adrenal cortex hormones), disease of the liver and visceral adiposis. As regards lipomatosis of that organ resulting mainly from dyslipidemia and hyperglycemia, the term “nonalcoholic fatty pancreas disease” was introduced. Experimental studies on animals and histological preparations of the pancreatic fragments show that the lipotoxicity of the collected adipocytes collected ion the organ release a cascade of proinflammatory phenomena, and even induces the processes of carcinogenesis. Pancreas adiposis is best defined in Computed Tomography and Magnetic Resonance Imaging. However, a series of works proved the usefulness in the diagnostics of that pathology of transabdominal and endoscopic ultrasonography. In that method, the degree of adiposis was based on the comparison of echogenicity of the pancreas and the liver, renal parenchyma, spleen and/or retroperitoneal adipose. Recently, the evaluation was expanded by the evaluation of the degree of pancreatic adipose with the pancreas-to-liver index, utilizing to that end a special computer program. According to our experience, the simplest solution is the method utilized by us. On one crosssection of the body of the pancreas, its echogenicity is assessed in comparison to retroperitoneal adipose and the visibility of the splenic vein, pancreatic duct and the major retroperitoneal vessels. Depending on the visualization of these structures, it is possible to determine the degree of pancreas adiposis. Such a study applies to 250 people, in whom the adiposis was detected in 16.5%, which is close to other cohort US examinations results.

The assessment of the role of baseline low-dose CT scan in patients at high risk of lung cancer.

Summary Background Despite the progress in contemporary medicine comprising diagnostic and therapeutic methods, lung cancer is still one of the biggest health concerns in many countries of the world. The main purpose of the study was to evaluate the detection rate of pulmonary nodules and lung cancer in the initial, helical low-dose CT of the chest as well as the analysis of the relationship between the size and the histopathological character of the detected nodules. Material/Methods We retrospectively evaluated 1999 initial, consecutive results of the CT examinations performed within the framework of early lung cancer detection program initiated in Szczecin. The project enrolled persons of both sexes, aged 55–65 years, with at least 20 pack-years of cigarette smoking or current smokers. The analysis included assessment of the number of positive results and the evaluation of the detected nodules in relationship to their size. All of the nodules were classified into I of VI groups and subsequently compared with histopathological type of the neoplastic and nonneoplastic pulmonary lesions. Results Pulmonary nodules were detected in 921 (46%) subjects. What is more, malignant lesions as well as lung cancer were significantly, more frequently discovered in the group of asymptomatic nodules of the largest dimension exceeding 15 mm. Conclusions The initial, low-dose helical CT of the lungs performed in high risk individuals enables detection of appreciable number of indeterminate pulmonary nodules. In most of the asymptomatic patients with histopathologically proven pulmonary nodules greater than 15 mm, the mentioned lesions are malignant, what warrants further, intensified diagnostics.

Difficulties in differentiating the nature of ascites based on ultrasound imaging

Transabdominal ultrasound not always allows to determine the nature of ascites based solely on its characteristics. Aim The aim of the study was to present difficulties in determining the nature of ascites using transabdominal ultrasonography solely based on extra-organ lesions as well as, after the inclusion of the overall abdominal assessment and the clinical picture. Materials and methods A total of 18 patients with non-neoplastic ascites and 62 patients with neoplastic ascites whose final diagnosis was based on cytological and histopathological findings were evaluated between 2005 and 2015. Abdominal ultrasound was performed to detect the presence of fluid in all accessible spaces, and, additionally, to determine the presence of potential peritoneal tumor implants as well as to evaluate the parietal peritoneum and the greater omentum. Different digital ultrasound machines equipped with 3–6 MHz and linear 7–12 MHz transducers were used in the study. Double-sided Fisher’s exact test with statistical significance at p < 0.05 was used for the analysis of the obtained results. Results Statistically significant differences between benign and neoplastic ascites were found for: anechoic peritoneal fluid (<0.0001); fluid and thickened omentum with smooth surface (<0.0001); fluid and thickened omentum with smooth surface and varices (0.01); fluid and thickened omentum with hypoechoic foci (0.049); fluid and thickened omentum with tumor implants (0.009). The inclusion of the overall assessment of abdominal organs and the clinical data allowed for an improvement in ultrasonographic diagnostic accuracy in benign and neoplastic ascites from 83.3% and 67.7% to 94.4% and 93.5%, respectively. Conclusions When used alone, an assessment of acoustic fluid characteristics and extra-organ peritoneal lesions limits the possibility to differentiate between benign and malignant ascites. These results improve after the inclusion of sonographic assessment of all abdominal organs in combination with clinical data.