Bruce B. Berry

Use of Online Symptom Checkers to Delineate the Ever-Elusive GERD versus Non-GERD Cough

Cough carries an annual prevalence in the population of 10-33% and remains the most common reason for primary care physician visits. Gastroesophageal reflux disease (GERD) is estimated to be present in 20-40% of Western adult populations. Pulmonary manifestations, such as cough, have been recognized as a potential consequence of GERD, with the prevalence of GERD-associated cough ranging from 10%-40%. This article is protected by copyright. All rights reserved.

Hepatobiliary and Pancreatic: Extrahepatic cavernous hemangioma presenting as a palpable abdominal mass

An 89-year-old Caucasian female with history of total abdominal hysterectomy with unilateral oophorectomy presented with abdominal pain, cramps, nausea, and diarrhea. Her vital signs were normal and physical examination was unremarkable except for a palpable abdominal wall mass of ~10 cm in the right upper quadrant. The mass was non-tender and non-pulsatile. Lab testing including complete blood count, basic metabolic panel, urine analysis, Cancer antigen (CA) 125, CA 19-9, and occult blood were all within normal limits. Computed tomography (CT) of the abdomen with contrast showed re-demonstration of benign cavernous hemangioma in the dome of the liver consistent with previous imaging five years prior (Fig. 1a). A new mass was present at the abdominopelvic junction on the right measuring 13 × 9 × 10 cm (Fig. 1b). The low attenuated mass with regions of nodular enhancement abuts the liver as well as loops of bowel including the duodenum. A fat plane is present between parts of the mass and the adjacent liver. An ultrasound-guided biopsy via core needle technique with subsequent histological workup revealed a hypervascular peritoneal mass consistent with a benign cavernous hemangioma and no evidence of malignancy (Fig. 2). Hepatic hemangiomas are the most common benign mesenchymal hepatic tumors, with prevalence ranging from 0.5–20%. The majority are discovered at autopsy or incidentally during imaging. Most patients with hemangiomas are asymptomatic, with lesions greater than 4 cm more likely symptomatic. Abdominal hemangiomas have been described in numerous locations, including the gastrointestinal tract, retroperitoneum, skeletal muscle, and mesentery. They traditionally are diagnosed on CT, but with unclear demarcation of its origin, subsequent imaging modalities should be considered. This patient’s clinical presentation was suspicious for a malignant mass in the abdomen. With histology confirming a benign cavernous hemangioma, the suspicion of a exophytic tumor remained. However, CT of the abdomen with contrast demonstrated no clear connection with the liver and made identification of hepatic origin challenging. Pedunculated exophytic hemangiomas show a thin pedicle that contains a feeding artery and draining vein, and this pedicle connects the hemangioma to the liver. In contrast, usual exophytic hemangiomas just show contrast enhancement at the contact surface with the caudate lobe. This case does not show evidence of either traditional finding on contrast CT, thus, the origin of the benign cavernous hemangioma remains unclear. Magnetic resonance imaging has been shown to be an excellent modality for both benign and exophytic liver tumors, and would be an useful imaging modality in this case. The differential diagnosis of intraabdominal masses in the elderly population is extensive and must include hemangioma. Contributed by AC Berry,* R Nakshabendi and BB Berry *University of South Alabama, Medicine, Mobile, Alabama, University of Florida College of Medicine-Jacksonville, Medicine, Jacksonville, Florida, and Wheaton Franciscan Healthcare, Medicine, Milwaukee, Wisconsin, USA Figure 2 Fibrovascular tissue with large irregularly shaped and dilated blood vessels, and lined by a single layer of endothelial cells. a b

Acute Right Lower Quadrant Abdominal Pain: An Uncommon Culprit

Gastroenterology Question: A 60year-old Caucasian man with a history of diverticulosis, diabetes mellitus type 2, and hypertension woke up in the middle of the night with right lower quadrant pain. The pain was dull, nonradiating, and not associated with bowel movement or urination. He had undergone a screening colonoscopy 6 months earlier showing diffuse diverticulosis of the colon, with no history of any diverticulitis. The patient was afebrile and physical examination revealed an obese male in no acute distress. Abdominal examination demonstrated tenderness and rebound in right lower quadrant of the abdomen, with minimal guarding. His laboratory results were unremarkable except for an elevated white blood cell count of 14.3 103/mL with 82% segmented neutrophils and mildly elevated serum alanine aminotransferase at 63 U/L. A computed tomography (CT) scan of the abdomen was performed (Figure A, sagittal view; Figure B, coronal view). A surgical consultation was obtained and the patient underwent abdominal laparoscopy that evening. What is the likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Embedded Pork Bone Causing Esophageal Perforation and an Esophagus-Innominate Artery Fistula

Chronically embedded foreign bodies can lead to perforations, mediastinitis, and abscess, amongst a host of other complications. A 20-year-old mentally challenged female presented with “something stuck in her throat,” severe dysphagia, and recurrent vomiting. Initial imaging was unremarkable; however, subsequent imaging and esophagogastroduodenoscopy two weeks later revealed an embedded pork bone. Surgery was performed to remove the bone and fix the subsequent esophageal perforation and esophagus-innominate artery fistula. This case helps reinforce the urgency in removing an ingested foreign body and the ramifications that may arise with chronically embedded foreign bodies.