Jesse Lachter

Enterocolic lymphocytic phlebitis preceding the development of inflammatory bowel disease: report of a case

A 37-year-old previously healthy male presented himself to the Emergency Care Department due to right lower quadrant (RLQ) abdominal pain, which had begun several hours earlier. Physical examination revealed marked abdominal tenderness with signs of peritoneal irritation and positive rebound tenderness. Laboratory tests were notable for leukocytosis (15.6 K/dL) with neutrophilia (79.4 %). Abdominal ultrasound showed a hyperechoic structure surrounded by thickened bowel wall in the RLQ, which according to the radiologist was highly suspicious for indicating acute appendicitis. Based on the above, it was decided to proceed immediately to exploratory laparotomy with appendectomy. At surgery a firm cecal mass was found near the ileocecal valve. The appendix was normal. Due to the high clinical probability of malignancy a right hemicolectomy was performed. Gross examination of the surgical specimen revealed a thickened cecal wall and ulceration of cecal mucosa. Histologic examination revealed a colonic mucosa with ischemic like changes and a transmural lymphocytic infiltration of the submucosal and subserosal veins. Some veins revealed a fibrinoid necrosis of their wall (Fig. 1). Based on these findings, a diagnosis of enterocolic lymphocytic phlebitis (ELP) was established. The patient did well following surgery, and was asymptomatic at discharge three days later. Three years later he was admitted to the Department of Medicine due to rectal bleeding. Colonoscopy revealed severe diffuse proctitis up to 10 cm from the anus. The histological examination revealed severe chronic active inflammatory changes consistent with inflammatory bowel disease (IBD) colitis. As a result a diagnosis of ulcerative colitis was suggested, and local therapy with hydrocortisone and mesalamine was started. The patient reported excellent symptomatic response, steroids were discontinued, and he continues to use oral mesalamine and to function well.

EUS‐FNA for diagnosis of Burkitt's lymphoma in the pancreas of a 3‐year‐old

Pancreatic tumors in young children are rare and most often are treated surgically. To provide an exact diagnosis, endoscopic ultrasound (EUS) examination with fine-needle aspiration (FNA) may be used, as FNA biopsy may potentially obviate unnecessary surgery. In the present case, a 3-year-old previously healthy child presented having months of decreased appetite, abdominal pain, and recent-onset scleral icterus. Labs found elevated total bilirubin (7.4 mg/dL), γ-glutamyltransferase (GGT; 509 U/L), alkaline phosphatase (ALP; 781 U/L), and lipase (1000 U/L). Abdominal US revealed two hypodense lesions with clear, sharp borders in the pancreas, one in the head measuring 4.8 × 3.8 × 4.1 cm and the other in the tail measuring 3.8 × 2.4 × 2.8 cm. Computed tomography (CT) scan confirmed the masses (Fig. 1). CT-guided biopsy was deemed unsafe because no window for transabdominal FNA which would not pass through the colon was found. A linear echoendoscope (EUFG38; Pentax) was used with an echotip 25-gauge needle to sample both lesions for cytology. EUS identified the common bile duct to be dilated to 6 mm, approximately twice the size of the portal vein (Fig. 2). Cytological examination using the cell-block method demonstrated classic Burkitt’s lymphoma ‘starry-sky’ pattern confirmed with c-myc staining. As a result of the successful use of EUS in this pediatric setting, establishing the diagnosis of this specific malignancy prevented unnecessary surgery and the patient began chemotherapy immediately, which has been very successful. This is the first report of EUS diagnosis of Burkitt’s lymphoma in such a young child; knowing this feasibility may encourage others to use it when indicated.

Exposure During Pancreatic Surgery. Do We Have to Examine the Falciform and Round Ligaments for Pancreatic Cancer Metastasis

CONTEXT Metastatic and locally advanced disease is unfortunately a common clinical occurrence in patients affected by pancreatic cancer. The most frequent sites of metastasis are the liver and the peritoneal lining. The falciform and round ligaments are routinely resected and sent for pathology, but no metastases have ever been reported. OBJECTIVE In this study, we assess whether the falciform and round ligaments are possible sites for metastases and if routine pathology examination of these structures is justified. DESIGN Retrospective, single institution study. PATIENTS The charts of all patients who underwent pancreatic resection from June 2005 through January 2011 were reviewed retrospectively. Data on age, gender, type of operation performed, preoperative CA 19-9 levels, vascular and perineural invasion, tumor differentiation and pathological staging were retrieved from the hospital electronic data base. Only patients with malignant lesions of the pancreas were included in the study. MAIN OUTCOME MEASURES Presence of pancreatic metastasis in the falciform and round ligaments. RESULTS Fifty-seven patients were included in the study. Forty patients had undergone pancreaticoduodenectomies, 10 subtotal pancreatectomies, 2 total pancreatectomies, and 1 distal pancreatectomy. Four patients had exploratory laparotomy but exploration revealed stage III or IV disease, thus the planned resection was not carried out. The falciform and round ligaments were all negative for metastasis in all patients. DISCUSSION Metastatic progression of pancreatic cancer is poorly understood. Theoretically, metastases to the falciform and round ligaments could occur by either contiguous, hematogenic or lymphatic spread. In our study, none of the patients had metastases to the falciform and round ligaments, regardless of the pathological staging. CONCLUSION We concluded that routine pathological examination of the falciform and round ligaments is not justified if the surgeon elects to remove the structures for ease of exploration and retraction during surgery. This may lighten the workload and reduce costs in a busy pathology laboratory.