Lee Tc

Gastrointestinal: afferent loop syndrome.

1346 Journal of Gastroenterology and Hepatology 21 (2006) 1346

Gastrointestinal: Lymphangioleiomyomatosis with protein‐losing enteropathy

A 29-year-old woman was referred for investigation because of diarrhea and peripheral edema. She had a low plasma albumin (22 g/L) without proteinuria or features of cirrhosis. Protein loss from the gastrointestinal tract was documented by measurement of the clearance of alpha-1 antitrypsin from the plasma using a 72 h stool collection. Clearance was markedly elevated (2818 mL/day) when compared with the reference range (<12.5 mL/day). Enteroscopy revealed engorged villi in the third part of the duodenum and biopsies confirmed the presence of lymphangiectasia. A coronal reformatted image of a contrast-enhanced abdominal computed tomography (CT) scan revealed a large cystic tumor in the right retroperitoneum (Fig. 1). After laparoscopic biopsy, chylous fluid leaked from a soft encapsulated tumor (Fig. 2). Laparoscopic biopsies showed a mixture of proliferating lymphovascular and smooth muscle cells that were positive for human melanoma black-45, a specific marker for lymphangioleiomyoma cells. In addition, a CT scan of the chest showed multiple thin-walled cysts in the basal segments of both lungs. There has been some improvement in symptoms with progesterone, diuretics and dietary therapy. Lymphangioleiomyomatosis (sometimes called lymphangiomyomatosis) is a rare disorder characterized by the proliferation of abnormal smooth muscle cells in the lungs and in the lymphatic system of the thorax and retroperitoneum. The disorder is largely restricted to premenopausal women. Presenting features can include progressive dyspnea, spontaneous pneumothorax, chylous pleural effusion and chylous ascites. There is also an association with renal angiomyolipomas and with tuberous sclerosis, perhaps because of a genetic link involving mutations in one of the tuberous sclerosis genes (TSC2). The prognosis of patients with lymphangioleiomyomatosis is variable but some patients progress to respiratory failure and need to be considered for lung transplantation. Other forms of treatment are debated but include progesterone supplements and surgical oophorectomy.

Gastrointestinal: Abdominal abscess associated with a ventriculoperitoneal shunt

Tubes can sometimes be used to move fluid into or out of the peritoneal cavity. One example is the LeVeen shunt for intractable ascites. This moves fluid from the peritoneal cavity into a central vein, usually the junction of the superior vena cava with the right atrium. These shunts are now rarely used because of a variety of complications including disseminated intravascular coagulation, variceal hemorrhage, infection, cardiac failure and venous thrombosis. Furthermore, a randomized trial showed that LeVeen shunts did not improve survival in patients with severe ascites associated with alcoholic cirrhosis. Shunts can also be used in hydrocephalus or low-pressure hydrocephalus to divert cerebrospinal fluid. The distal end of the shunt can be placed in the right atrium or in the peritoneal or pleural cavity. In those patients with shunts in the peritoneal cavity, abdominal complications are uncommon but include ascites, peritonitis, abscesses and pseudocysts containing cerebrospinal fluid. Clinical features of a shunt abscess include fever and abdominal pain. The diagnosis is usually made by an abdominal ultrasound study or by an abdominal computed tomography scan (CT). Treatment consists of intravenous antibiotics, removal of the shunt from the peritoneal cavity and conversion of the shunt to external drainage. The images shown below are from a 76-year-old man who was treated with a ventriculoperitoneal shunt for normal-pressure hydrocephalus in 2003. The shunt was revised in 2004 because of suspected shunt dysfunction. Six months later, he developed abdominal pain and fever that was associated with an elevated white cell count. An ultrasound study showed fluid collections in the left abdomen and the reformatted, enhanced CT scan revealed a well-defined lobulated fluid collection in the left abdomen (Fig. 1). The tip of the shunt catheter was outlined within the collection (arrow). The course of the shunt catheter was traced on the maximum intensity projection shown in Fig. 2 (arrow). The diagnosis of a shunt-related abscess was confirmed by the percutaneous aspiration of pus. Cultures revealed a methicillin-resistant Staphylococcus aureus, Proteus mirabilis and Staphylococcus epidermidis. Symptoms resolved after use of intravenous antibiotics and removal of the shunt from the peritoneal cavity.

Ileal obstruction in a 73-year-old woman

A 73-year-old woman presented to our emergency department with complaints of progressive abdominal fullness and vomiting for 2 months. Her past history was unremarkable apart from breast cancer 10 years …

Nautilus-patterned small intestines

A 69-year-old woman presented to our hospital due to diffuse abdominal pain and bloody stool for 3 days. …

An unexpected cause of chronic diarrhoea

A 41-year-old man suffered from chronic diarrhoea of 3 years’ duration, accompanied by weight loss of 20 kg. He was referred to our hospital for double-balloon enteroscopy (DBE). …

Hepatobiliary and pancreatic: Hepatic abscess associated with a hepatoenteric fistula

What abnormalities are shown on the contrast-enhanced computed tomography scan in Fig. 1? There is a cavity in the right lobe of the liver that contains a large amount of air and demonstrates an airfluid level. In addition, intrahepatic bile ducts are dilated and there is a possible mass involving the duodenum. The patient was a man, aged 56, who had been treated surgically for rectal cancer 5 years previously. He subsequently developed liver metastases and had undergone two wedge resections and gamma-knife therapy. On admission to hospital, his symptoms included abdominal pain, fever and jaundice. On the reformatted coronal image (Fig. 2), a fistula (arrow) was suspected between the abscess cavity and metastatic tumor involving the duodenum. The patient was treated with percutaneous drainage of the abscess and percutaneous drainage of the biliary system. With injection of contrast into the abscess cavity, some contrast passed through a fistula into the duodenal lumen. In a typical hepatic abscess, air may be present in the abscess cavity but the volume of air is relatively small and usually appears as ‘air pockets’. The presence of a large volume of air with an airfluid level should raise the possibility of a fistula between the abscess and the alimentary tract. Indeed, there are a number of case reports where hepatic abscesses have resulted from invasion of the duodenum by a primary hepatic tumor. To our knowledge, however, this is the first report of a hepatic abscess caused by a hepatoenteric fistula associated with a metastatic tumor. Although therapeutic measures such as those described above may result in improvement in symptoms, such patients usually have a poor prognosis because of widespread malignant disease.