Narendra Pandit

Barium peritonitis: a disastrous complication of an unnecessary diagnostic study

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Fever of unknown origin: a rare presentation of giant hepatic hemangioma

Abstract Hepatic hemangioma is mostly asymptomatic and incidental finding on imaging. Fever of unknown origin as a sole presentation is rare. We present an interesting case report of a 49-year-old female, who presented with fever for three months. Extensive blood investigations and infectious workup failed to reveal the cause. Contrast computed tomography of abdomen revealed a giant (15 × 11 cm) hemangioma arising from left lateral segment of liver, and was attributed as a cause for fever. Surgical excision of hemangioma completely ameliorated the fever.

Giant pseudoaneurysm of subclavian artery after blunt chest trauma

Subclavian artery (SCA) pseudoaneurysm after blunt chest trauma is rare and its delayed presentation months after the SCA injury is even rarer. Herein we discuss a case of SCA pseudoaneurysm in a 74-year-old man who presented to us 5 months after blunt chest trauma. He had been managed conservatively for the fracture of first rib and clavicle until presentation to our hospital. He had uncontrolled hypertension and a rapidly increasing large painful swelling (10 by 8 cm) in left clavicular region along with purplish discoloration of the overlying skin. The diagnosis was confirmed after computed tomography angiography and the patient was successfully treated with surgical evacuation of clots, primary repair of the rent in the SCA, and plating of clavicular fracture.

Hanging Undifferentiated Embryonal Sarcoma of the Liver in Adult: an Unusual Presentation of an Aggressive Tumor

Undifferentiated embryonal sarcoma of the liver (UESL) is a rare, highly aggressive hepatic neoplasm of mesenchymal origin seen almost exclusively in pediatric population [1]. It was termed UESL for the first time by Stocker et al. in 1978 [2]. This disease is very rare in adults with less than 70 cases reported in English literature [3–5]. Though the tumor usually presents as a large liver tumor in an adult, a giant (> 10 cm) and hanging tumor arising from the Reidel’s lobe of the liver over a narrow stalk is very unusual and has not been reported in literature to date. We describe a case of a 29-year-old young female with a short clinical course and resectable hanging UESL, but unfortunately developed early recurrence despite R0 resection, signifying a poor prognosis disease.

Isolated Peritoneal Recurrence After Liver Resection for Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) continues to be the common and lethal malignancy worldwide that often arises in the setting of background liver disease [1]. Options for treating HCC have expanded dramatically over the last few decades from initially resection to liver transplantation (LT) with the expansion of tumor criteria and improved results [2]. Liver resection (LR) is the standard of care for patients without underlying liver disease, while LT is the gold standard for patients with Child-Pugh B/C cirrhosis and limited hepatic reserve within transplant criteria. Despite treatment, unfortunately around 70% of patients in LR group and only 10% in LT group develop recurrence over 5-year period [1]. Majority of recurrence when they occur are intrahepatic. Extrahepatic or peritoneal recurrences have been described in less than 3% of patients following LR, and only few data are available from a case series [3, 4]. We report a unique case of isolated peritoneal recurrence developing 2 years following successful resection of right liver HCC. Case Report

Caroli’s disease: a diagnostic challenge

Carolis disease is a rare congenital malformation of the intrahepatic bile ducts characterized by duct ectasia and dilation, which may involve the biliary tract in a focal or multifocal manner. Caroli’s disease is less common than Caroli’s syndrome, and both are extremely rare with an approximate prevalence of less than one in 1,000,000 inhabitants. Caroli’s disease combined with congenital hepatic fibrosis and/or renal cystic disease is referred to Caroli’s syndrome. It is currently included in group V of the Todani classification of biliary tract cystic diseases and was first described by the French gastroenterologists, Jacques Caroli et al., in 1958. The clinical course can be asymptomatic in the first two decades from birth, in fact, typical symptoms may scarcely arise throughout the patients’ life. Caroli’s disease may diffusely affected the liver or be localized to one lobe or segment. Caroli’s disease predispose to biliary stasis and intrahepatic stones formation leading to cholangitis, liver abscesses, septicemia, and ultimately to secondary biliary cirrhosis. Most used diagnosis methods are ultrasound, computed tomography (CT), magnetic resonance cholangiopancreatography (MRPC).

Extreme Small Bowel Enteroatmospheric Fistula

Small bowel enteroatmospheric fistula is a serious and devastating complication of open abdomen. We present an interesting image of a 40-year-old gentleman who developed multiple small bowel enteroatmospheric fistulae following open abdomen management for complicated intra-abdominal peritonitis.

Ectopic Liver Tissue on the Gallbladder: a Rare Incidental Finding

Ectopic liver is a rare developmental anomaly that most commonly is incidentally detected in the abdomen, with the gallbladder being the most common site during laparoscopic surgery. Although the natural course of the ectopic liver is unpredictable, rarely they can become symptomatic due to torsion, necrosis, rupture, pyloric obstruction, and malignant transformation. Here, we report an interesting image of an ectopic liver on the gallbladder with its own vascular supply, detected during laparoscopic cholecystectomy in a patient with gallstone-induced acute pancreatitis.

Diagnosing Gastric Cancer in Chest X-ray

A 60-year-old lady presented with symptoms of chronic iron deficiency anaemia. On evaluation with routine chest X-ray, it surprisingly revealed an irregular mass-like opacity in proximal part of stomach suggesting gastric cancer. The diagnosis was later confirmed with upper GI endoscopy and CT scan abdomen. Hence, in modern era of advanced diagnostics, chest X-ray findings should not be overlooked.

Undifferentiated embryonal sarcoma of liver in an adult with spontaneous rupture and tumour thrombus in the right atrium: Images for Surgeons

Undifferentiated embryonal sarcoma of liver (UESL) is an uncommon tumour, which is predominantly seen in children. It is very rare in adults, with only 60 cases reported in the English literature. It usually presents with an abdominal pain or a lump. Spontaneous rupture with tumour thrombus in the right atrium (RA) although described for hepatocellular carcinoma (HCC), is very rarely seen with UESL. We report an UESL in an adult which ruptured into the peritoneal cavity with tumour thrombus extending into the RA. A 34-year-old gentleman presented with complaints of pain and lump in the right upper abdomen for 7 days. He also had early satiety and obstipation for 4 days. On examination, he was ill-looking, pale, tachypnic with heart rate of 110 beats/min and low blood pressure (90/60 mmHg). Abdomen was distended with a lump (18 × 16 cm) in the right hypochondrium. Laboratory investigations were unremarkable apart from low haemoglobin (6.0 g/dL). He received three pints of packed red blood cells, which improved the vital parameters. The contrast-enhanced computed tomogram (CECT) abdomen confirmed a well-circumscribed hypodense mass lesion (16 × 14 cm) with a solid-cystic component arising from the segments IV, V and VIII of the right liver, compressing the gastric antrum and transverse colon (Fig. 1). There was non-visualization of middle hepatic vein and inferior venacava (IVC). Transthoracic echocardiography showed tumour thrombus extending into the RA (Fig. 2). The tumour markers; α-fetoprotein and carcinoembryonic antigen were normal. The diagnosis of ruptured malignant liver tumour with an extension into the heart was made and he was planned for emergency laparotomy in order to control his ongoing bleeding and obstruction. Intraoperatively, 3 L of hemoperitoneum was detected. A ruptured, soft jelly-like tumour (15 × 14 cm) was enucleating from the liver and was overlying the antrum and transverse colon. The right liver (segments IV, V and VIII) comprised the main tumour bulk, which was carefully excised with a palliative intent and haemostasis achieved. Post-operatively, the patient developed pedal oedema and gross ascites, probably due to the residual right atrial tumour which was managed with diuretics. He was discharged on post-operative day 15. Histopathology revealed an UESL (Fig. 3). We could not consider him for chemoradiotherapy due to the poor performance status. At 6 months of follow-up, imaging showed tumour progression at the liver and RA. UESL is a rare, primary liver malignancy with a poor prognosis. It is usually large, solitary and well-circumscribed lesion with variable areas of haemorrhage, necrosis and cystic degeneration. Tumour size often exceeds 10 cm and can be as large as 30 cm at presentation in adults.