Sukanta Ray

Hepatobiliary and pancreatic tuberculosis: A two decade experience

BackgroundIsolated hepatobiliary or pancreatic tuberculosis (TB) is rare and preoperative diagnosis is difficult. We reviewed our experience over a period two decades with this rare site of abdominal tuberculosis.MethodsThe records of 18 patients with proven histological diagnosis of hepatobiliary and pancreatic tuberculosis were reviewed retrospectively. The demographic features, sign and symptoms, imaging, cytology/histopathology, procedures performed, outcome and follow up data were obtained from the departmental records. The diagnosis of tuberculosis was based on granuloma with caseation necrosis on histopathology or presence of acid fast bacilli.ResultsOf 18 patients (11 men), 11 had hepatobiliary TB while 7 had pancreatic TB. Two-thirds of the patients were < 40 years (mean: 42 yrs; range 19–70 yrs). The duration of the symptoms varied between 2 weeks to 104 weeks (mean: 20 weeks). The most common symptom was pain in the abdomen (n = 13), followed by jaundice (n = 10), fever, anorexia and weight loss (n = 9). Five patients (28%) had associated extra-abdominal TB which helped in preoperative diagnosis in 3 patients. Imaging demonstrated extrahepatic bile duct obstruction in the patients with jaundice and in addition picked up liver, gallbladder and pancreatic masses with or without lymphadenopathy (peripancreatic/periportal). Preoperative diagnosis was made in 4 patients and the other 14 were diagnosed after surgery. Two patients developed significant postoperative complications (pancreaticojejunostomy leak [1] intraabdominal abscess [1]) and 3 developed ATT induced hepatotoxicity. No patient died. The median follow up period was 12 months (9 – 96 months).ConclusionTuberculosis should be considered as a differential diagnosis, particularly in young patients, with atypical signs and symptoms coming from areas where tuberculosis is endemic and preoperative tissue and/or cytological diagnosis should be attempted before labeling them as hepatobiliary and pancreatic malignancy.

Esophageal leiomyomatosis – an unusual cause of pseudoachalasia

Esophageal leiomyomatosis is a rare hamartomatous disorder with varied presentation. In the literature, it is described mostly in children, and is associated with Alports syndrome. A case of leiomyomatosis that presented as achalasia not associated with Alports syndrome is described in a 35-year-old woman with a 16-year history of dysphagia. Barium swallow showed a smooth narrowing at the lower end of the esophagus with a longer than usual stricture length. Endoscopy showed a dilated esophagus with a submucosal nodule in the region of the cardia. A computed tomography scan revealed circumferential thickening of the esophagus involving the gastroesophageal junction, with fat planes maintained with the adjacent structure. Endoscopic ultrasound demonstrated a lesion arising from the muscularis propria. The manometry findings were suggestive of achalasia. She underwent transhiatal esophagectomy with gastric pull-up. Leiomyomatosis should be considered as a cause of psuedoachalasia in patients with symptoms suggestive of achalasia and atypical barium findings. Attempts should be made to confirm the diagnosis preoperatively using computed tomography and/or endoscopic ultrasound. Esophagectomy is the treatment of choice.

An Unusual Cause of Acute Abdomen in Adults: Giant Cystic Lymphangioma of the Pancreatic Head. A Clinical Case and Literature Review

CONTEXT Cystic lymphangioma of the pancreas presenting as acute abdomen in adults has not been reported before. CASE REPORT We report the case of a young man who presented with severe pain in the upper abdomen and abdominal swelling. On imaging, he was found to have a giant multiseptate cystic lesion occupying almost the entire abdomen anterior to the pancreas. On exploration, a cystic mass involving the head of the pancreas and densely adherent to the antrum, and the second and third parts of the duodenum was found and a classic Whipple pancreaticoduodenectomy was done. Histology revealed a diagnosis of cystic lymphangioma. CONCLUSION Cystic lymphangioma is a rare benign tumor of the pancreas and this is the first reported case in an adult presenting with acute abdomen. Though rarely diagnosed preoperatively, this entity should also be considered in the differential diagnosis of cystic lesions of the pancreas. Complete surgical excision is curative.

Hemosuccus Pancreaticus Associated with Severe Acute Pancreatitis and Pseudoaneurysms: A Report of Two Cases

CONTEXT Hemosuccus pancreaticus is a rare cause of upper gastrointestinal hemorrhage. The intensity of bleeding ranges from intermittent occult bleeding to massive acute bleeding leading to death. Although most cases can be managed by angioembolization, surgery plays an important role. CASE REPORT We report two cases of hemosuccus pancreaticus managed at our institution in the past three years. Both cases occurred associated with acute pancreatitis. A pseudocyst was found in one case. Angioembolization failed in one case and was not tried in the other because of hemodynamic instability. Both cases were successfully managed by surgery. CONCLUSION Timely intervention, either by embolization or by surgery, can control this potentially life-threatening bleeding. Choice of treatment, surgery or embolization, depends on technological availability and expertise of the practitioner.

Pancreatic and Peripancreatic Nodal Tuberculosis in Immunocompetent Patients: Report of Three Cases

CONTEXT Pancreatic and peripancreatic tuberculosis in immunocompetent patients is extremely rare. It often mimics pancreatic malignancy. Majority of the cases are diagnosed after an image guided biopsy or after an operation. CASE REPORT We report three cases of pancreatic tuberculosis in immunocompetent patients. All three cases were diagnosed without laparotomy. Diagnosis was made by contrast enhanced computed tomography or endoscopic ultrasound guided fine needle aspiration of the peripancreatic mass and all three cases were treated successfully with antituberculous drugs. CONCLUSION Pancreatic and peripancreatic tuberculosis should be considered in the differential diagnosis of a peripancreatic mass when the patient is young, residing in the endemic zone of tuberculosis or had past history of tuberculosis. Extensive necrosis of peripancreatic lymph nodes with rim enhancement further supports the diagnosis of tuberculosis. Every attempt should be made to diagnose the cases before start of therapy to prevent unnecessary operation.

Groove Pancreatitis: Report of Three Cases with Brief Review of Literature

Groove pancreatitis (GP) is a rare type of segmental pancreatitis, and it remains largely an unfamiliar entity to most physicians. It is often misdiagnosed as pancreatic cancer and autoimmune pancreatitis. With better understanding of radiological findings, preoperative differentiation is often possible. If there is preoperative diagnosis of GP, one can employ non-surgical treatment. But most of the patients ultimately require surgery. Pancreaticoduodenectomy (PD) is the surgical treatment of choice. We report three cases of GP that were treated by Whipple’s operation at our unit. All the three patients had a history of long-standing alcohol intake. In the first and third patients, we had a preoperative diagnosis of GP. But, in the second patient, our pre-operative and intra-operative diagnosis was a pancreatic head malignancy. Diagnosis of GP was made only after histopathological examination. All the three patients had uneventful postoperative recovery and were well at 55-, 45- and 24-month follow-up respectively. In addition to detail descriptions of our three cases, a detailed review of the current literature surrounding this clinical entity is also provided in this article.

Valproic Acid-Induced Severe Acute Pancreatitis with Pseudocyst Formation: Report of a Case.

Valproic acid is the most widely used anti-epileptic drug in children, and it is probably the most frequent cause of drug-induced acute pancreatitis. Outcomes for patients with valproic acid-associated pancreatitis vary from full recovery after discontinuation of the drug to severe acute pancreatitis and death. Here, we present a case of valproic acid-induced severe acute pancreatitis with pseudocyst formation in a 10-year-old girl with cerebral palsy and generalized tonic-clonic seizure. There was no resolution of the pseudocyst after discontinuation of valproic acid. The patient became symptomatic with a progressive increase in the size of the pseudocyst. She was successfully treated with cystogastrostomy and was well at 12-month follow-up.

Groove pancreatitis presenting as recurrent acute pancreatitis

A middle aged male presented with recurrent acute pancreatitis without any feature of extrahepatic biliary obstruction. Evaluation revealed mass in groove area with duodenal lumen compromise without any features of chronic pancreatitis. He underwent classical Whipple′s operation with the suspicion of periampullary tumor but histopathology was suggestive of groove pancreatitis ruling out malignancy. This case is first case to report recurrent acute pancreatitis as presentation of groove pancreatitis.

An uncommon organism in ascitic fluid.

Ann Saudi Med 2014 July-August www.annsaudimed.net 358 A 32-year-old nonalcoholic, nondiabetic male, who had a history of mild acute biliary pancreatitis one year back and who subsequently underwent laparoscopic cholecystectomy, presented with abdominal pain and abdominal distension for almost four months. He denied any history of trauma, alcohol use, pancreatogenic drug intake, fever, or jaundice. At presentation he had pallor, tachycardia, and ascites; rest of the systemic examination was unremarkable. The investigation revealed hemoglobin 10 mg/dL (normocytic-normochromic), total leukoleukocyte count 7500/ mm3 (eosinophil 3%), albumin 2.5 g/dL (reference value 3.5-5 g/dL), serum amylase 1356 U/L (reference value An uncommon organism in ascitic fluid

Giant mucinous cystic neoplasms of pancreas and liver with unusual adipose tissue component: a case report

Simultaneous occurrence of pancreatic and hepatic mucinous cystic neoplasms is very rarely reported in the literature. We present a case with extensive fatty component of the pancreatic tumour arising from the head of the pancreas and attaining a huge size before being treated by Whipples pancreatoduodenectomy and subsequently by a right hepatectomy for the hepatic tumour.