Toshihiro Ichimori

Spontaneous intramural duodenal hematoma complicating acute pancreatitis.

A 49-YEAR-OLD MAN WHO is also a heavy drinker was referred to our hospital with sudden back pain and drowsiness. He had no history of anticoagulant use or trauma. He reported 1-week history of recurrent abdominal pain and vomiting after every meal. Physical examination revealed localized resistance with tenderness in the right upper abdomen. Laboratory examination revealed potassium, 2.5 mEq/L; urea nitrogen, 42 mg/dL; creatinine, 1.9 mg/dL; total bilirubin, 2.8 mg/dL; gamma-glutamyltransferase, 952 U/L; and amylase, 1,374 U/L; these values indicated acute pancreatitis. The International Normalized Ratio was within normal range. Arterial blood gases on room air were as follows: pH, 7.541; PO2, 56.1 mmHg; PCO2, 64.4 mmHg; base excess, 28.5 mmol/L; and bicarbonate 55 mmol/L, suggesting metabolic alkalosis. Abdominal contrast-enhanced computed tomography (CT) in the early phase revealed an nonenhancing intramural hematoma with luminal narrowing in the descending part of the duodenum and peripancreatic fluid

Hepatobiliary cystadenoma exhibiting morphologic changes from simple hepatic cyst shown by 11-year follow up imagings.

BackgroundA long-term follow up case of hepatobiliary cystadenoma originating from simple hepatic cyst is rare.Case presentationWe report a case of progressive morphologic changes from simple hepatic cyst to hepatobiliary cystadenoma by 11 – year follow up imaging. A 25-year-old man visited our hospital in 1993 for a simple hepatic cyst. The cyst was located in the left lobe of the liver, was 6 cm in diameter, and did not exhibit calcification, septa or papillary projections. No surgical treatment was performed, although the cyst was observed to gradually enlarge upon subsequent examination. The patient was admitted to our hospital in 2004 due to epigastralgia. Re-examination of the simple hepatic cyst revealed mounting calcification and septa. Abdominal CT on admission revealed a hepatic cyst over 10 cm in diameter and a high-density area within the thickened wall. MRI revealed a mass of low intensity and partly high intensity on a T1-weighted image. Abdominal angiography revealed hypovascular tumor. The serum levels of AST and ALT were elevated slightly, but tumor markers were within normal ranges. Left lobectomy of the liver was performed with diagnosis of hepatobiliary cystadenoma or hepatobiliary cystadenocarcinoma. The resected specimen had a solid component with papillary projections and the cyst was filled with liquid-like muddy bile. Histologically, the inner layer of the cyst was lined with columnar epithelium showing mild grade dysplasia. On the basis of these findings, hepatobiliary cystadenoma was diagnosed.ConclusionWe believe this case provides evidence of a simple hepatic cyst gradually changing into hepatobiliary cystadenoma.

Intestinal perforation due to ingestion of blister-wrapped tablet in a press-through package

mitochondrial abnormalities such as polymorphism, including megamitochondria, moderately increased electron density of matrix, and the presence of numerous crystalline linear inclusions of unknown composition within the matrix. The average diameter of these structures was 10 nm and the average space between them 20 nm. They were especially evident in megamitochondria (Fig. 1). Occasionally the mitochondrial matrix contained single tiny fatty droplets. Other authors observed similar mitochondrial changes in NASH but in adult patients (5, 7). Like Caldwell et al. (7), we assume that abnormal mitochondria observed in nonalcoholic steatohepatitis, especially megamitochondria, and development of crystalline linear inclusions, may represent either an adaptive process in the cell or hepatocyte injury. We conclude that their detection may be useful in the diagnosis of NASH in pediatric as well as adult patients.

Lymphoepithelial cyst of the pancreas that was difficult to distinguish from branch duct-type intraductal papillary mucinous neoplasm: Report of a case

A 58-year-old woman was admitted to our hospital to optimize the management of her diabetes mellitus. A computed tomography (CT) scan showed a 30-mmdiameter, multilocular cyst in the head of the pancreas. The tumor markers, including DUPAN 2, SPAN-1, and carbohydrate antigen 19-9, were within the normal ranges. A contrast-enhanced CT scan showed a nonenhanced, multilocular cyst. Abdominal magnetic resonance imaging showed a multilocular cyst. Endoscopic retrograde cholangiopancreatography showed that the main pancreatic duct was normal. Based on these findings, we suspected a branch duct type intraductal papillary mucinous neoplasm. A distal pancreatectomy with a splenectomy was performed, since more of the mass was located on the dorsolateral side, inconsistent with the preoperative imaging results. On the resected specimen, a 4-cm-diameter, multilocular cyst containing serous fluid was found. Pathologically, the cyst wall was lined with squamous epithelium surrounded by abundant lymphoid tissue with follicles, consistent with a lymphoepithelial cyst of the pancreas, which is an unusual benign cyst.

Letter to the editorIntestinal perforation due to ingestion of blister-wrapped tablet in a press-through package

Intestinal perforation due to ingestion of blister-wrapped tablet in a press-through package