A preliminary study on the prevention of hemorrhage after laparoscopic pancreaticoduodenectomy by wrapping gastroduodenal artery stump in the left external liver lobe and the left caudate lobe / 中华外科杂志

Objective: To investigate the safety and efficacy of embedding the stump of gastroduodenal artery between the left lateral lobe of the liver and the left caudate lobe to prevent bleeding after laparoscopic pancreaticoduodenectomy. Methods: The clinical data of 41 patients who underwent laparoscopic pancreaticoduodenectomy at the second Hospital of Hebei Medical University from October 2021 to April 2022 were analyzed retrospectively.There were 27 males and 14 females, aged (63.0±9.2)years (range: 48 to 78 years), and the body mass index was (24.1±3.2)kg/m2 (range: 15.4 to 31.6 kg/m2). After routine laparoscopic pancreaticoduodenectomy, the stump of gastroduodenal artery was embedded between the left lateral lobe and the left caudate lobe of the liver, and the hepatic parenchyma of the left lateral lobe and the left caudate lobe were sutured with absorbable sutures.The occurrence and recovery of postoperative complications (pancreatic fistula, biliary fistula, postoperative abdominal bleeding, abdominal infection, liver abscess) were observed. Results: All the operations of 41 patients were completed successfully.The operation time was (277.5±52.0) minutes (range: 192 to 360 minutes). The entrapment time of gastroduodenal artery stump was (3.1±0.6) minutes (range: 2.3 to 4.2 minutes), and the intraoperative blood loss (M(IQR)) was 300 (200) ml (range: 50 to 800 ml).The results of ultrasound examination of hepatic artery on the first day after operation showed that the blood flows of hepatic artery were unobstructed.Postoperative pancreatic fistula occurred in 3 cases, including grade B pancreatic fistula in 2 cases (1 case with abdominal infection) and biochemical leakage in 1 case. Three patients with pancreatic fistula were discharged successfully after continuous abdominal drainage. There was no biliary fistula, abdominal bleeding, abdominal infection, liver abscess or postoperative liver dysfunction. Conclusion: The encasement of the gastroduodenal artery stump by the left outer and left caudate lobes of the liver may be an effective way to prevent bleeding from the rupture of the gastroduodenal artery stump after laparoscopic pancreatoduodenectomy, which is easy and safe to perform.

Tratamiento mininvasivo de las complicaciones del traumatismo hepático cerrado / Minimally invasive management of blunt hepatic trauma complications

RESUMEN Antecedentes: el manejo no operatorio del traumatismo hepático cerrado es exitoso en el 95% de los pacientes hemodinámicamente normales. Las lesiones de alto grado presentan una tasa de complicaciones de hasta un 14%, y una mortalidad del 27% cuando requieren cirugía abierta. Material y métodos: estudio descriptivo de informe de casos. Resultados: 3 casos con traumatismo hepático de alto grado. "A": manejo no operatorio inicial, lavado laparoscópico por hemoperitoneo sintomático, drenaje percutáneo de absceso hepático, recambio de catéter y CPRE, por fístula biliar persistente. "B": cirugía de control de daño inicial sin hepatectomía, drenaje percutáneo de absceso hepático y posterior recambio. "C": manejo no operatorio inicial, lavado laparoscópico por hemoperitoneo sintomático, posterior drenaje percutáneo de absceso hepático y recambio de drenajes. No presentaron mortalidad. Conclusión: estos casos resumen la utilización de las diferentes modalidades del manejo del traumatismo hepático cerrado y la posibilidad del manejo mininvasivo de las complicaciones.

ABSTRACT Background: Nonoperative management of blunt hepatic trauma is successful in 95% of hemodynamically stable patients. The complication rate of high-grade injuries is 14% and mortality reaches 27% when they require open surgery. Material and methods: We conducted a descriptive study of case reports. Results: Three cases of high-grade hepatic trauma are reported. "A": initial nonoperative management, laparoscopic lavage due to symptomatic hemoperitoneum, percutaneous drainage of liver abscess, catheter replacement and ERCP due to persistent biliary fistula. "B": initial damage control surgery without liver resections, percutaneous drainage of liver abscess and catheter replacement. "C": initial nonoperative management, laparoscopic lavage due to symptomatic hemoperitoneum, percutaneous drainage of liver abscess and catheter replacement. None of the patients died. Conclusion: These cases summarize the use of different management modalities of blunt hepatic trauma and the possibility of minimally invasive management of the complications.

Ultrasonido en el punto de atención: reporte de un caso de absceso hepático / Point of care ultrasound diagnostic: a case report of a hepatic abscess

Resumen El ultrasonido en el punto de atención es una herramienta diagnóstica que ha tomado relevancia en el escenario intra y extrahospitalario, al tratarse de un estudio no invasivo que permite que los hallazgos clínicos se correlacionen directamente con los signos y síntomas que presenta el paciente. El objetivo del presente trabajo es evidenciar la utilidad clínica aplicada al caso de una paciente con una bacteremia persistente, en la cual se identificó el foco de infección por evaluación ultrasonográfica, para dirigir posteriormente la terapia. Presentamos un caso clínico en el que, por medio de esta herramienta, se estableció el diagnóstico de un absceso hepático insospechado clínicamente; se demuestra su utilidad clínica como extensión de la valoración médica especializada al obtener una experiencia favorable de su correcta utilización en un caso complejo.

Abstract Point of care Ultrasound is a diagnostic tool that has gained relevance in the hospital and outpatient setting, as it is a non-invasive study that allows direct correlation of clinical findings and the signs and symptoms that the patient presents. The objective of this paper is to show its clinical utility evident as applied to a female patient who had persistant bacteremia, in which the site of infection was identified through ultrasound evaluation. We present a clinical case whose diagnosis of hepatic abscess was possible by the use of ecography and shows its usefullness as an extension of specialized medical evaluation by showing a favorable experience of its correct use in a complex case. We present a clinical case in which the diagnosis of a clinically unsuspected liver abscess was obtained using this tool.

Ruptura espontánea de absceso hepático del lóbulo izquierdo en hemitórax derecho / Spontaneous rupture of liver abscess of the left lobe in the right hemithorax

Introducción: La extensión transdiafragmática del absceso hepático piógeno constituye un caso raro de empiema pleural. Es una enfermedad de progresión rápida y con altas tasas de mortalidad, cercanas al 100 por ciento si no se trata a tiempo. Objetivo: Describir el caso de una paciente con empiema pleural derecho, secundario a ruptura de absceso piógeno del lóbulo hepático izquierdo. Caso clínico: Paciente femenina de 70 años de edad que acude al cuerpo de guardia con fiebre, dolor abdominal, síndrome general. La tomografía computadorizada mostró absceso hepático el lóbulo izquierdo con licuefacción casi total y posteriormente presentó como complicación un empiema torácico derecho. La paciente fue tratada con drenaje con sonda pleural. A pesar de los tratamientos antibióticos y quirúrgicos oportunos la paciente fallece en shock séptico. Conclusiones: Se reporta un caso raro de empiema secundario a absceso hepático del lóbulo izquierdo. La demora de la paciente en acudir a instituciones de salud conllevó al fallecimiento de la paciente a pesar del tratamiento antibiótico y quirúrgico(AU)

Introduction: The transdiaphragmatic extension of the pyogenic liver abscess constitutes a rare case of pleural empyema. It is a rapidly progressive disease with high mortality rates close to 100 percent if it is not treated in time. Objective: To describe the case of a patient with right pleural empyema secondary to a ruptured pyogenic abscess of the left hepatic lobe. Clinical case: A 70-year-old female patient who came to emergency with fever, abdominal pain and general syndrome. The computed tomography scan showed a liver abscess in the left lobe with almost total liquefaction, and later a right thoracic empyema was a complication. The patient was treated with chest tube drainage. Despite timely antibiotic and surgical treatments, the patient died of septic shock. Conclusions: A rare case of empyema secondary to liver abscess of the left lobe is reported. The delay of the patient in going to health institutions led to the death of the patient despite antibiotic and surgical treatment(AU)

Enfermedad por arañazo de gato con compromiso hepato-esplénico en adultos inmunocompetentes / Hepatosplenic cat-scratch disease in immunocompetent adults cat scratch

La enfermedad por arañazo de gato (EAG) es una zoonosis emergente causada por Bartonella henselae. Puede presentarse de forma atípica, incluyendo meningitis, neuroretinitis, endocarditis y compromiso hepatoesplénico, lo cual es poco frecuente en adultos inmunocompetentes. Su manejo terapéutico es controvertido dada la ausencia de ensayos aleatorizados al respecto. Se describen 5 casos de EAG con compromiso hepato-esplénico, donde la correcta anamnesis epidemiológica permitió la sospecha diagnóstica, evitando la realización de procedimientos invasivos en la mayoría de los casos. La posibilidad de realización de PCR y serología para Bartonella spp. fueron de vital importancia

Cat scratch disease (CSD) is an emerging zoonosis caused by Bartonella henselae. It can occur atypically including meningitis, neuroretinitis, endocarditis and hepatosplenic involvement, a rare occurrence in immunocompetent adults. Therapeutic management is controversial, supported by case series and retrospective data published literature. Five cases of CSD with hepatosplenic involvement are described. The correct clinical and epidemiological anamnesis allow the diagnostic and avoid the performance of invasive procedures in most cases. The possibility of performing Bartonella spp PCR and serology is crucial

Laparoscopy treatment of liver abscess secondary to an unusual foreign body (rosemary twig)

A hepatic abscess caused by a swallowed foreign body is a rare and challenging diagnosis. Most patients have nonspecific symptoms, and more than 90% of patients do not remember having swallowed it, which occurred accidentally. In this setting, fish bones, chicken bones, and toothpicks are the most found foreign bodies. We reported the case of a 54-year-old male patient admitted with abdominal pain and intermittent fever. He was diagnosed with liver abscess and treated successfully with antibiotics and a laparoscopic procedure; a rosemary twig was found during the abscess drainage procedure. Furthermore, a literature review of 22 cases of laparoscopic treated liver abscesses associated with a foreign body was made.

Pathological effects of ECHINOSTOMA PARAENSEI infection associated with pyogenic abscesses caused by PSEUDOMONAS AERUGINOSA in swiss mice / Efectos patológicos de la infección por ECHINOSTOMA PARAENSEI asociada a abscesos piógenos causados ​​por PSEUDOMONAS AERUGINOSA en ratones suizos / Efeitos patológicos da infecção por ECHINOSTOMA PARAENSEI associada a abscessos piogênicos causados ​​por PSEUDOMONAS AERUGINOSA em camundongos suíços

The trematode Echinostoma paraensei is an intestinal parasite transmitted by ingestion of the infectious stage of metacercariae. For scientific purposes, its life cycle has been maintained in the laboratory, allowing analysis using various biological approaches. Different parasite isolates have revealed atypical patterns of migration and establishment in ectopic sites in Swiss-Webster mice. During the investigation of the biological life cycle of an E. paraensei isolate from the silvatic rodent Nectomys squamipes collected in the municipality of Rio Bonito (State of Rio de Janeiro), a bacterial coinfection with Pseudomonas aeruginosa was observed, which produced anatomopathological alterations, mainly in the liver, bile ducts, pancreas, and small intestine. The main macroscopic signs were the whitish suppurative pyogenic punctual lesions. The histological sections stained by hematoxylin-eosin showed an intense inflammatory reaction formed by mononuclear cells and macrophages surrounding the bile ducts, although the hepatic parenchyma still presented its normal aspect. Thus, pyogenic abscesses can be associated with E. paraensei infection depending on the strain and aggravating pathogenesis in the definitive host.

El trematodo Echinostoma paraensei es un parásito intestinal transmitido por ingestión de la etapa infecciosa de las metacercarias. Para fines científicos, su ciclo de vida se ha mantenido en el laboratorio, lo que permite el análisis mediante diversos enfoques biológicos. Diferentes aislamientos de parásitos han revelado patrones atípicos de migración y establecimiento en sitios ectópicos en ratones Swiss-Webster. Durante la investigación del ciclo biológico de un aislado de E. paraensei del roedor silvático Nectomys squamipes colectado en el municipio de Rio Bonito (Estado de Rio de Janeiro), se observó una coinfección bacteriana con Pseudomonas aeruginosa, que produjo alteraciones anatomopatológicas, principalmente en el hígado, los conductos biliares, el páncreas y el intestino delgado. Los principales signos macroscópicos fueron las lesiones puntuales piógenas blanquecinas supurativas. Los cortes histológicos teñidos con hematoxilina-eosina mostraron una intensa reacción inflamatoria formada por células mononucleares y macrófagos que rodeaban las vías biliares, aunque el parénquima hepático aún presentaba su aspecto normal. Por tanto, los abscesos piógenos pueden asociarse con la infección por E. paraensei dependiendo de la cepa y agravando la patogenia en el hospedador definitivo.

O trematódeo Echinostoma paraensei é um parasita intestinal transmitido pela ingestão da fase infecciosa das metacercárias. Para fins científicos, seu ciclo de vida foi mantido em laboratório, permitindo análises por meio de diversas abordagens biológicas. Diferentes isolados de parasitas revelaram padrões atípicos de migração e estabelecimento em sítios ectópicos em camundongos Swiss-Webster. Durante a investigação do ciclo de vida biológico de um isolado de E. paraensei do roedor silvático Nectomys squamipes coletado no município de Rio Bonito (Estado do Rio de Janeiro), foi observada uma coinfecção bacteriana por Pseudomonas aeruginosa, que produziu alterações anatomopatológicas, principalmente no fígado, dutos biliares, pâncreas e intestino delgado. Os principais sinais macroscópicos foram as lesões pontuais piogênicas supurativas esbranquiçadas. Os cortes histológicos corados pela hematoxilina-eosina mostraram intensa reação inflamatória formada por células mononucleares e macrófagos circundando as vias biliares, embora o parênquima hepático ainda apresentasse seu aspecto normal. Assim, abscessos piogênicos podem estar associados à infecção por E. paraensei dependendo da cepa e agravando a patogênese no hospedeiro definitivo.

Abscesos hepaticos en tiempos de pandemia (covid19) / Hepatic abscesses in time of pandemic (COVID 19)

Introducción. Los abscesos hepáticos son infecciones focales supurativas. La Klebsiella pneumoniae es el agente etiológico más frecuente. Afecta principalmente a hombres de edad media, diabéticos, con afecciones hepáticas o en contexto de inmunodepresión. Se clasifican en abscesos colangíticos, pioflebíticos, hematógenos, por continuidad, traumáticos y criptogénicos, según mecanismo de producción. Se manifiestan con dolor abdominal en hipocondrio derecho, sd. febril y sd. colestásico en presencia de obstrucción de vía biliar. La ecografía, TAC y la Resonancia magnética de abdomen son los métodos de elección para determinar topografía y morfología de las colecciones. El tratamiento consiste en el drenaje oportuno de la colección por vía percutánea o quirúrgica, asociado al tratamiento antibiótico. Objetivos: 1. Análisis epidemiológico de abscesos hepáticos durante la Pandemia por Covid 19 en una Institución privada de Tucumán. 2. Estudiar la fisiopatología y agentes patógenos responsables de los mismos. 3. Comparar estadísticas con era similar no Covid 19. Material y métodos. Estudio descriptivo retrospectivo. Se incluyeron seis pacientes con diagnóstico de Absceso Hepático, cinco de ellos del período de la era Covid 19 y uno de la era no Covid 19. Las variables analizadas fueron: cantidad de pacientes ingresados al Servicio, pacientes con absceso hepático, sexo, edad, comorbilidades, métodos de diagnóstico imagenológico utilizados, localización anatómica del absceso, número de lesiones, microbiología de la muestra quirúrgica y en sangre, tratamiento implementado, días desde el diagnóstico hasta la resolución, STROC y recidiva. Resultados: En el análisis epidemiológico se evidenció un notable descenso de la actividad quirúrgica en el periodo del 2020, respecto al mismo período del año previo, a predominio del mes de abril con un porcentaje de descenso del 52%, coincidiendo este período con el inicio de la cuarentena en la provincia. En nuestra serie resultaron todos masculinos, hipertensos y 3 de ellos diabéticos. Todos estudiados por ecografía y 3 complementaron con TAC con contraste EV. Fueron tratados en un promedio de 48hs desde el diagnóstico. Cultivos positivos, Klebsiella Pn (3), St aureus (1), E. Coli (1), Bacilo gram ­ (1). Hemocultivos: 3 negativos, 2 positivos para Klebsiella Pn y 1 para St. Aureus. 3 pacientes fueron sometidos a drenaje percutáneo, 2 a laparoscópico y uno convencional. Se registraron 2 STROC IIIA y 1 IIIB. Un paciente obitó, el resto recibió alta sanatorial. Se registraron 2 recidivas. Conclusiones: Nuestros pacientes, en su totalidad masculinos y diabéticos, desarrollaron abscesos hepáticos piógenos; el agente patógeno más frecuente fue la Klebsiella Pneumoniae. Los abscesos criptogénicos fueron los más prevalentes. En las recidivas documentadas, se determinó misma ubicación topográfica y agente etiológico del primer episodio, lo que nos lleva a preguntarnos sobre la eficacia del tratamiento implementado en cada caso.

Introduction: liver abscess is a common infection. Klebsiella pneumoniae was de most frecuently etiologic agent. The patients were middle-aged men with diabetes, another liver afection or immunodepression context. According to the production mechanism, they are classified in colangitics, pyophlebics, haematogenes, by continuity, traumatic and cryptogrnics. Patients usually present with right upper quadrant, fever, colestasic síndrome when bile-way obstruction exist. Imaging techniques such as ultrasonography, computed tomography scanning and magnetic resonance are useful tools to demostrtate a space occupying lesión and morfology of liver abscess. Treatment consist in timely drainage by percutaneous or surgical route, plus antibiotic treatment. Objetives: 1. Epidemiological análisis of liver abscesses during the pandemic Covid 19 in a private center in Tucumán. 2. Study physiology and pathogenic agents. 3. Campare statistics whit previusly period. Materials and methods: retrospective descriptive study. Six live abscess diagnosis patient were included, five of them included in stage Covid 19 and only one belong stage no Covid 19. Variables analysed: number of patients belong to the Service, number of patients whit liver abscess diagnosis, sex, age, comorbilities, imaging methods, location and number of abscess, microbiology of surgical sample and blood, treatment, days from diagnosis to resolution, STROC and recidivation. Results: epidemiological análisis showed a decrease in surgeries in the period 2020, compared to the same period of the previous year, a predominance in April with a percentage decrease of 52%, coinciding with the start of quarantine in the province. All patients were male, hypertensive and 3 of them with diabetes. Al lof them studied by ultrasound and tomography with contrast. They were treated at 48hours of diagnosis. Microbiology of surgical sample positive: Klebsiella Pn (3), St aureus (1), E. Coli (1), Bacillos gram ­ (1). Microbiology of blood: 3 negative, 2 positive to Klebsiella Pn and 1 to St. Aureus. 3 patients were drainage by percutaneous , 2 by laparoscopic and 1 by surgical conventional. They registered 2 STROC IIIA y 1 IIIB. 1 patiente dead, the rest were external from hospital. Conclusions: our patients developed liver abscess, they were male, diabetics and the most frecuently agent was the Klebsiella pneumoniae. Criptogenics abscess were the most prevalent. The same topographic location in the liver and the etiologic agent was determined in recurrence. That´s why we wonder about the effectiveness of the treatment implemented.

Síndrome de absceso hepático invasor por Klebsiella pneumoniae, serie de casos / Invasive liver abscess syndrome caused by Klebsiella pneumoniae, case series

Resumen Introducción: Los abscesos hepáticos primarios producidos por Klebsiella pneumoniae y las implicancias sistémicas relacionadas constituyen el síndrome de absceso hepático invasor por Klebsiella pneumoniae. Objetivo: Describir las características clínicas, epidemiológicas y la evolución de esta entidad en nuestro centro. Pacientes y Métodos: Cohorte retrospectiva de pacientes adultos internados en el Hospital Italiano de Buenos aires entre el 1 de enero de 2001 y el 1 de mayo de 2020. Se incluyeron pacientes con diagnóstico de absceso en cualquier órgano con aislamiento en cultivo de absceso o hemocultivo positivo para Klebsiella pneumoniae para ser analizadas las características epidemiológicas, clínicas y la evolución de aquellos con localización primaria hepática. Resultados: 10 pacientes fueron incluidos. Dos (20%) pacientes fueron orientales. La mediana de edad fue 69 años (IIC 64-79), nueve (90%) fueron hombres. La co-morbilidad más frecuente fue diabetes mellitus tipo 2 (40%). Cuatro (40%) pacientes tuvieron diseminación a otros órganos. La mediana de internación fue 21,5 días (IIC 15-43), 60% (n: 6) requirió internación en unidad de cuidados intensivos y 30% (n: 3) de los pacientes falleció. Conclusión: El síndrome de absceso hepático invasor por Klebsiella pneumoniae es una enfermedad infrecuente, potencialmente mortal. Este estudio intenta reportar las características de los pacientes con esta patología en nuestra población.

Abstract Background: Primary liver abscesses caused by Klebsiella pneumoniae and their related systemic complications produce the invasive liver abscess syndrome due to Klebsiella pneumoniae. Aim: To describe the clinical, epidemiological and evolution characteristics in our center. Methods: A retrospective cohort of hospitalized adults in Hospital Italiano de Buenos Aires between January 1st, 2001 and May 1st, 2020. We included patients with diagnosis of abscess in any organ with rescue in culture or positive blood culture for Klebsiella pneumoniae. Epidemiological, clinical characteristics and prognosis of those with hepatic primary localization were analyzed. Results: 10 patients were included. Two (20%) patients were Oriental. Median age was 69 years (interquartile range 64-79), nine (90%) were men. The most frequent comorbidity was type 2 diabetes (40%). Four (40%) patients had spread to other organs. The median hospitalization was 21.5 days (IIC 15-43), 60% (n: 6) were hospitalized in the intensive care unit and 30% (n: 3) died. Conclusions: The invasive liver abscess syndrome due to Klebsiella pneumoniae is a rare life-threatening disease. Our study reports the characteristics of patients with this syndrome in our population.

Morphological characteristics of liver abscesses according its etiology / Características morfológicas de los abscesos hepáticos según su etiología

Although infrequent in the diagnostics areas, liver abscesses are of significant relevance, which is related to the high morbidity and mortality figures they can cause if they are not detected and treated in time. Although multiple operational classifications are described, the one most recognized for its usefulness is that related to its causative agent (pyogenic or bacterial infection, hydatid origin or secondary to infected hydatidosis, and amoebic or by invasive amebiasis). The objective of this article was to generate a study report regarding the morphological characteristics of liver abscesses, characterizing them according to their etiology, as well as describing their study and the latest recommended treatments.

Los abscesos hepáticos son entidades nosológicas de baja frecuencia, pero de significativa relevancia, la que se relacionada con las elevadas cifras de morbilidad y mortalidad que pueden causar si no son detectados y tratados a tiempo. Si bien se describen múltiples clasificaciones operacionales, aquella más reconocida por su utilidad es la relacionada a su agente causal (piógenos o bacterianos, hidatídicos o secundarios a hidatidosis infectada, y amebianos o por amebiasis invasora). El objetivo de este artículo fue generar un documento de estudio respecto de las características morfológicas de los abscesos hepáticos, caracterizándolos de acuerdo con su etiología, así como describir su estudio y tratamiento recomendado de acuerdo con el estado del arte.

Type 1 autoimmune pancreatitis: relapse with liver abscess / Pancreatite autoimune tipo 1: recidiva com abscesso hepático

ABSTRACT: Type 1 autoimmune pancreatitis is a cause of chronic pancreatitis related to the systemic disease known as IgG4-related Sclerosing Disease. Case report: We report the case of a 64-year-old male patient who presented recurrentepigastric pain radiating to the back, associated with jaundice, xerostomia, nausea, and vomiting, since 2014, diagnosed two years later with an unresectable pancreatic adenocarcinoma. The diagnosis was questioned after a few follow-up months without clinical deterioration when it was suggested the possibility of type 1 autoimmune pancreatitis in its pseudotumoral form. The patient was then treated with glucocorticoids, obtaining significantclinical improvement. After two years of follow-up, he returned asymptomatic with images suggestive of sclerosingcholangitis and a large liver abscess. Importance of the issue: The present case denotes the difficulty found in this diagnosis due to clinical and radiological resemblances with pancreatic adenocarcinoma. Besides that, it presents a seldom described disease complication, the liver abscess. (AU)

RESUMO: A pancreatite autoimune tipo 1 é uma causa de pancreatite crônica relacionada à doença sistêmica conhecida como Doença Esclerosante relacionada à IgG4. Relato do caso: Relatamos o caso de um paciente do sexo masculino,64 anos, que apresentou quadros recorrentes de dor epigástrica com irradiação para as costas, associada com icterícia, xerostomia, náuseas e vômitos desde 2014, diagnosticado após 2 anos com adenocarcinoma pancreático irressecável. O diagnóstico foi questionado após alguns meses de acompanhamento sem deterioração clínica, quando aventaram a possibilidade de forma pseudotumoral da pancreatite autoimune tipo 1. Realizou tratamento com glicocorticoides, obtendo melhora clínica importante. Após dois anos de acompanhamento, retorna assintomático com imagens sugestivas de colangite esclerosante e volumoso abscesso hepático. Importância do problema: O presente caso denota uma dificuldade encontrada no diagnóstico dessa entidade devido a semelhanças clínico-radiológicas com o adenocarcinoma pancreático. Além disso, apresenta uma complicação pouco descrita da doença, o abscesso hepático. (AU)

Ascariasis hepatobiliar en una lactante con desnutrición severa: reporte de caso / Hepatobiliary ascariasis in severely malnourished infant: case report

Resumen La Ascariasis es la geohelminitiasis más común del mundo, catalogándose como una enfermedad tropical desatendida, que puede causar compromiso pulmonar, gastrointestinal, hepatobiliar y nutricional. Se presenta el caso inusual de una lactante procedente de una zona de extrema pobreza quien consultó por fiebre, vómito, ausencia de deposiciones, distensión y dolor abdominal. Fue diagnosticada con pseudoobstrucción intestinal, desnutrición severa, choque séptico de origen intraabdominal, retraso del neurodesarrollo y deprivación psicoafectiva, cuyas imágenes reportaron ascariasis hepatobiliar y granulomas hepáticos calcificados y abscedados, con infestación severa por Ascaris lumbricoides. Recibió manejo antibiótico y antiparasitario con recuperación exitosa. En nuestro medio, las infecciones por helmintos son causa frecuente de anemia, retraso cognitivo y del crecimiento en niños en edad escolar. Sin embargo, la infestación y complicaciones hepatobiliares como colangitis, colecistitis, pancreatitis, litiasis biliar y hepatitis abscedada son inusuales en menores de dos años. A través de este caso se pretende resaltar la presentación atípica de la enfermedad en lactantes e incitar al fortalecimiento de las intervenciones en salud pública. MÉD.UIS.2020;33(1):67-72.

Abstract Ascariasis is the most common geohelminitiasis in the world. It is categorized as an unattended tropical disease, which can cause pulmonary, gastrointestinal, hepatobiliary and nutritional compromise. We present the unusual case of an infant from an extreme poverty area presenting fever, vomiting, absence of bowel movements, bloating and abdominal pain. She was diagnosed with intestinal pseudoobstruction, severe malnutrition, abdominal septic shock, neurodevelopmental delay and emotional deprivation. The images reported hepatobiliary ascariasis and calcified and abscessed hepatic granulomas, with severe infestation by Ascaris lumbricoides and Trichuris trichiura. She was treated with antibiotics and antiparasitic agents with successful recovery. In our environment, helminth infections are a frequent cause of anemia, stunting and neurodevelopmental delay in school-age children. However, infestation and hepatobiliary complications such as cholangitis, cholecystitis, pancreatitis, biliary lithiasis and hepatic abscess are unusual in children under two years old. Through this case, it is intended to highlight the atypical presentation of this disease at the age of this patient and encourage the strengthening of public health interventions. MÉD.UIS.2020;33(1):67-72.

Microabscesos hepáticos en una paciente con síndrome antifosfolipidos. Reporte de caso / Liver microabscesses in a patient with antiphospholipid syndrome. Case report

Los abscesos hepáticos en la actualidad se siguen considerando un reto diagnóstico. Estos pueden dividirse en tres categorías principales según las condiciones subyacen­ tes: infecciosas, malignas e iatrogénicas. Incluyen aquellos secundarios a la extensión directa de una infección local, bacteriemia sistémica e infecciones intraabdominales procedente de la porta, Sin embargo, a lo largo de los años, con los estudios diagnósti­ cos la lista de factores de riesgo aumento, obligando a mas investigaciones para su en­ tendimiento; logrando su pronto reconocimiento y tratamiento eficaz con el fin de obtener buenos resultados. Se presenta un caso de femenino con antecedentes de sín­ drome antifosfolípidos con dolor abdominal asociado a intolerancia a la vía oral. Image­ nología abdominal muestra lesiones compatibles con microabscesos hepáticos siendo imposible la toma de muestra, requiriendo cubrimiento antibiótico de amplio espectro con resolución clínico radiológico completa. Tac de abdomen que muestra lesiones hepáticas múltiples con discreta colestasis intrahepática, lesiones compatibles con mi­ croabscesos múltiples.

Liver abscesses are currently still considered a diagnostic challenge. These can be divi­ ded into three main categories according to the underlying conditions: infectious, malig­ nant and iatrogenic. They include those secondary to the direct extension of a local infection, systemic bacteraemia and intra­abdominal infections from the portal, however, over the years, with diagnostic studies the list of risk factors increased, forcing more re­ search for its understanding; achieving its prompt recognition and effective treatment in order to obtain good results. A case of a female with a history of antiphospholipid syn­ drome with abdominal pain associated with oral intolerance is presented. Abdominal imaging shows lesions compatible with hepatic microabscesses, the sampling being im­ possible, requiring broad­spectrum antibiotic coverage with complete radiological clini­ cal resolution. Abdominal tac showing multiple liver lesions with discrete intrahepatic cholestasis, lesions compatible with multiple microabscesses.

A case report of an uncommon Extra-Pulmonary Tuberculosis presenting as an Isolated Tuberculous Liver Abscess in a 63-year-old immunocompetent male

BACKGROUND@#Hepatic or liver tuberculosis is an uncommon form of extra-pulmonary tuberculosis which accounts for less than 1% of all tuberculous infections. Furthermore, tuberculous liver abscess (TLA), a subset of hepatic tuberculosis is extremely rare with a prevalence of 0.34% and is usually associated with foci of infection either in the lung, gastrointestinal tract, or an immunocompromised state.@*CASE PRESENTATION@#A case of a 63-year-old immunocompetent male, with no history of prior pulmonary tuberculosis, was initially diagnosed with pyogenic liver abscess and treated with empiric two-week therapy of Metronidazole 500mg/tab 1 tablet TID and Ciprofloxacin 500mg/tab 1 tablet BID. However, there was the persistence of right upper quadrant pain and jaundice despite compliance to therapy, hence admission. Initial antibiotics were re-initiated and subsequently underwent ultrasound-guided liver aspiration draining a thick, light brown abscess. Microbiologic cultures of the abscess turned out negative but AFB smear revealed 1+ on the AFB national TB program scale signifying 10-99 AFB seen/ 100 visual fields in at least 50 fields. Currently, there are no local treatment recommendations specific for isolated tuberculous liver abscess, thus was empirically started on 2HRZE/4HR for six months. On follow-up, the patient had no recurrence of liver abscess via a repeat ultrasound of the whole abdomen. @*CONCLUSION@#This is an uncommon presentation of extra-pulmonary tuberculosis, an isolated tuberculous liver abscess in an immunocompetent male presenting with persistent right upper abdominal quadrant pain and jaundice. Despite the endemicity of tuberculosis in the Philippines, an isolated tuberculous liver abscess is uncommon or often overlooked. The excellent clinical prognosis of these patients with appropriate therapy necessitates timely diagnosis of this infrequent clinical entity and will prevent further unnecessary surgical interventions.

Sudden death caused by Clostridium perfringens sepsis presenting as massive intravascular hemolysis

An 80-year-old Japanese woman with diabetes mellitus was admitted with gastrointestinal symptoms and pyrexia. At presentation, liver abscesses and severe hemolytic anemia were noted. Before detailed diagnostic evaluation and adequate treatment, she suddenly died 2.5 hours after admission. The autopsy and bacteriological examinations revealed liver abscesses and massive intravascular hemolysis caused by Clostridium perfringens as well as other miscellaneous critical pathological findings, including acute renal tubular necrosis, lung edema, and pulmonary fat embolism. In this article, the detailed autopsy results are described and clinicopathologic characteristics on Clostridium perfringens-related sudden death are discussed with a review of the literature.

Characteristics of Klebsiella pneumoniae Isolates from Stool Samples of Patients with Liver Abscess Caused by Hypervirulent K. pneumoniae

Hypervirulent Klebsiella pneumoniae: Liver Abscess Isolates versus Intestinal Flora

No abstract available.

Tale of Two: A ‘case report’ of two giant urinary bladder stones and recurrent anemia in a 78-year-old Filipino male

@#BACKGROUND: This is a rare case of two large urinary bladder stones causing severe infection of the urinary tract affecting the bone marrow due to chronic immune stimulation in a patient with recurrent anemia. Urinary bladder calculi are hard masses of minerals. They develop when the minerals in concentrated urine crystallize. This often happens when the bladder cannot be emptied. Signs and symptoms can vary from severe abdominal pain to blood in the urine. Sometimes, bladder stones don't cause any symptoms. If left untreated, bladder stones may lead to infections and other complications such as hepatic abscess via a hematogenous route. CASE: This is a case of a seventy-eight-year-old man with a history of multiple blood transfusions secondary to anemia of unknown cause. He came into our institution for a second opinion. We worked up the patient, which showed hepatic abscess and two large urinary bladder calculi. Further investigation of the anemia later led to a diagnosis of primary myelofibrosis. DIAGNOSTICS: Ultrasound showed a complex mass on the left hepatic lobe measuring 7.5 cm x 6.0 cm x 2.1 cm consistent with a hepatic abscess. The culture of the abscess was positive for E. coli. Computed Tomography (CT) scan of the lower abdomen showed heterogeneous mass measuring 8.6 cm x 8.7 cm x 9.2 cm within the urinary bladder (see Figure 2). Urinalysis was consistent with a urinary tract infection. Urine culture showed E. coli. Video-assisted cystoscopy showed two urinary bladder calculi, measuring 1.5 cm x 3.2 cm x 4.2 cm weighing 30 grams each (see Figure 3). The calculi were composed of 100% Calcium Oxalate. He underwent a series of diagnostic examinations for anemia including gastroscopy to rule out a bleeding ulcer. Complete blood count showed hemoglobin of 77 g/L and a hematocrit of 0.23. Finally, bone marrow core biopsy was done which is consistent with primary myelofibrosis. CONCLUSION: Urinary bladder stones can be asymptomatic and may present only with vague abdominal pain. It should be one of the considerations in asymptomatic patients with long-standing prostatitis or benign prostatic hyperplasia. Detailed history, thorough physical examinations, and cautious diagnostic tests are mandatory to confirm the diagnosis. A hepatic abscess may arise from infections in the urinary tract such as prostatitis through hematogenous extension. Therefore, it is important to address the origin of the infection to prevent such complications. This is a rare case of an elderly man who presented with chronic anemia and later found out to have large urinary bladder stones that caused severe infection leading to immune stimulation of the bone marrow, hence the diagnosis of primary myelofibrosis by bone marrow biopsy. Such a rare case must be thought of holistically and analytically.