Cystobiliary fistula in hepatic hydatid disease: diagnostic and therapeutic challenge

In Hydatid disease of the liver cystobiliary fisula [CBF] constitutes an anatomic and a clinicopdthologic entity characterized by the occurrence of a life-threatening cholangitis with increased morbidity and the prolongation of hospital stay. An accurate preoperative diagnosis of this complication is essential for its prompt surgical management. The diagnosis of hydatid disease and the existence of CBF is based primarily on both of the clinical presentation and the characteristic appearance on ultrasonographic [US] and/or computed tomographic [CT] imaging, and confirmed by endoscopic retrograde cholangiography [ERC]. The aim of this work was to study the different diagnostic and therapeutic aspects of cystobiliary fistula in hydatid disease of the liver. From 1996 to 2003, among 63 patients treated for hydatid cysts of the liver, 17 with complicated cysts were included in the current study. They were 11 males and 6 females with a mean age of 34.5 years [ranged from 12 to72 yrs]. According to the clinical presentation, they were divided into 3 groups; group A: nine patients presented with cholangitis, group B: five patients had history of jaundice and group C: three patients presented with jaundice. In 14 patients [groups A and B], the diagnosis of CBF was suspected by abdominal US and/or CT imaging and confirmed by ERC. In the remaining 3 patients [group C], CBF was not documented and they were excluded. Preoperative endoscopic sphencterotomy ES was done in group A with retrieval of hydatid daughter cysts. Among the patients of group A, Seven patients [subgroup Al] were subsequently submitted to surgery entailing endocystectomy in 5 and hepatic resection in two. The remaining 2 patients in group A [subgroup A2] were managed by endoscopic therapy only. Patients of group B [n = 5], were not submitted to preoperative ES and were subsequently managed by hepatic resection in one patient and endocystectomy in four. There was no mortality in the studied group. Postoperative bile leak occurred in four cases; one after hepatic resection and three after endocsytectomy in group B for whom preoperative endoscopic sphincterotmy [ES] was not done. In contrast, none of the patients who were submitted to preoperative ES [subgroup Al] had bile leak. Postoperative wound infection was reported in three patients and minimal subphrenic collection that was aspirated under US guidance was in two. A chest complication in the form of atelecatasis was recorded in one patient. The mean hospital stay was 12.4 days. All patients received albendazole treatment. Surgery still remains the treatment of choice for hydatid cysts of the liver complicated with cystobiliary fistula [CBF]. The results of this work highlight the validity of diagnostic ERC in confirming the diagnosis of CBF in suspected patients with complicated hydatid cysts of the liver. Also, therapeutic ERC has a place in the treatment algorithm of CBF as it was found to be a safe and a reliable therapeutic alternative especially in high risk patients for surgery

Malignant gastrocolic fistula; A masquerading cause for fresh bleeding per rectum

Male diabetic, hypertensive patient, aged 55 yr presented with weight loss, epigastric pain and recurrent vomiting with anorexia, and anemia [Hb 7 gm]. He had one attack of melena followed by passage of fresh blood per rectum once. Patient looked anemic, loosing weight and somewhat toxic. Laboratory profile showed hypochromic microcytic anemia and elevated ESR. Tumor markers and LDH were within normal. Stool test for Helicobacter pylori antigen was negative with normal liver

Pelvic endometriosis a Rare Cause of massive hemorrhagic Ascites

Endometriosis is defined as the presence of endometrial tissue outside the uterine cavity. It generally involves the peritoneum, ovaries and rectovaginal septum. Recurrent hemorrhagic ascites secondary to endometriosis is an unusual occurrence, 42 cases have been reported worldwide since 1954. It is more commonly seen in black nulliparous females. We report a case to draw attention to this condition as a potential cause for massive hemorrhagic ascites

Rare gastric tumors: clinical presentations, endoscopic aspects and management challenges

Many challenges will be present on dealing with rare gastric tumors there. The aim of the present work was to study the clinical presentations, endoscopic aspects of some of the uncommon gastric tumors and the different lines of management of such cases. Ten patients, five males and five females, presented with rare gastric tumors were included in the study. Their age ranged between 42 and 73 years. The main presentations were; epigastric pain, vomiting associated with a sizable epigastric and right hypochondrial mass in one patient, upper gastro intestinal tract bleeding in four patients, vague epigastric pain and dyspeptic manifestation not responding to medication in two patients, non specific symptoms [abdominal pain and dyspepsia] which were modified by a known primary malignant disease and the effects of its treatment were the presentation in three patients. Esophago-gastro-duodenoscopy was done for all patients; [the number, site and appearance of the lesions were described], this was repeated twice for the first patient [one year interval] with evidence of GERD grade I and extrinsic antral compression with no definite masses or ulcers, no biopsy was taken. Endoscopic biopsy could not be taken in two patients, inconclusive in two [CT guided core liver biopsy settled the diagnosis in one patient with multiple liver secondaries while surgical resection specimen was the only option in the other three patients] and conclusive in five. Metastatic Gastric Tumors [MGT] were found in three patients, mesenchymal tumors in three, hepatoid adenocarcionoma, gastric carcinoid, and high grade MALT lymphoma one patient each and synchronous tumors in one patient [lower oesophageal adenocarcinoma and antral mesenchymal tumor]. The primary tumor was cutaneous malignant melanoma, breast adenocarcinoma, and pancreatic adenocarcinoma in the three patients with metastatic gastric tumors. Six patients were treated surgically; two by chemotherapy, one by percutaneous biliary drainage followed by chemo-radiotherapy, and one patient received supportive medication. Four patients are still alive during a follow up period of 12 - 32 months, while six patients died within 9 to 28 weeks from the time of diagnosis. The diagnosis of MGTs is often difficult as gastric involvement is usually masked by manifestations of the original tumor. A negative endoscopic biopsy in mesenchymal tumors with intact overlying gastric mucosa is always a diagnostic challenge. Poor response of most gastric tumors to chemo-radiotherapy makes surgery the main line of treatment

Obstructive jaundice. Calcular versus malignant obstruction

Ninety-three patients with obstructive jaundice were assessed as regards the different patterns of presentation of calcular versus malignant obstruction, their diagnosis, management and the prognosis in each group. Patients with calcular obstruction presented earlier than the malignant groups with very good prognosis provided that the proper line of management is chosen for each case that not only does it free the CBD from stones but also insures free drainage of bile from the liver to the intestines. Patients with malignant obstruction were presented very late and most of the procedures were palliative leading to a high mortality and morbidity rates. Early detection of patients would be the hope for improving the prognosis of this category of patients