Idiopathic gross dilatation of the pancreatic duct with exocrine insufficiency in a patient with type 1 neurofibromatosis.

Pancreatic duct dilatation occurs in conditions including chronic pancreatitis, pancreatic carcinoma and intraductal papillary mucinous neoplasms. Although several pancreatic benign and malignant tumours have been reported in association with type 1 neurofibromatosis, an association with gross pancreatic duct dilatation or ectasia has not been previously published. We report on a patient with type 1 neurofibromatosis found to have idiopathic gross pancreatic duct dilatation and exocrine insufficiency. A 51-year-old female with type 1 neurofibromatosis presented with weight loss and steatorrhoea. Computed tomography and magnetic resonance cholangiopancreatography showed a possible cystic lesion in the head of the pancreas, a grossly dilated main pancreatic duct and minimal thinned out pancreatic parenchyma. Endosonography confirmed diffuse dilatation of the pancreatic duct with no evidence of a separate cystic neoplasm. Endosonography-guided aspiration revealed non-mucinous, clear fluid with high amylase and normal carcinoembryonic antigen levels. The patient was prescribed pancreatic enzyme supplementation and showed symptomatic improvement. Associations between type 1 neurofibromatosis and pancreatic duct ectasia or chronic pancreatitis have not been reported, and this finding may be coincidental. Clinical presentation in conjunction with multimodal imaging and biochemical and cytological fluid analysis did not reveal the aetiology of the ectatic duct system and attenuated glandular tissue in this patient which is most likely congenital.

Location and Diameter of Intracranial Meningioma as Predictors of Peritumoral Brain Oedema and Mass Effect.

INTRODUCTION: The presence of peritumoral oedema or mass effect with intracranial meningiomas is associated with poor clinical outcomes. This study aimed to investigate magnetic resonance (MR) morphologic features of meningioma, which can predict peritumoral oedema and mass effect. METHODS: Data of 100 consecutive patients diagnosed with meningioma on MRI brain at the neurosurgical MRI unit, National Hospital of Sri Lanka, reported by a Consultant Radiologist were analysed in a retrospective study. Binary logistic regression models were fitted to identify predictors of perilesional oedema and mass effect. RESULTS: Female-to-male ratio was 5.8:1. Patients were aged 18-80 years. Majority (n = 78) were in supratentorial compartment with 16 at parasagittal location. Cerebellopontine angle was the commonest infratentorial site (n = 9). Size of meningiomas ranged from 1.1 to 9.1 cm (largest dimension). Mass effect (n = 68), perilesional oedema (n = 37), and midline deviation (n = 31) were the most commonly reported complications. Maximum diameter of meningioma and its location significantly predicted the presence of perilesional oedema [χ2(2,47) = 6.03, P = .049, Nagelkerke R2 = 18.2%] and mass effect [χ2(2,71) = 16.73, P = .000, Nagelkerke R2 = 39.4%] in two logistic regression models. CONCLUSION: The probability of mass effect and perilesional oedema increased with the maximum diameter. Meningioma extending to both supratentorial and infratentorial compartments had the highest risk of having concomitant perilesional oedema and mass effect.

Acute kidney injury due to high-output external biliary drainage in a patient with malignant obstructive jaundice: a case report.

BACKGROUND: Persistent high output is a rare but potentially serious complication of percutaneous biliary drainage. CASE PRESENTATION: A 68-year-old Sinhalese woman with a palliative self-expanding metal stent placed for an inoperable hilar cholangiocarcinoma presented with worsening obstructive jaundice. Ultrasonography showed intrahepatic duct dilatation with the self-expanding metal stent in situ. Since this was indicative of a blocked stent, percutaneous transhepatic cholangiogram-guided internal biliary stenting through the self-expanding metal stent was attempted and failed. Therefore, an external biliary drain was left in the dilated biliary system. Post procedure, she developed a high biliary output of 3-4 liters per day and went into oliguric acute kidney injury with metabolic acidosis, most probably due to inadequate fluid replacement and hypovolemia. CONCLUSION: Although the mechanism by which this occurs in some cases is unclear, early identification and prompt fluid resuscitation prevent acute kidney injury. The adoption of new strategies for internal drainage of long complex strictures will both prevent and ameliorate this problem.

Spontaneous rupture of a parastomal hernia with evisceration of small bowel: a case report.

BACKGROUND: Long standing ostomy related complications such as parastomal hernia and stoma prolapse may be at a higher risk of developing spontaneous rupture and evisceration, especially in patients suffering from chronic cough. Such patients may need early refashioning of the stoma to prevent this serious complication. Parastomal evisceration is a very rare complication of stomas and to date, only few cases have been reported in the literature. CASE PRESENTATION: A 51 year old patient with chronic obstructive pulmonary disease (COPD) and extensive hidradenitis suppurativa of the perineum underwent a temporary defunctioning loop sigmoid colostomy and subsequent perineal skin excision and skin grafting. The ostomy was complicated by a parastomal hernia and stoma prolapse 6 weeks post operatively. Five months later he developed spontaneous rupture of parastomal hernia and evisceration of small bowel. Urgent surgery was done and reduction of small bowel loops and re-siting of the sigmoid colostomy was done. DISCUSSION AND CONCLUSIONS: Parastomal evisceration is an extremely rare life threatening stoma-related complication which requires urgent treatment.