A rare case of accessory liver lobe torsion in a pediatric patient who showed recurrent epigastralgia and who was treated by elective laparoscopic resection.

BACKGROUND: Accessory liver lobe (ALL) is a rare liver malformation. An ALL develops due to malformation of the endodermal caudal foregut and segmentation of the hepatic bud in the third week of gestation. Most ALLs are asymptomatic and are detected incidentally during abdominal surgery. The incidence of ALL is < 1% in patients who undergo abdominal surgery. However, some ALLs twist and cause acute abdomen. We experienced a pediatric case of ALL torsion in a patient who underwent elective laparoscopic surgery. CASE PRESENTATION: The 5-year-old girl had a 3-month history of epigastralgia and vomiting, which occurred every 2 weeks. Abdominal ultrasonography with color Doppler imaging revealed an 11.8 × 13.6 mm nonvascular lesion with mixed echogenicity near the round ligament of the liver. Enhanced computed tomography confirmed a 14 × 16 × 20 mm low-attenuation mass surrounded by a hyperdense line and disproportionate fat stranding on the right side of the round ligament of the liver. There was no ascites or hemorrhage. These findings suggested an abscess of the round ligament of the liver. Her symptoms improved with the administration of oral antibiotics; thus, we planned to perform elective exploratory laparoscopy and subsequent resection. Two trocars (5 mm) were inserted through a multichannel port device at the umbilicus and one trocar (3 mm) was inserted at the right lateral abdomen. Upon observation of the abdominal cavity, the omentum was observed adhering to the round ligament of the liver. Macroscopic observation revealed no apparent mass lesions. We performed adhesiolysis of the omentum from the round ligament of the liver using a vessel sealing system. We performed resection at the site at which adhesion had formed between the round ligament of the liver with the surrounding tissue using a vessel sealing system and the resected specimen was extracted through the umbilical wound. The postoperative course was uneventful. A pathological examination revealed necrotic liver tissue. The resected tissue was founded to be an ALL with ischemic change. CONCLUSIONS: The recurrent abdominal pain was induced by torsion of the ALL. Pediatric surgeons should consider ALL torsion as a differential diagnosis for epigastralgia of unknown etiology.

Síndrome del ligamento arcuato medio / Median arcuate ligament syndrome

Se presenta el caso de una paciente mujer de 63 años de edad, que por epigastralgia severa acompañada de náuseas y sudoración, cursa internaciones en noviembre de 2017 y en febrero de 2018. Como antecedentes de enfermedad cercana, en 2015 presentó un infarto agudo de miocardio (IAM) inferolaterodorsal por disección de la arteria circunfleja. Los estudios post IAM mostraron buena performance miocárdica. En ambas internaciones, la paciente fue evaluada en Unidad Coronaria (UCO) y en Clínica Médica detectándose leve aumento de transaminasas con fosfatasa alcalina (FAL), electrocardiograma (ECG) y Troponina T dentro de parámetros normales. En la primera internación, la ecografía abdominal y la ecoendoscopia biliar descartaron síndrome de la vía biliar y afección pancreática; las transaminasas hepáticas se normalizaron espontáneamente. Durante la segunda internación, y ante reiteración de la sintomatología, se sospechó afección vascular abdominal alta debido al antecedente de disección coronaria; por lo que se le solicitó Angiotomografía de tórax y de abdomen que confirmaron el diagnóstico de Síndrome del Ligamento Arcuato Medio diafragmático. Conclusiones: Los nuevos métodos complementarios de diagnóstico por imágenes permitieron realizar el diagnóstico de esta entidad poco sospechada. (AU)

The case of a 63-year-old female patient is presented, who -due to severe epigastric pain accompanied by nausea and sweating- was admitted to hospital in November 2017 and February 2018. In her medical history of recent disease, she had presented an acute myocardial infarction (AMI) inferolaterodorsal by circumflex artery dissection in 2015. Post-AMI studies showed good myocardial performance. In both hospitalizations, the patient was evaluated in the Coronary Unit (CU) and in the Medical Clinic, showing a slight increase in transaminases with alkaline phosphatase (AF); electrocardiogram (ECG) and Troponin T were within normal parameters. In her first hospitalization, abdominal ultrasound and echoendoscopy of the biliary system ruled out bile duct syndrome and pancreatic disease; liver transaminases normalized spontaneously. During the second hospitalization, and due to repeated symptoms, an upper abdominal vascular condition was suspected due to her history of coronary dissection. Therefore, chest and abdomen CT angiography were indicated which confirmed the diagnosis of diaphragmatic median arcuate ligament syndrome. Conclusions: The new complementary methods of diagnostic imaging allowed the diagnosis of this scarcely suspected syndrome. (AU)

Three Cases Successfully Treated with Uzushakusekishigan / 日本東洋医学雑誌

Uzushakusekishigan is a Kampo formula described in ‘Jin Gui Yao Lue' for treatment of “heart pain that spreads out to the back, or back pain that spreads to the heart.” We successfully treated three patients with this formula. Patient 1 was a 53-year-old man suffering from precordial pain which occurred after amputation of the right forearm;patient 2 was a 46-year-old man with epigastralgia that occurred after taking cold meals;and patient 3 was a 28-year-old woman suffering from epigastralgia accompanied with panic disorder. Epigastric discomfort and resistance occurred in all three cases, prompting us to prescribe this formula. There are few reports of successful application of uzushakusekishigan, and it is not clear what symptoms and pathologies are relevant when prescribing this formula. However, our findings strongly suggest that uzushakusekishigan should be considered when treating severe chest or abdominal pain.

Usefulness of Plain Computed Tomography with Swallowing of GastrografinTM for the Diagnosis of a Late-Onset Iatrogenic Diaphragmatic Hernia following Biopsy of a Diaphragmatic Tumor: Report of a Case.

Although diaphragmatic hernia (DH) may be congenital, posttraumatic, or iatrogenic, DHs after diaphragmatic surgery are rarely reported in the literature. This report describes the rare case of a 14-year-old girl complicated by iatrogenic DH following the biopsy of granulomatous lesions of the left diaphragm, when a mediastinal mixed germ cell tumor was extirpated. Plain computed tomography (CT) with swallowing of GastrografinTM was useful for the diagnosis of this disorder. The patient presented to our hospital with frequent epigastric pain and vomiting 11 months after the original surgery. Chest X-ray, a gastrointestinal contrast study, and plain CT with swallowing of GastrografinTM revealed the left DH with gastric content. At laparotomy, the diaphragmatic defect, 3 × 3 cm in diameter, was repaired using nonabsorbable sutures after hernia reduction. The patient showed a rapid recovery with complete resolution of symptoms. We should consider the presence of iatrogenic DH in patients who develop epigastralgia after procedures involving the diaphragm, even at 11 months after the original surgery. Furthermore, plain CT with swallowing of GastrografinTM is useful for the diagnosis of this disorder.

Localized autoimmune pancreatitis mimicking pancreatic cancer: Case report and literature review.

Autoimmune pancreatitis (AP) is a rare autoimmune pancreatic manifestation of systemic immunoglobulin G4 (IgG4)-related sclerosing disease. Distinguishing between AP and pancreatic cancer is crucial because the clinical courses, treatments, and prognoses of these two disease entities are quite different. We herein report a case involving a 52-year-old man with subacute epigastralgia who visited our hospital for evaluation of a suspicious pancreatic mass found during esophagogastroduodenoscopy. Enhanced computed tomography (CT) revealed an enlarged lesion in the pancreatic head with encasement of hepatic vessels. The lesion also exhibited increased 18F-fluorodeoxyglucose accumulation on positron emission tomography/CT imaging, which was highly suggestive of pancreatic cancer. After open biopsy, morphologic examination showed an inflammatory infiltrate in the pancreas, which was compatible with chronic sclerotic pancreatitis. Further laboratory tests revealed an elevated serum IgG4 level, and the diagnosis of sclerotic pancreatitis was then confirmed. After corticosteroid treatment, the pancreatic lesion showed shrinkage on follow-up CT, and the serum IgG4 titer decreased to the normal range. This case suggests that clinicians should be familiar with the clinical presentations and diagnostic criteria of AP versus pancreatic cancer. An awareness of the differences between these diseases may avoid misdiagnosis and unnecessary surgical intervention.

Investigation of Clinical Indications of Goreisan in Patients with Epigastralgia in the Summer Season / 日本東洋医学雑誌

Teian Azai classically described that summer heat was caused by humidity in addition to hot weather. It may occur after becoming chilled while asleep, enjoying the evening cool, and taking cold foods and drinks. Humidity and high temperature prevent <i>qi</i> circulation in the stomach. Therefore, he insisted that goreisan, a formula improving water circulation, could be applied for diverse symptoms caused by summer heat. We present two cases of patients with epigastralgia caused by cold foods and drinks in air-conditioned environments, whose symptoms were improved by goreisan. In prior treatment, anchusan in case1, and rikkunshito in case 2 were not effective for their epigastralgia. Nineteen cases of epigastralgia after taking cold foods and drinks in summer, including these two cases, revealed that goreisan was efficacious against summer epigastralgia with white fur on the tongue and a stuck feeling in the pit of the stomach. Abdominal fluid congestion is a major abdominal sign for an indication of goreisan, but a stuck feeling in the pit of the stomach presented in some effective cases with goreisan. We concluded that epigastralgia caused by cold foods and drinks with white fur on the tongue and a stuck feeling in the pit of the stomach could be a target for the application for goreisan.

Investigation of Clinical Indications of Goreisan in Patients with Epigastralgia in the Summer Season / 日本東洋医学雑誌

Teian Azai classically described that summer heat was caused by humidity in addition to hot weather. It may occur after becoming chilled while asleep, enjoying the evening cool, and taking cold foods and drinks. Humidity and high temperature prevent <I>qi</I> circulation in the stomach. Therefore, he insisted that goreisan, a formula improving water circulation, could be applied for diverse symptoms caused by summer heat. We present two cases of patients with epigastralgia caused by cold foods and drinks in air-conditioned environments, whose symptoms were improved by goreisan. In prior treatment, anchusan in case1, and rikkunshito in case 2 were not effective for their epigastralgia. Nineteen cases of epigastralgia after taking cold foods and drinks in summer, including these two cases, revealed that goreisan was efficacious against summer epigastralgia with white fur on the tongue and a stuck feeling in the pit of the stomach. Abdominal fluid congestion is a major abdominal sign for an indication of goreisan, but a stuck feeling in the pit of the stomach presented in some effective cases with goreisan. We concluded that epigastralgia caused by cold foods and drinks with white fur on the tongue and a stuck feeling in the pit of the stomach could be a target for the application for goreisan.

Experimental study on treatment of epigastralgia with Shugan Pills / 中成药

AIM: To study the action of Shugan Pills (SHGP) (Fructus Toosendan, Rhizoma corydalis, Radix Paloniae Albe, Radix Aucklandiae, Cortex Magnoliae Officinalis, Fructus Aurantii, etc.) on treatment of epigastralgia. METHODS: The analgesic effect was tested by the hot plate test and writhing method. The anti gastric ulcer action of SHGP was observed on the gastric ulcer induced by water immersion stress, reserpine and absolute ethyl alcohol. The effect on gastric secretion in rats was studied with pylorus ligation. The effect on gastrointestinal motility was observed by determination of gastric emptying and small intestinal propulsion ability in mouse. RESULTS: SHGP enhanced hot pain threhshold and decreased the number of twisting body in mouse. SHGP markedly inhibited gastric ulcer induced by water immersion stress, reserpine and absolute ethyl alcohol. SHGP significantly inhibited the secretion of gastric acid and pepsin and promoted the secretion of gastric mucus. SHGP markedly delayed gastric emptying in normal mouse and when gastric emptying and small intestinal propulsion was stimulated by neostigmine. SHGP faintly strengthed the effect of atropine on inhibition of gastrointestinal motility. CONCLUSION: Shugan Pills could have analgesic effect, anti gastric ulcer action, it inhibited the secrection of gastric juice and the activity of gastric smooth muscle. These effects might be the pharmacological mechanisms of SHGP on treatment of epigastralgia.