An adult choledochal cyst--the magnetic resonance cholangiopancreatography findings: report of a case.

We herein report an unusual adult patient with a congenital choledochal cyst. A 28-year-old woman presented with recurrent episodes of abdominal pain in the right upper quadrant. Abdominal ultrasonography showed fusiform dilatation of the common bile duct without any obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP) were performed to make a precise diagnosis. No abnormal pancreatobiliary junction was detected on ERCP. The MRCP images more clearly defined the type and extent of the choledochal cyst as observed at surgery. The cyst and gallbladder were excised and a Roux-en-Y hepaticojejunostomy was performed. We also reviewed the relevant English literature and concluded that MRCP offers diagnostic information that is equivalent or superior to that of ERCP for the evaluation of type I choledochal cysts in adults and because this modality is noninvasive, it should therefore be the preferred imaging technique for an examination of adult patients with choledochal cysts.

Serum insulin like growth factor-1 (IGF-1) and insulin like growth factor binding protein-3 (IGFBP-3) levels in liver cirrhosis.

BACKGROUND/AIMS: Impaired growth hormone-insulin like growth factor system in hepatic cirrhosis leads to cirrhosis-related complications. In this study, we aimed to investigate whether serum levels of insulin like growth factor-1 and insulin like growth factor binding protein-3 are related to the level of hepatic dysfunction, clinical grade, and etiologic factors of the disease in patients with liver cirrhosis. METHODS: Forty-two patients with liver cirrhosis who were diagnosed by means of clinical findings, endoscopy, imaging studies, or histopathology were enrolled in the study. An age- and sex-matched control group was comprised of 37 healthy controls with no signs of liver disease by clinical or laboratory findings. The demographic features (age, sex, height, and weight) and serum levels of liver function tests, urea, creatinine, sodium, potassium, insulin like growth factor-1, and insulin like growth factor binding protein- 3 and hemogram values were recorded for each individual. The patients were grouped according to Child Pugh classification and etiology. RESULTS: Insulin like growth factor-1 and insulin like growth factor binding protein-3 levels were significantly lower in the cirrhotic group in comparison to the control group (p<0.005). A statistically significant decrease in levels of insulin like growth factor-1 and insulin like growth factor binding protein-3 was correlated with the degree of liver dysfunction, namely, lowest decrease in Child Pugh class A and highest decrease in class C. With respect to etiology, insulin like growth factor- 1 levels of alcohol-related liver cirrhosis were significantly lower than those of hepatitis B- related cirrhosis. There was no relation between insulin like growth factor binding protein-3 level and etiology. In the cirrhotic group, insulin like growth factor- 1 level was positively correlated with serum albumin and negatively correlated with serum creatinine and sodium levels and spleen size. Likewise, insulin like growth factor binding protein-3 level was positively correlated with serum albumin. There was a negative correlation between insulin like growth factor binding protein-3 level and serum bilirubin and spleen size. CONCLUSIONS: Insulin like growth factor-1 and insulin like growth factor binding protein-3 levels are related to the level of clinical impairment and were independent of the etiology. They may serve as novel markers of hepatocellular dysfunction.

Carcinoma arising from villous adenoma of the ampullary bile duct: Report of a case.

Adenocarcinoma arising from the villous adenoma of the ampullary biliary epithelium is an extremely rare disorder. The preoperative diagnosis and treatment of the disease represent a major difficulty. A 67-year-old woman was admitted to the hospital with a chief complaint of jaundice. Preoperative investigations revealed obstructive type jaundice due to a 2-cm mass at the end of common bile duct. She was operated on and after undergoing a sphincterotomy, small, yellowish, grape-like particles fell down from the ampullar orifice. A frozen-section examination of these particles revealed villous adenoma. Next, a transduodenal resection of ampulla and reconstruction were performed. The frozen-section examination of the resected material also revealed a villous adenoma. The patient was discharged uneventfully. The histological examination revealed a villous adenoma arising from the biliary epithelium and some adenocarcinoma foci. The surgical margins were tumor free. Nevertheless, she developed hepatic metastases 15 months after surgery. This case shows the importance of surgeons to keep in mind the fact that frozen examinations may sometimes miss a malignancy and they therefore cannot be relied upon to rule out malignancy in villous adenoma of the ampullary bile duct.

A succesfully managed inflammatory pseudotumour of liver without surgery: report of a case.

The inflammatory pseudotumor (IPT) of the liver is an extremely rare focal lesion of the parenchyma with unknown aetiology. It has the appearance of a malignant tumor but has a benign histology and clinical course. Herein, we report a case of IPT in a 55 year-old woman. She had complained of right upper quadrant pain and subfebrile fever. Imaging studies revealed a heterogeneous, solitary mass in right lobe of liver which was 90 x 81 mm in size. Histopathological examination of ultrasonography-guided true-cut biopsy demonstrated IPT. After the initiation of the antibiotic and nonsteroidal anti-inflammatory drugs (NSAID), the size of hepatic pseudotumor decreased (20 x 20 mm) and then completely disappeared. To rule out a malignancy and to reach the diagnosis of IPT, biopsy from the mass is mandatory. After the diagnosis, IPT gave an excellent response to short course of antibiotic and NSAID therapy. To prevent unnecessary resective liver surgery, IPT should be kept in mind in the differential diagnosis of liver mass which can be successfully managed medically.

Morgagni hernia in an adult: atypical presentation and diagnostic difficulties.

Foramen of Morgagni hernias are rare diaphragmatic hernias, usually occurring on the right and located in the anterior mediastinum. Adult patients diagnosed with a foramen of Morgagni hernia are usually asymptomatic and associated with obesity, trauma or other causes of increased intraabdominal pressure. Plain pulmonary roentgenogram, radiological studies of the gastrointestinal system with contrast material, computerized tomography and magnetic resonance imaging studies are helpful in diagnosis. In this article, a 78-year-old female case with a Morgagni hernia incidentally diagnosed on chest X-ray is presented.

Safety of biopsy in liver hemangiomas.

Hemangiomas are the most common tumors of the liver. Almost all cases are easily detected by ultrasonography, computed tomography, magnetic resonance imaging, and erythrocyte-tagged technetium-99m scintigraphy. In case of inconclusive radiologic features and a history of malignancy or underlying liver disease, liver biopsy is indicated. Bleeding is the most feared complication of biopsy of hemangiomas due to its highly vascular structure. In our clinic, we biopsied seven patients with suspected masses and they were diagnosed histopathologically afterwards as having hemangiomas. We did not observe any complication including bleeding during or after the procedure. Although the case number is too small to reach a definite conclusion, we think that our report deserves attention in showing that concerns about bleeding during biopsy of hemangiomas may be overstated.

Comparison of cefotaxime and ofloxacin in treatment of spontaneous bacterial peritonitis.

BACKGROUND/AIMS: Gold-standard treatment of spontaneous bacterial peritonitis currently involves 3rd generation cephalosporins. To evaluate the efficacy of ofloxacin in this infection, we compared a combined therapy with intravenous and oral ofloxacin to intravenous cefotaxime. METHODS: Thirty cirrhotic patients with spontaneous bacterial peritonitis were assigned to receive either intravenous (1 g/12 h) cefotaxime for 7 days (n=17) or intravenous (200 mg/12 h) ofloxacin for 2 days followed by oral (200 mg/12 h) ofloxacin for 5 days (n=13). All cases had community-acquired spontaneous bacterial peritonitis. RESULTS: The infection resolution rate on the 7th day of therapy was 82.4% in the cefotaxime group and 92.3% in the ofloxacin group. Hospital survival rates were 82.4% and 100%, respectively. CONCLUSIONS: Oral ofloxacin after a short course of intravenous ofloxacin is effective in the treatment of uncomplicated spontaneous bacterial peritonitis. This regimen may allow physicians to treat these patients as outpatients as soon as their intravenous therapy is completed.