Pancreatitis, Panniculitis, and Polyarthritis (PPP) Syndrome in the Setting of Severe Acute Pancreatitis.

The coexistence of lobular panniculitis, polyarthritis, and intraosseous fat necrosis in patients with acute pancreatitis is commonly referred to as pancreatitis, panniculitis, and polyarthritis (PPP) syndrome. It is a rare condition associated with serious complications and high mortality. A 70-year-old female was admitted with severe acute necrotizing pancreatitis due to gallstone disease. Laboratory findings indicated an intense systemic inflammatory response syndrome (SIRS). The patient rapidly progressed toward persistent organ failure. During her hospital stay, she also developed panniculitis and polyarthritis, related to severe acute pancreatitis. Eventually, the patient expired despite medical therapy.

Co-Existence of An Unusual Branching Pattern of Celiacomesenteric Trunk With Complete Common Mesentery in a 48-Year-Old Man: A Case Report.

Celiacomesenteric trunk (CMT) refers to the common origin of celiac trunk and superior mesenteric artery which is a very rare anatomical variation. CMT is incidentally diagnosed during angiography or abdominal computed tomography scanning. The diagnosis of CMT may inform surgical practice and prevent damage during invasive radiologic procedures, lowering thus the rate of iatrogenic errors. Complete common mesentery is in its turn a rarer congenital anomaly that arises from an abnormal rotation of primitive small intestine during embryonic development. We report a case of a 48-year-old man, suffering from chronic abdominal pain, and postprandial discomfort. The patient underwent an abdominal contrast-enhanced computed tomography that detected a CMT associated with common complete mesentery. According to our review of bibliography, this is the first case report to simultaneously report both congenital anomalies (CMT and common complete mesentery). Furthermore, the CMT described here has not been described in previous classifications and represent a novel anatomical variation of CMT.

A fortuitous discovery of a neurofibroma in a female patient with type 1 neurofibromatosis: a case report.

Neurofibromatosis type 1 (NF1) is a neurocutaneous condition with an autosomal dominant pattern of inheritance. This congenital disease is characterized by a wide spectrum of clinical manifestations and degree of severity. This case report describes a female patient in her early 20s who presented with a complaint of lumbosciatica-like pain evolving for several months. The condition initially escaped the attention of clinicians until a lumbar computed tomography scan and spinal magnetic resonance imaging were performed. The patient was then transferred to the general surgery department, where a clinical diagnosis of NF1 was established. The clinical manifestations were specific for this disease, including café-au-lait macules, plexiform neurofibroma, and a history of neurofibromatosis in her mother. The patient underwent surgical resection of the neurofibroma, which resulted in a favorable outcome. However, 2 years later, a new mass attached to the second lumbar spinal nerve was revealed by a follow-up computed tomography scan. Long-term and close follow-up of NF1 is required because of the high risk of malignancy and recurrence in NF1 patients.

Prevalence and associated factors of lower digestive symptoms in type 2 diabetics in Tunisia.

AIMS: To estimate the prevalence of lower digestive symptoms according to the Rome III criteria among diabetic patients of type 2, and second to identify the factors associated with the digestive symptoms among these subjects. METHODS: A cross-sectional study was carried out among recruited diabetes mellitus type 2 patients from basic health centers at Sousse and Monastir (Tunisia). Diagnosis of digestive symptoms was based on Rome III criteria. We studied the influence of socio-demographic characteristics, life style, diabetes mellitus characteristics, somatization, psychological state (HAD scale) and quality of life (SF-12 scale) on the prevalence of digestive symptoms. RESULTS: Four hundred and seventeen patients were enrolled in our study. The average age was 61.3±10.4 years with a female predominance (68.8%). The overall prevalence of digestive symptoms was 44.8%. The main digestive symptoms found were abdominal bloating (23%), diarrhea (11.7%), constipation (8.6%), irritable bowel syndrome (8.6%) and fecal incontinence (8.1%). Logistic regression showed that digestive intolerance (OR=2.28; 95%CI[2-5.31]), request care for a digestive problem (OR=2.95; 95%CI [1.49-5.83]), anti-acid treatment (OR=4.22; 95%CI [1.13-15.69]), diabetic retinopathy (OR=2.66; 95%CI [1.52-4.7]), somatization (OR=1.75; 95%CI [1.06-2.88]), and a deteriorated mental health state (OR=2.8; [1.66- 4.72]) were the independent factors associated with digestive symptoms. CONCLUSION: Digestive symptoms cause an important request for care and have a negative impact on quality of life of diabetics. Thus digestive symptoms should be systematically diagnosed in patients with type 2 diabete.

A Giant Choledochal Cyst Mimicking Pancreatic Pseudocyst: A Case Report.

A choledochal cyst (CC) is a rare congenital anomaly manifested as cystic dilatation of the biliary tree. A giant choledochal cyst is defined as a cyst with a maximum diameter of ≥ 10 cm. It is an unusual entity and rarely revealed in adulthood. We describe the case of a giant, infected CC presenting as acute pancreatitis with results of abdominal ultrasound and computed tomography consistent with a pancreatic pseudocyst. The diagnosis of CC was made on magnetic resonance cholangiopancreatography (MRCP) findings. We proceeded with cholecystectomy and the complete resection of the diverticulum after its dissection. The defect in the common bile duct was closed transversally over a T-tube. At the last follow-up two years after his admission, the patient is symptom-free with normal liver enzymes To the best of our knowledge, this is the first case reported of giant CC complicated with both infection and pancreatitis.

Gastric Trichobezoar Causing Gastrointestinal Bleeding: A Case Report.

Trichobezoar is an underdiagnosed entity that has to be considered in children and adolescents, especially females, suffering from trichotillomania and trichophagia. Late diagnosis of trichobezoars showed that they cause gastrointestinal bleeding or perforation. A 17-year-old girl patient was admitted with abdominal pain and gastrointestinal bleeding. On abdominal examination, a well-defined mass in the epigastrium and the left upper quadrant was identified. Upper gastrointestinal (GI) endoscopy identified an enormous trichobezoar, which was later removed by surgery. Misdiagnosed gastric bezoars may cause life-threatening complications. Early detection for trichobezoar requires effective screening of trichotillomania. Psychiatric counseling is important to prevent bezoar recurrence.

Radical versus conservative surgical treatment of liver hydatid cysts: A paired comparison analysis.

BACKGROUND: The management of liver hydatid cysts (LHC) is complex and includes surgery, percutaneous drainage, chemotherapy and observation. Broadly, there are two types of surgical treatment for LHC - conservative surgery (CS) and radical surgery (RS). The purpose of this study was to compare the outcome of RS and CS. METHODS: Data from all patients with LHC treated in Sahloul Hospital, between January 2000 and December 2019, were retrieved. To minimize selection bias, paired comparison analysis (PCA) was performed. RESULTS: A total of 914 patients were included in this study. RS and CS were performed in 284 and 630 patients, respectively. After PCA, 206 patients were included in each group. The incidence of intraoperative bleeding was significantly higher in the RS group. The overall morbidity was significantly lower in the RS group. Thity-four patients developed recurrence with significantly higher recurrence in CS group. CONCLUSION: RS is associated with fewer postoperative complications and lower recurrence rate compared to CS. RS may be the preferred procedure for LHC if the expertise is available.

[Left paraduodenal hernia: a rare cause of acute intestinal obstruction]. / Hernie para duodénale gauche: une cause rare d'occlusion intestinale aiguë.

Left paraduodenal hernia is a congenital internal hernia rarely complicated by acute intestinal occlusion and resulting, sometimes, in life-threatening loops ischemia. We report the case of a 28-year old man treated for occlusive syndrome. Abdominal computerized tomography (CT) scan objectified acute upper intestinal obstruction; intraoperative exploration found jejunal loops incarcerated into left paraduodenal hernia. The neck was closed and the operative suites were simple. Left paraduodenal hernia is often diagnosed when patients have complications. Surgery is the treatment of choice, in particular laparoscopy.

Surgical clip migration following laparoscopic cholecystectomy: A rare cause of acute cholangitis.

Clip migration following laparoscopic cholecystectomy (LC) is a rare and late complication of LC. The first case of surgical clip migration after LC was reported in 1992, and since then less than 100 cases have been reported in the literature. We report the case of cholangitis secondary to a surgical clip migration in an 83 years old male patient, 8 years after LC. Contrast-enhanced computed tomography of the abdomen (CT) showed intra and extrahepatic ducts dilatation secondary to a hyperdense object located in the distal common bile duct (CBD). It was removed successfully from the CBD by endoscopic retrograde cholangiopancreatography after sphincterotomy. At the last follow-up of one year after her admission, the patient is symptom-free with normal liver enzyme and abdominal CT. Surgical clip migration into CBD, should be included in the differential diagnosis while treating patients with the past surgical history of LC. Early diagnosis and treatment of this complication can avoid serious complications.

Ectopic pancreas: A rare cause of occult gastrointestinal bleeding.

Ectopic pancreas (EP) is a rare entity characterized by the development of pancreatic tissue in areas other than the pancreas. We present the case of a 16-year-old female with a heterotopic pancreas in the jejunum revealed by occult gastrointestinal bleeding. Contrast-enhanced computed tomography (CT) of the abdomen revealed a 2 × 3 cm enhancing nodular jejunal mass suspicious of a neuroendocrine or gastrointestinal stromal tumor. Octreoscan was planned but the patient presented in the emergency department with fever and sudden onset severe abdominal pain. The patient underwent emergency laparotomy. On abdominal exploration, appendicular perforation was present for which appendectomy and peritoneal lavage were performed. The small jejunal lesion seen on CT was identified during surgery and segmental jejunal resection with end-to-end anastomosis was performed. The histopathological examination of the jejunal mass revealed the presence of pancreatic acini and ductal structures without islets of Langerhans in the submucosa of the small intestine covered by normal mucosa. At the last follow-up of eight months after surgery, the patient is symptom-free and the abdominal CT is normal. Preoperative diagnosis of EP requires high clinical suspicion and should be included in the differential diagnosis while treating patients with gastrointestinal bleeding or gastrointestinal mass on CT.

Osteoclastic giant cell tumor of the pancreas with synchronous jejunal gastrointestinal stromal tumor: A case report.

Osteoclastic giant cell tumor of the pancreas is a rare aggressive tumor, counting for 2-7% of all pancreatic cancers. Surgery is considered the most appropriate treatment. We report a case of a 84-year-old man with incidentally detected 11cm tumor in the pancreatic tail and another 6 cm tumor located in the jejunum on abdominal computed tomography. The patient underwent distal pancreatectomy with splenectomy along with segmental resection of the tumor bearing part of the jejunum. On histological examination, osteoclast-like giant cells with some areas of metaplastic bone were observed which confirmed the diagnosis of osteoclastic tumor of the pancreas. The jejunal tumor was strongly c-kit positive on immunohistochemistry which confirmed the diagnosis of GIST. On the last follow up at 2 years after surgery, there is no evidence of recurrence or distant metastasis. Pancreatic OGCT has a better prognosis after resection than pancreatic adenocarcinoma. Its co-existence jejunal GIST, as seen in the index case, has not been reported in the English literature till date.

Isolated hepatic tuberculosis presenting as hydatid cyst.

Primary hepatic tuberculosis is a rare manifestation of extra-pulmonary tuberculosis even in highly endemic countries. The incidence of hepatic tuberculosis has increased in the recent years due to high prevalence of HIV/AIDS. Radiological imaging is an important tool for making the diagnosis, but often the imaging findings are non-specific and may mimic other benign or malignant hepatic diseases. We report a case of 54-year-old woman who was detected to have hepatic mass on radiological imaging which was misdiagnosed as hydatid cyst. Intraoperatively, the characteristic features of hydatid cyst were absent. A partial resection of this cystic mass was performed. Histopathological examination of the resected specimen revealed granulomatous inflammation consisting of histiocytes and Langhans-type giant cells surrounded by lymphocytes suggestive of hepatic tuberculosis. The patient was administered antitubercular therapy for 1 year. Repeat imaging on follow up showed disappearance of the hepatic lesion.