Hepar lobatum carcinomatosum revealing an occult metastatic lobular carcinoma of the breast.

Hepar lobatum carcinomatosum is an unusual cause of chronic liver failure, usually maskerading as cirrhosis. The pathogenesis of this syndrome is unclear. We report a case of liver failure revealing an occult lobular carcinoma of the breast, which offers the opportunity to gain further insight into the mechanisms of this rare cause of chronic liver disease. A 57-year-old woman, without history of malignancy, presented with hepatomegaly, ascites and altered liver tests (serum transaminase activity >5 N and hyperbilirubinemia). The transjugular liver biopsy performed at diagnosis showed an extensive fibrosis, containing scattered tumor cells, typical of metastatic lobular carcinoma of the breast. Four months later, after discovery of a rectal adenocarcinoma, a laparoscopy was performed; peritoneal carcinomatosis was discovered. A surgical biopsy of the liver was taken during the procedure: it showed histological features suggestive of chronic Budd-Chiari syndrome, with venocentric fibrosis and reversed lobulation. Intraluminal invasion of small hepatic veins and sinusoidal obstruction by neoplastic cells were observed. A small focus of lobular carcinoma was eventually discovered in the left mammary gland. The present case report expands the spectrum of clinical presentations associated with hepar lobatum carcinomatosum and points out to the importance of vascular injury in the pathogenesis of this rare cause of chronic liver disease.

Treatment of arteriovenous malformation of the pancreas: a case report.

Pancreatic arteriovenous malformation (AVM) is a rare disease, generally asymptomatic, but sometimes complicated by gastrointestinal bleeding or pancreatitis. We report a case of a 55-year-old man presenting with a large pancreatic AVM. The diagnosis was obtained on a computed tomography scan. A treatment by transarterial embolization was carried out successfully. Selective arterial embolization of pancreatic AVM can represent an effective treatment in the first intention.

Feasibility of and interest in combined endoscopic ultrasonography and biliary drainage in unexplained acute biliopancreatic disorders.

Combined endoscopic ultrasonography and duodenal bile drainage for microscopic bile examination was prospectively evaluated in patients with unexplained acute biliopancreatic disorders defined as follows: isolated biliary-type pain (group 1), biliary-type pain and elevated transaminases (group 2), or acute pancreatitis (group 3). All patients had prior negative transabdominal ultrasonography. Endoscopic ultrasonography and bile drainage were combined under anesthesia during the same procedure. Combined endoscopic ultrasonography and bile drainage was feasible without any complication in the 48 patients studied. Biliary lithiasis was diagnosed in 20 patients (42%), 5 in group 1 (38%), 7 in group 2 (39%), and 8 in group 3 (47%). Endoscopic ultrasonography and microscopic bile examination were positive respectively in 17 (36%) and in 13 (27%) patients. In conclusion, combined endoscopic ultrasonography and bile drainage for microscopic bile examination is a simple procedure. Biliary lithiasis is diagnosed in a high proportion of patients with unexplained acute biliopancreatic disorders.

Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial.

BACKGROUND & AIMS: Emergency endoscopy may be difficult in upper gastrointestinal bleeding when blood obscures the visibility. Erythromycin, a motilin agonist, induces gastric emptying. We investigated whether an intravenous bolus infusion of erythromycin would improve the yield of endoscopy in these patients. METHODS: Patients admitted within 12 hours after hematemesis were randomly assigned to erythromycin (250 mg) or placebo, 20 minutes before endoscopy. The primary end point was endoscopic yield, as assessed by objective and subjective scoring systems and endoscopic duration. Secondary end points were the need for a second look, endoscopy-related complications, blood units transfused, and length of hospital stay. RESULTS: Fifty-one patients received erythromycin and 54 received placebo. A clear stomach was found more often in the erythromycin group (82% vs. 33%; P < 0.001). This difference remained significant in patients with cirrhosis. Erythromycin shortened the endoscopic duration (13.7 vs. 16.4 minutes in the placebo group; P = 0.036) and reduced the need for second-look endoscopy (6 vs. 17 cases; P = 0.018). Length of hospital stay and blood units transfused did not significantly differ between the 2 groups. No complications were noted. CONCLUSIONS: Erythromycin infusion before endoscopy in patients with recent hematemesis makes endoscopy shorter and easier, thereby reducing the need for a repeat procedure.