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Severe Abdominal Pain in a Young Girl After a Hug
الطبيبة العجيبة - الثلاثاء, 2009-06-23 01:55 | الطب الداخلي › الهضمية › أمراض الكبد | المحتوى الطبي
الوصف الكامل Background
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A 16-year-old girl in Macedonia presents to the local emergency department (ED) with a sudden onset of severe abdominal pain following what she describes as a "bear hug from a friend." The pain began a couple of hours before arrival to the ED. She describes the pain as sharp, constant, most intense in the right upper quadrant, and radiating to her right shoulder. The patient also reports having mild, dull abdominal discomfort and a feeling of progressive abdominal fullness for the past few months, but she has not sought medical attention for these symptoms. She also complains of having a diffuse, itchy rash that seems to have appeared around the same time as the onset of the abdominal discomfort. The patient has no history of food allergy and has not eaten any new foods before this episode. She denies having any fevers, nausea, or abnormal bowel movements. She has not had any changes in her skin coloration. She reports occasional use of acetaminophen in the last 2 weeks for the abdominal discomfort, but she is not otherwise taking any regular medications. She has no chronic medical conditions or past surgical history. She reports no significant family history. There are 2 dogs in her house which she cares for, but no other pets are present.
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On physical examination, the patient is in obvious discomfort. Her body temperature is 99.1°F (37.3°C), she has a blood pressure of 110/70 mm Hg, and her pulse is 110 bpm. Her skin is pale and without jaundice, but she does have a diffuse urticarial rash that is most prominent on the trunk and proximal extremities. She appears well-nourished and well-developed. Her chest has symmetrical movements during respiration and clear breath sounds are noted on auscultation. Her heart sounds are normal, with a regular rhythm and no detectable murmurs. A firm mass overlying the liver edge in the right upper quadrant is noted on palpation. The entire upper abdomen is markedly tender and rigid, particularly in the right subcostal region.
The laboratory testing is remarkable for leukocytosis, with a white blood cell (WBC) count of 18.6 × 103/µL (18.6 × 109/L) and 40% neutrophils (0.40), 22% lymphocytes (0.22), 8% monocytes (0.08), and 21% eosinophils (0.21) (normal ranges: WBC, 4.5-11 × 103/µL; neutrophils, 40-70%; lymphocytes, 22-44%; monocytes, 4-11%; eosinophils, 0-8%). An elevated total bilirubin level of 1.98 mg/dL (33.8 μmol/L) was also noted (normal range, 0.3-1.0 mg/dL). Her aspartate aminotransferase (AST; also known as serum glutamic oxaloacetic transaminase [SGOT]) is 101 U/L and her alanine aminotransferase (ALT; also known as serum glutamic pyruvic transaminase [SGPT]) is 104.7 U/L. Her hematocrit and platelet counts are normal. An upright radiograph of the abdomen shows a nonspecific bowel gas pattern and no findings of pneumoperitoneum. An ultrasound is performed for a suspicion of possible gallbladder disease; it reveals a large hypoechogenic zone in the liver, with irregular margins and a small amount of free fluid around the liver. A computed tomography (CT) scan of the abdomen is subsequently performed (see Figures 1 and 2).
كتابة حرة وطرح موضوع النقاش!
What is the diagnosis?
Hint: Consider the rapid onset of an allergic-type reaction
in conjunction with an abdominal mass.
a-Hepatic hydatid cyst rupture
b-Acute cholecystitis
c-Cholangitis
d-Hepatocellular carcinoma
a
So the answer is A
إجاباتكم صحيحة
Which of the following statements is NOT true?
الجواب هو a
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a. Surgery is the treatment of choice for complicated hydatid cysts, such as those communicating with the biliary tree.
b. Albendazole is used only as a prophylactic agent in cases with ruptured hydatid cysts.
c. Ultrasonography is the method of choice for detecting liver cysts.
d. The most valuable test for postsurgical follow-up is immunoelectrophoresis.
e. Echinococcus granulosus causes unilocular cysts.
*********************************************************************************
Which of the following is the most common complication of liver hydatid cysts?
a. Intraperitoneal rupture
b. Anaphylaxis
c. Liver abscess
d. Intrabiliary rupture
e. Ascites
:thank u (الطبيبة العجيبة )
Nice case
Let me give you this twist and you tell me what the diagnosis is:
The same case senario but
1- Age is 35
2- She takes oral contracetive pills
3- There is no rash or eosinophilia
4- Normal liver enzymes and bilirubin
5- Ultrasound shows hyperechoic lesion around 10 cm in the right lobe of the liver
and On CT : the lesion is well defined with early contrast enhancement during the arterial phase and central scar . The contrast washes out quickly leaving a central scar more prominent. Small amount of free blood is seen in the peritoneal cavity thought to be originating from the liver lesion
What is this lesion:
About Amazing Doctor's Question it's:
b. Anaphylaxis
Dr ABIM: it's Hepatic adenoma:
early contrast enhancement during the arterial phase and central scar
Hepatic adenoma: focal nodular lesion
I havn't noticed this sentences sorry, I'll change the answer to Peliosis hepatis
اقتباس:
Small amount of free blood is seen in the peritoneal cavity thought to be originating from the liver lesion
I havn't noticed this sentences sorry, I'll change the answer to Peliosis hepatis
Eventhough I think Focal nodular hyperplasis still that answer as it is more common and the findings of the CT are typical for it.
what you have quoted from the case as there is bleeding it is may be fromt he lesion itself.
I am not pretty sure if Peliosis hepatis has the same findings of on the CT.
I am not pretty sure if Peliosis hepatis has the same findings of on the CT.
You are right Hassa!
it's adenoma I've read about peliosis hepatin in UTD 17.1 that's what I found:
Peliosis hepatis — Peliosis hepatis is rare and characterized by multiple, small, dilated blood-filled cavities in the hepatic parenchyma. It is most commonly associated with hepatic tumors or with cholestatic jaundice, but can be caused by several drugs including anabolic steroids, arsenic, azathioprine, mercaptopurine, oral contraceptives, danazol, diethylstilbestrol, tamoxifen, vitamin A, and hydroxyurea [41,80,81]. Lesions may resolve with discontinuation of the offending agent.
so it's adenoma bleeding !
BUT
Patients taking OCPs tend to have larger, more vascular tumors, have more symptoms, and reports of hemorrhage or rupture in patients with FNH have all occurred in patients taking OCPs
Up to date 17.1[/eng]
Hassan
You continue to surprise me with your fund of knowledge: The CT scan is typical for FNH (focal nodular hyperplasia) though bleeding from there is quite rare: theoretically possible
Adenoma does not have central scarring but it can still be associated with OCP (oral contraceptive pills)
Dr Omar thank you for the complement
Thanx Dr Omar
شكرا دكاترة على المشاركة والتفاعل وشكرا دكتور عمر ABIM كتير على مقارنة المعلومات مع بعضها التي تساعد على التركيز
أما الآن ... فجاء دور أسإلتي
بانتظار إجاباتكم
a. Surgery is the treatment of choice for complicated hydatid cysts, such as those communicating with the biliary tree.
b. Albendazole is used only as a prophylactic agent in cases with ruptured hydatid cysts.
c. Ultrasonography is the method of choice for detecting liver cysts.
d. The most valuable test for postsurgical follow-up is immunoelectrophoresis.
e. Echinococcus granulosus causes unilocular cysts
الجواب الصحيح هو b
a. Intraperitoneal rupture
b. Anaphylaxis
c. Liver abscess
d. Intrabiliary rupture
e. Ascites
الجواب الصحيح هو d
color=red]
The mass communicates with the gallbladder and is associated with a small amount of free fluid around the liver and in the peritoneal cavity.
These imaging findings in the setting of
eosinophilia,
an associated allergic reaction,
and a history of acutely worsening abdominal pain with sudden pressure applied to the abdomen,
are consistent with a ruptured hydatid cyst.
Echinococcosis, otherwise known as hydatid or alveolar cyst disease, is an infection caused by the larval stage of small taeniid-type tapeworms of the Echinococcus species.
Human disease is acquired by ingesting viable parasite eggs, usually in food.
There are 3 forms of human hydatid disease.
Echinococcus granulosus and Echinococcus vogeli produce unilocular cystic lesions,
whereas Echinococcus multilocularis produces multilocular alveolar lesions that are locally invasive.
E vogeli is uncommon and occasionally found in the South American highlands.
E multilocularis is more common than E vogeli, but it is probably not the etiologic organism in this case.
It is different from E granulosus in that
it remains in a proliferative phase,
is always multilocular,
and survives in wild canines as the definitive hosts and small rodents as the intermediate hosts.
It has 3 proglottides, including
immature,
mature,
gravid.
The gravid proglottid splits into eggs that can be found in the feces of the definitive host.
Intermediate hosts, such as humans, sheep, cattle, and goats, get infected by
consuming plants that are contaminated by the feces of affected animals or by
direct contact with an affected animal.
After humans ingest the eggs, they hatch into embryos in the small intestine.
The embryos penetrate the intestinal mucosa, enter the portal circulation, and are carried to the liver. Some are destroyed in the liver while others form into hydatid cysts.
A small percentage of the eggs may pass through the liver and form cysts in other parts of the body, including
the lungs,
central nervous system (CNS),
spleen,
pancreas.
After the developing embryos localize in a specific organ, they transform and develop into larval echinococcal cysts. This process is referred to as primary echinococcosis.
The cyst is composed of 2 layers:
-endocyst
-pericyst
the endocyst, which is filled with clear fluid, and the pericyst, which is a fibrous capsule that develops as a host response to the growth of the echinococcal cyst.
Nutritive substances that contribute to the cyst's growth pass through the pericyst.
The pericyst encompasses the endocyst, which is of larval origin.
It is composed of an outer laminated layer, or hyaline membrane, and an inner multipotential germinal layer.
Daughter cysts develop from the inner aspect of the germinal layer, as do germinating cystic structures called brood capsules.
New larvae, called protoscolices, develop in large numbers within the brood capsule.
The cysts typically expand slowly over a period of years, at a rate of approximately 1-3 cm per year
In some cases, cholangitis or, even more rarely, pancreatitis may ensue.
Infection of the cyst may also occur, and it is usually caused by bacteria residing in the biliary system. This may result in fever, leukocytosis, and possible formation of a liver abscess.
Patients may be septic and should be treated aggressively with broad-spectrum antibiotics if signs of systemic infection are present
Symptoms following the rupture are often dramatic and may include severe abdominal pain, syncope, or fever. Some patients exhibit signs of an allergic reaction, such as pruritus, urticaria, eosinophilia, or even anaphylaxis.
Intraperitoneal rupture usually results in secondary implantation of cysts into the peritoneal cavity. Some rare but possible complications of liver echinococcosis include ascites, portal hypertension, Budd-Chiari syndrome, or compression of the vena cava
.
Rupture of the cyst into the vena cava is a very rare but universally fatal complication.
Pulmonary hydatid cysts, when symptomatic, can cause chest pain, chronic cough, or hemoptysis. They may rupture into the bronchial tree and cause expectoration of a cyst fluid. Rupture of the hydatid cyst into the pleural cavity leads to pleuritic chest pain and dyspnea.
Although rare, localization of hydatid cysts in the CNS can cause neurologic symptoms related to mass effect, including headache and seizures.
Infection of skeletal tissue can cause pathological fractures as a result of invasion of the medullar cavity and slow bone erosion.
Cardiac involvement may result in pericarditis or conduction abnormalities