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Waht is this procedure?


Waht is this procedure?


حالة سريرية

الوصف الكامل Background

Can you tell what is being done in this procedure and what is patient diagnosis?

ABIM's picture
by


shot... where are the pictures?
I will try again

ABIM's picture
ABIM


more pics

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ABIM


can someone show me how to show the pictures

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ABIM


drhanadi's picture
drhanadi
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drhanadi
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دكتور بس بتعمل copy لرابط الصورة وبعدين بتلصقه بالتعليق + image icon

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drhanadi
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One hint: The patient initial presentation is acute abdominal patient , sever in the epigastric region radiating to the back. The pain improved later but another dull discomfort developed in the epigastric region not allowing him to eat.
Any idea?

ABIM's picture
ABIM


بالنسبة للايكو ما شفت شي Laughing out loud
ما خطر ببالي هو التالي التهاب بنكرياس تالي لانسداد قناة جامعة بحصاة و وبظن ما يجرى هو خزع مصرة أودي بERCP .
كنت ما بدي شارك بس قلت لحالي جرب Embarrased

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drhanadi
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Quote:
وبظن ما يجرى هو خزع مصرة أودي بERCP .

Rolling Eyes

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Green Wave

Quote:
ما خطر ببالي هو التالي التهاب بنكرياس تالي لانسداد قناة جامعة بحصاة و وبظن ما يجرى هو خزع مصرة أودي بERCP .
كنت ما بدي شارك بس قلت لحالي جرب

You are close . The first half is true. The patient had pancreatitis. but can you look at the second image (where there is a strapped blue wire) look at the mucosa there and tell me where is the scope ?

ABIM's picture
ABIM


[img] On the ultrasound: look at the black space and the fine white line (pointed at with black arrows)

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ABIM


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ABIM


Picture6.jpg 9.17 كيلوبايت
[img]

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ABIM


Ok .. here another hint
For the US : you see one large "black space" . Usually black (anechoic) material is liquid.
The picture is taken from the stomach as well as the intervention . Any idea?

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ABIM


مخاطية معدة Surprised معناها أنا شاطرة Eye-wink
بصراحة ما عرفت شو هي العملية التي تتم عن طريق المعدة فدورت بالنت و طلعت بالاختراع التالي :
مريضنا تشكل عنده pseudocyst والعملية هي drainage the pseudocyst through the stomach by creating a small opening between the cyst and the stomach during endoscopy
هالمرة صح ؟

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drhanadi
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و ماذا شكلها هي السودوسيست؟

Buzz_LightYear


التهاب البنكرياس لاحقا قد يسبب تنخر بالبنكرياس بالاضافة لتجمع السوائل فبيعطينا كيسة كاذبة يمكن هي الظاهرة بالايكو باعتبار في ظل أسود = سائل Rolling Eyes
وبظن أفضل وسيلة لرؤيتها هي الCT وهي صورة Eye-wink

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drhanadi
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وهي صورة ترسيمية لكيفية تشكلها Eye-wink

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drhanadi
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Quote:
هالمرة صح ؟

صح

You got it. This an example where endoscpic treatment has progressed . Typically such patients used to be treated with external drain (placed by radiologist) or by surgery. Nowadays and espcially with the help of endoscopic ultrasound we can see the pseudocyst and puncture it with a needle then pass a wire and dilate the tract (by creating a whole from the stomach into the wall of the cyst to finally leave 2 drains (last picture) that will drain patients pseudocyst into the stomach .
Patient does not feel anything .
Here is a view of the same patients CT scan

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ABIM


the pseudocyst is the low density structure in the middle of the CT image infront of the spine and behind the stomach (which is partially filled with dye: very white and partially has air(very black)

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ABIM

nice Surprised
thanx doctor ,I have enjoyed it Very Happy
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drhanadi
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Ok
let me make the question a little harder.
This patient has recurrent pancreatitis for 4 years. However he had some treatment... that made him feel better for almost 2 years with no more attacks (there are some clue about that treatment on the CT scan)
But lately the pancreatitis recurred and was preceded with right upper quadrent pain and liver enzymes ALT 87 AST 55. Later in his course the pain resolved except the dullness and fullness described above and the latest liver enzymes
ALT 25 AST 44.
The patient does not know how alcoholo taste or smell and does not take medications except for bisoprolol for hypertention.
The question
1- What do you thing is the cause for his recurrent pancreatitis and why
2- What was the treatment that he had 2 years ago which helped him for a while
3- What is the recommeded treatment now

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ABIM


emmmm
شكلي عم صعبها كتير... ما

you can tell me frankly so I can avoid such difficult topics in the future

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ABIM

Quote:
emmmm
شكلي عم صعبها كتير... ما

you can tell me frankly so I can avoid such difficult topics in the future

No doc,it's just the timing.......u know...exams are on the way.....

[eng]But lately the pancreatitis recurred and was preceded with right upper quadrent pain and liver enzymes ALT 87 AST 55. Later in his course the pain resolved except the dullness and fullness described above and the latest liver enzymes
ALT 25 AST 44

how did that resolved,I mean it was just the usual supportive Tx of pancreatitis...

O.K I have a theory.....

recurrent acute pancreatitis in the past years was because of gallstones....(whenever I hear reacurrent acute pancreatitis I instantly think of gallstones-is that wrong doc?? I do this cuz it is on of the two most common causes of acute pancreatitis,and on the other hand it doesn't cause chronic pancreatitis......)

so,recurrent ap treated supportively and then they found gallstones on echo ,so they decided to do sphincterectomy(whcih I really don't know if can be shown on the CT)

now for the new pain,,,
I'd like to ask a few more things:

Quote:
But lately the pancreatitis recurred and was preceded with right upper quadrent pain and liver enzymes ALT 87 AST 55. Later in his course the pain resolved except the dullness and fullness described above and the latest liver enzymes
ALT 25 AST 44.

the ruq pain that preceded the pancreatitis,how long did it last???
fever???
what about bilirubin???
alp???
[/eng]

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mbs2380
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Salam....
well, it's really difficult.. beside i have zero experience in CTs... but i will take a chance...
although what mbs said seems so logical... i can't find stones in the gallbladder.. beside there is some thing like necrosis in the 3rd a 4th parts of the liver... so this is my theory:
i think there is something wrong in the kidney... it's large wit absence of calyculi... if i suppose that the are cysts in it, the i have the following:
Cysts in kidney + HTN + pancreatic cysts with recurrent pancreatitis + transient elevation in liver enzymes with CT image make me think of ruptured cysts (i'm not sure about this also Embarrased Embarrased Embarrased ) >>>>> i'm thinking of polycystic kidney disease...
i know it's so imaginary... but i can't help Laughing out loud Laughing out loud Laughing out loud
i would like to see UA and lower slides of the CT.....
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Fouad
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Quote:
Salam....
well, it's really difficult.. beside i have zero experience in CTs... but i will take a chance...
although what mbs said seems so logical... i can't find stones in the gallbladder.. beside there is some thing like necrosis in the 3rd a 4th parts of the liver... so this is my theory:
i think there is something wrong in the kidney... it's large wit absence of calyculi... if i suppose that the are cysts in it, the i have the following:
Cysts in kidney + HTN + pancreatic cysts with recurrent pancreatitis + transient elevation in liver enzymes with CT image make me think of ruptured cysts (i'm not sure about this also Embarrased Embarrased Embarrased ) >>>>> i'm thinking of polycystic kidney disease...
i know it's so imaginary... but i can't help Laughing out loud Laughing out loud Laughing out loud
i would like to see UA and lower slides of the CT.....

I am impressed fouad Cool ...... Eye-wink

this is an interesting theory.....
I want u to be right,and want myself to be wrong...cuz I said it is seounds more logical and interesting than mine.......
My cosolation would be that I haven't taken nephrology yet,and don't know how to read the CT.....Sad

Are those white shadows in the Kidney cysts????

and for the necrosis in the liver....I can see nothing ....

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mbs2380
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Fouad
WOW
I really appreciate your efforts and imagination. I want to pay your attention to
1- The white small objects in the gallballder bed along the edge of the liver.
2- The CT cut is above the left kidney (not shown here) and shows only small portion of the right kidney that is secreting the IV dye and you can see the renal cortex well enhanced
3- I am not sure why you can necrosis of the liver ? can you describe what you see in more details
mbs2380
very good analysis but you said

Quote:
they found gallstones on echo ,so they decided to do sphincterectomy

Can you tell us how do you think sphincterotomy is going to help or treat the gallbladder stones?

here some more cuts

ABIM's picture
ABIM

I know that the most common 2 causes for AP r : alcohol & gall stones
but the pt had 4 years Hx of AP WHY DID they wait all that time ?
they could do cholecystectomy right ?
sphirectomy will help the stones in the common bile duct to pass out without making obstruction
I remember that in the management of AP due to gallstones(later after the pt is stabilize)they do cholecystectomy along with sphirectomy and T tube placement (AM I RIGHT?)
i'm thinking of another etiology like parasites or maybe idiopathicRolling Eyes
can u doc give us other info?
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drhanadi
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Quote:
I remember that in the management of AP due to gallstones(later after the pt is stabilize)they do cholecystectomy along with sphirectomy and T tube placement (AM I RIGHT?)

The T tube information is rather old and obsolete. It is rarely (if ever done) after the spread of ERCP.

Quote:
they could do cholecystectomy right

One more time you got it right drhanadi: the patient had cholecystectomy 2 years ago (and those white small objects seen at the site of the gallbladder bed are surgical clips used to clip the cystic duct before removing the gallbladder laparoscopically (try to see them in the first CT scan image)
So Fouad you did not seen gallbladder stones because simply there is no gallballder
Eye-wink
So patient had recurrent "biliary pancreatitis" and he experienced good relief after laparoscopic cholecystectomy. Fisrt question answered
Now why did he have another episode of pancreatitis (with the pattern of liver enzymes mentioned above)
You can search "recurrent pancreatitis " and tell me what is the most common cause for it?

ABIM's picture
ABIM

Quote:
they could do cholecystectomy right ?

I thought that we can do the patient just sphincterectomy without cholecystitis.........
before u -doctor-wrote the answer my recommendation was that we do him cholecystectomy now.......

so :
recurrent pancreatitis......ercp and sphincterectomy
then an interval without any sumptoms(which is good)

but then a new onset......so now we can do him cholecystectomy.....

cuz for me the management of AP means :
stabilize the pt then search for the reason and fix it.......
so after stabilizing him they probably found that the culprit is the gallbladder (so here the point that I ask myself about: ERCP with cholecystectomy V.S just ERCP with sphincterectomy) before reading ur posts I thought that sphincterectomy is sufficient but then I read ur comments and
I first got upset cuz I thought that I started to forget the gastro (which I love the most among the things I 've learnt till now) ......
so I searched for an evidence and what I found is that :
Prophylactic cholecystectomy should be offered to patients whose gallbladders remain in-situ after endoscopic sphincterotomy and common bile duct clearance

based on this SR:
http://www.cochrane.org/reviews/en/ab006233.html

so I am wrong but happy to know that it was a controversial issue one day.....and looking at the bright side ,I will never forget this inshallah... Very Happy

sorrry for talking too much....

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