Pancreatic Cyst
Pancreatic Cyst: Diagnostic Approach
A 63-year old woman was admitted because of a non symptomatic pancreatic cyst of 7.0 x 8.0 cm diagnosed by an abdominal ultrasound. She had a past history of breast cancer treated by surgery, radiotherapy and chemotherapy one year before. Physical examination was normal. Blood tests including tumor markers as carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (Ca 19-9) and the carbohydrate antigen 15-3 (Ca 15-3) were normal.
After a CT-scan, an Endoscopy Ultrasound with a fine needle aspiration (FNA-EUS) was indicated as a diagnostic approach. EUS-FNA was performed under anesthesia, with antibiotic prophylaxis, using an ultrasound needle EZ-Shot (NA-200H-8022B, Olympus)
The liquid analysis showed tumor markers elevated as follows:
CEA 359,8 ng/ml (N= 0 - 4,60),
Ca19-9 474,9 U/ml (N= 0 - 37),
Ca72-4 580,1 U/ml (N= 0 - 7).
Amylase 176 U/l (N= <120),
Lipase 150 (N= <120),
LDH 333 (N= <200)
The final diagnostic of Mucinous Cyst Adenoma was done.
Discussion:
Pancreatic cysts are found in 25% of patients that are evaluated during radiologic examinations. Diferential diagnosis includes basically pseudocysts, serous adenomas, mucinous adenomas and cystoadenocarcinomas. Although very rare, in our patient the possibility of a pancreatic pseudocyst secondary to asymptomatic pancreatitis post chemotherapy existed.
At endoscopy ultrasound (EUS) the pancreatic cystic lesions have certain morphologic characteristics that help to clarify their origin (mucinous or not). Mucinous lesions are bigger in size and usually present a septum or wall inside of the cyst. However, sometimes these characteristics are not enough and EUS-FNA with cystic liquid analyses becomes necessary.
Liquid analysis with a Ca 72-4 level >40 U/ml has a 63% sensitivity and 98% specificity for distinguishing mucinous cystadenomas and cystadenocarcinomas from serous cystadenomas and pseudocysts. A CEA level >400 ng/ml has a 57% sensitivity and a 100% specificity for distinguishing mucinous tumours and cystadenocarcinomas from pseudocysts. A CEA level <4 ng/ml had a 100% sensitivity and a 93% specificity for distinguishing serous cystadenomas from mucinous cystadenomas, cystadenocarcinomas and pseudocysts.
Finally, FNA-EUS with a combined measurement of CA 72-4 and CEA may be used to distinguish accurately mucinous cystadenomas and cystadenocarcinomas from serous cystadenomas and pseudocysts.
References:
1. Hammel P, et al. Diagnostic value of CA 72-4 and carcinoembryonic antigen determination in the fluid of pancreatic cystic lesions. Eur J Gastroenterol Hepatol. 1998 Apr; 10 (4):345-8.
2. Hammel P, et al. Preoperative cyst fluid analysis is useful for the differential diagnosis of cystic lesions of the pancreas. Gastroenterology. 1995 Apr; 108 (4):1230-5.
Persistent Jaundice Post-Cholecystectomy
The microscopy shows inflammatory cell infiltrate with prominent plasma cells and evidence of interface hepatitis (piecemeal necrosis), bridging necrosis, but without fibrosis. Presence of lobular collapse was identified.
Persistent Jaundice Post-Cholecystectomy
A 29-years old woman was admitted to our institution because of persistent jaundice after Cholecystectomy. She was submitted to surgery fifteen days before in another institution due to multiple gallbladder gallstones seen by an ultrasound examination, associated to high serum bilirubin levels.
She had a previous history of a cesarean section 8 years ago, and a mother with hypothyroidism. There was no previous history of blood products transfusions, alcohol consumption or smoking.
Three months before the initial symptoms, she began taking statins because of hypercholesterolemia. The initial laboratory data previously to surgery showed: INR 1.0 (N= 1.0-1.4);TP100% (N= 80-100); Total Bilirubin 15,2 mg/dl (N= 0-1.0); Direct Bilirubin 14,9 mg/dl (N= 0-0.5); Aspartate Aminotransferase (AST) 1060 U/L (N= 15-37); Alanin Aminotransferase (ALT) 890 U/L (N= 15-37); Alkaline Fosfatase 210 U/L (N= 50-136); Hemoglobin 8,43 g/dl (N= 12.0-16), Leukocytes 8532 / mm3 (N= 4000-11000); Albumin 3.5 g/dl (N= 3.5-5.0)
To us her history and laboratory data clearly showed a hepatocellular disease. We performed additional laboratory tests including: Iron test, ferritin levels, ceruloplasmin, serum viral markers (A, B, C), alpha-1 antitrypsin, immunoglobulin G levels and autoimmunity antibodies. The last ones (antinuclear and anti-smooth muscle antibodies) were positive.
A liver biopsy was performed, that confirmed the absence of fibrosis, and the presence of an Autoimmune Hepatitis.
The initial treatment consisted in Prednisone 1mg/kg/d, calcium supplements and vitamin D. After the initial 20 days, the prednisone doses was slowly reduced until 10 mg/d and IMURAN® (Azathioprine) (GlaxoSmithKline, Glaxo Wellcome SA, Guayaquil, Ecuador) was added at doses of 50 mg/d.
Eight days after starting the treatment a good patient evolution was seen: Hemoglobin 11,6 mg/dl (N= 12.0-16), Total Bilirubin 6,81 mg/dl (N= 0-1.0) Direct Bilirubin 4,92 mg/dl (N= 0-0.5); AST 208 U/L (N= 15-37); ALT 278 U/L (N= 15-37). Finally three months after treatment, all laboratory levels became normal.
DISCUSSION
The correct differentiation between clinical cholestasis and hepatocellular diseases is very important in patients with jaundice. A good differential diagnoses and workup is essential for a correct treatment in these patients. Our patient was sent to our institution because of a persistent jaundice after cholecystectomy in a clinical course of high bilirubin levels with gallstones. However, the laboratory data clearly showed a pattern of a hepatocellular disease. Due to her clinical history and laboratory data the differential diagnoses in this case was: drug hepatitis versus viral hepatitis versus autoimmune hepatitis. The laboratory data with autoimmunity antibodies as: antinuclear autoantibodies (ANA), anti-smooth muscle antibody test (ASMA), anti-liver kidney microsomal antibody (anti-LKM), anti-soluble liver antigen (anti-SLA) are necessary in the initial workup. In our patient the presence of an autoimmune hepatitis type 1 was confirmed by the positive ANA and ASMA tests. Biopsy seems the gold standard workup test in patients with autoimmune hepatitis; however, his role is controversial in patients with cirrhosis by this disease. In our case, biopsy was performed to clarify if there was not a subclinical chronicity of the disease, confirming an acute episode without fibrosis. Immunosupressor drugs are the treatment of choice in these patients. In our patient we initially prescribed prednisone 1mg/kg/d during the first weeks, gradually diminishing the dose until 10 mg/d. Finally, the addition of IMURAN® (Azathioprine) (GlaxoSmithKline, Glaxo Wellcome SA, Guayaquil, Ecuador) at doses of 50 mg/d was performed as a maintenance regimen.
REFERENCE
1. Czaja AJ, Freese DK. Diagnosis and treatment of autoimmune hepatitis. Hepatology 2002;36 (2):479-97.
Case of the Month
INTERMITTENT RECTAL BLEEDING
An 80-years old woman was admitted to our institution because of a 7-month rectal bleeding. She described an intermittent bleeding, with some discomfort during stool evacuations, associated with nausea and hyporexia. There were no particular antecedents during clinical history and the physical examination was normal.
The laboratory tests showed a mild anemia (Hb 11mg/dl). During colonoscopy, an anorectal polyp of 20 mm, type Is was detected. The lesion takes in some degree the pectinate line.
We performed an endoscopic mucosal resection (EMR) as treatment, using a Colonoscope (Olympus® Endoscope Evis Exera® 160 series), an injection needle (Injector Force® 23G /5 mm, Olympus®) and one oval snare (Snare Master® 25mm of diameter, Olympus®).
After the procedure an immediate bleeding was observed, and was treated by coagulation using the tip of the oval snare.
DISCUSSION: The treatment of rectal adenomas is surgical or endoscopic resection. In the case of lesions of less than 2 cm the EMR is the treatment of choice. For lesions of more than 2 cm the endoscopic submucosal dissection (ESD) or the EMR by piecemeal technique are indicated. However, in cases which there are a compromise of the pectinate line, the EMR and ESD are discussed due to the technical difficulty and the anal pain induced by the electrosurgical devices. In this case, we performed a one piece resection of the rectal lesion using the electrosurgical snare, and the pectinate area with adenoma was removed using a cold snare.
Evolution: absence of rectal or anal pain, fever or rectal bleeding after procedure. The histopathology analysis shows a tubulovillous adenoma.
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