Hepatocellular Carcinoma: An Unusual Presentation of this Rare Clinical Entity in Children

Malignant hepatic tumors are rare in children and hepatocellular carcinomas only represent 20% of cases. A previously healthy 10 year-old male was admitted for sudden abdominal pain. Ultrasound imaging showed an ileo-ileal intussusception with spontaneous resolution, but in the face of worsening pain, fever, and a palpable epigastric mass, abdominal magnetic resonance imaging was performed, showing a liver lesion. Laboratory tests presented elevated liver enzymes and C-reactive protein, so a liver abscess was considered and treated with metronidazole plus ceftriaxone. All of the microbiology tests as well as tumoral markers were negative. Despite clinical and laboratory improvement, the lesion persisted in the imaging. A liver biopsy confirmed a hepatocellular carcinoma, and the patient was submitted to surgical resection and chemotherapy. Contrarily to adults in whom most cases are secondary to chronic liver disease, children may not have risk factors for the disease, which makes it harder to make a prompt diagnosis.info:eu-repo/semantics/publishedVersio

Surgical Management of Calcified Hydatid Cysts of the Liver

Hydatid disease of the liver is still a major cause of morbidity in Greece. Beside the common complications of rupture and suppuration, calcification of the hepatic cysts represent a not well studied, less frequent and sometimes difficult surgical problem. In the present study 75 cases with calcified symptomatic liver echinococcosis were operated on in the 1st Propedeutic Surgical Clinic between 1964 to 1996. Twenty-eight patients were male and 47 female with ages from 23 to 78 years. The diagnosis was based mainly on the clinical picture and radiological studies. In 5 cases the operative method was cystopericystectomy. We performed evacuation of the cystic cavity and partial pericystectomy and primary closure of the residual cavity in 6 cases, omentoplasty or filling of the residual cavity with a piece of muscle of the diaphragm in 4 cases and external drainage by closed tube, in 60 cases. In 12 of those with drainage, after a period of time, a second operation with easy, removal of most of the calcareous wall plaques was performed. The mortality rate was 2%

Imaging of biliary carcinoma, fistula and primary sclerosing cholangitis and percutaneous metallic stenting in malignant biliary obstruction

AbstractBiliary carcinoma, biliary fistula with occasional gallstone ileus and primary sclerosing cholangitis (PSC) are serious diseases and present specific diagnostic and therapeutic challenges. Stenting of biliary obstruction has also involved problems, but the reports are contradictory and partly limited. The aim of the present work was to evaluate and compare various imaging modalities in biliary diseases. The study also aimed to evaluate the usefulness of metallic stents in malignant biliary obstruction.The study population consisted of 210 patients with gallbladder carcinoma, bile duct carcinoma, biliary fistula, PSC or malignant biliary obstruction and eight control patients with various hepatobiliary diseases. The imaging findings of 80 patients with gallbladder carcinoma, 58 patients with bile duct carcinoma, and 16 patients with biliary fistula were reviewed. Nine patients with PSC underwent magnetic resonance cholangiography (MRC) and magnetic resonance imaging (MRI) of the liver, ultrasonography (US) of the liver and the bile ducts and endoscopic retrograde cholangiography (ERC). Eight control patients had had MRC and MRI of the liver and ERC. The medical records and radiographs of 39 patients with malignant biliary obstruction treated with percutaneously inserted metallic stents were also analysed. The stents included 48 Wallstents and seven Memotherm stents.In cases of gallbladder carcinoma, US visualised the primary tumour in 68% and computed tomography (CT) in 57% of the cases examined, but both methods were insufficient for accurate staging. In bile duct carcinoma, US revealed the primary tumour in 63% and CT in 44% of the cases examined. Both methods were sensitive in diagnosing peripheral intrahepatic cholangiocarcinoma, but inaccurate for more distal bile duct carcinoma or abdominal spread. The infiltrating type of gallbladder carcinoma and bile duct carcinoma were difficult to detect. US and CT were sensitive in revealing bile duct obstruction.The patients with biliary fistula and gallstone ileus had undergone various examinations with pathological, but not diagnostic results, and there was often a delay to diagnosis. Imaging did not reveal any of the ten spontaneous fistulas, but CT showed one of the five cases of gallstone ileus, and Gastrografin® meal revealed the single case of Bouveret’s syndrome. Fistulography or cholangiography revealed all but one of the six iatrogenic fistulas. A nonvisualised or shrunken gallbladder at US should raise a suspicion of biliary enteric fistula in an appropriate clinical setting.MRC-MRI depicted the changes of PSC correctly in nine patients (radiologist 1) and in eight patients with one false positive finding (radiologist 2) in a blinded analysis. In the segmental comparison MRC missed especially bile duct dilatations. MRC was too pessimistic in the evaluation of the predictors of poor outcome. US detected features suggestive of PSC in eight patients (radiologist 3). US was unable to indicate the predictors of poor outcome.Of the patients with metallic stents in malignant biliary obstruction, 30% had early and 66% late complications, including stent obstructions, which occurred in 27% of the patients at a mean of 4.4 months. The cause was mostly tumour ingrowth or overgrowth. The 25-week and 50-week patency rates were 71% and 42%. The patency rates of the patients with cholangiocarcinoma were significantly the lowest. There was also a tendency towards lower patency with less dilatation of the stents, an increasing number of the stents, longer strictures and hilar strictures. Many other complications were infectious. 31% of the patients had late reinterventions.Academic Dissertation to be presented with the assent of the Faculty of Medicine, University of Oulu, for public discussion in the Auditorium 7 of the University Hospital of Oulu, on March 23rd, 2001, at 12 noon.Abstract Biliary carcinoma, biliary fistula with occasional gallstone ileus and primary sclerosing cholangitis (PSC) are serious diseases and present specific diagnostic and therapeutic challenges. Stenting of biliary obstruction has also involved problems, but the reports are contradictory and partly limited. The aim of the present work was to evaluate and compare various imaging modalities in biliary diseases. The study also aimed to evaluate the usefulness of metallic stents in malignant biliary obstruction. The study population consisted of 210 patients with gallbladder carcinoma, bile duct carcinoma, biliary fistula, PSC or malignant biliary obstruction and eight control patients with various hepatobiliary diseases. The imaging findings of 80 patients with gallbladder carcinoma, 58 patients with bile duct carcinoma, and 16 patients with biliary fistula were reviewed. Nine patients with PSC underwent magnetic resonance cholangiography (MRC) and magnetic resonance imaging (MRI) of the liver, ultrasonography (US) of the liver and the bile ducts and endoscopic retrograde cholangiography (ERC). Eight control patients had had MRC and MRI of the liver and ERC. The medical records and radiographs of 39 patients with malignant biliary obstruction treated with percutaneously inserted metallic stents were also analysed. The stents included 48 Wallstents and seven Memotherm stents. In cases of gallbladder carcinoma, US visualised the primary tumour in 68% and computed tomography (CT) in 57% of the cases examined, but both methods were insufficient for accurate staging. In bile duct carcinoma, US revealed the primary tumour in 63% and CT in 44% of the cases examined. Both methods were sensitive in diagnosing peripheral intrahepatic cholangiocarcinoma, but inaccurate for more distal bile duct carcinoma or abdominal spread. The infiltrating type of gallbladder carcinoma and bile duct carcinoma were difficult to detect. US and CT were sensitive in revealing bile duct obstruction. The patients with biliary fistula and gallstone ileus had undergone various examinations with pathological, but not diagnostic results, and there was often a delay to diagnosis. Imaging did not reveal any of the ten spontaneous fistulas, but CT showed one of the five cases of gallstone ileus, and Gastrografin® meal revealed the single case of Bouveret’s syndrome. Fistulography or cholangiography revealed all but one of the six iatrogenic fistulas. A nonvisualised or shrunken gallbladder at US should raise a suspicion of biliary enteric fistula in an appropriate clinical setting. MRC-MRI depicted the changes of PSC correctly in nine patients (radiologist 1) and in eight patients with one false positive finding (radiologist 2) in a blinded analysis. In the segmental comparison MRC missed especially bile duct dilatations. MRC was too pessimistic in the evaluation of the predictors of poor outcome. US detected features suggestive of PSC in eight patients (radiologist 3). US was unable to indicate the predictors of poor outcome. Of the patients with metallic stents in malignant biliary obstruction, 30% had early and 66% late complications, including stent obstructions, which occurred in 27% of the patients at a mean of 4.4 months. The cause was mostly tumour ingrowth or overgrowth. The 25-week and 50-week patency rates were 71% and 42%. The patency rates of the patients with cholangiocarcinoma were significantly the lowest. There was also a tendency towards lower patency with less dilatation of the stents, an increasing number of the stents, longer strictures and hilar strictures. Many other complications were infectious. 31% of the patients had late reinterventions

Gallbladder cancer, a much more frequent entity than we thought. Review of the literature

Ο καρκίνος της χοληδόχου κύστεως μπορεί να μην είναι συχνός, η θνητότητά του όμως είναι υψηλή. Τα δύο αυτά δεδομένα σε συνδυασμό με την μεγάλη γεωγραφική διασπορά της συχνότητάς του εμποδίζουν τους ερευνητές να διεξάγουν προοπτικές μελέτες ικανές να οδηγήσουν σε παγκοσμίως αποδεκτές κατευθυντήριες οδηγίες όσο αφορά την αντιμετώπισή του. Τα τελευταία χρόνια έχει αυξηθεί πολύ ο αριθμός των, λαπαροσκοπικών κυρίως, χολοκυστεκτομών για καλοήθεις παθήσεις και ως εκ τούτου αυξήθηκε ο αριθμός των διαγνώσεων του καρκίνου της χοληδόχου κύστεως ως τυχαίο εύρημα μετά από χολοκυστεκτομή για καλοήθη πάθηση σε σημείο που οι μισές και πλέον διαγνώσεις του γίνονται με αυτόν τον τρόπο. Το review αυτό συγκεντρώνει τις έρευνες που αφορούν την αντιμετώπιση του τυχαίως διαγνωσθέν καρκίνου χοληδόχου κύστεως τα τελευταία 15 χρόνια το οποία και αναλύονται διεξοδικώς. Τα συμπεράσματα που προκύπτουν δείχνουν ότι σε πολλά κομβικά σημεία στην αντιμετώπιση του καρκίνου, όπως τον τύπο της επανεπέμβασης ή το χρονικό παράθυρο από την χολοκυστεκτομή έως και την επανεπέμβαση, τα δεδομένα είναι αντικρουόμενα, κυρίως μεταξύ Δύσης και Ανατολής, ενώ νέες μελέτες που δημοσιεύονται ανατρέπουν παλαιότερες κατευθυντήριες οδηγίες. Συνεπώς, ο τυχαίως διαγνωσθέν καρκίνος χοληδόχου κύστεως απαιτεί περισσότερη προσοχή από του ερευνητές καθώς απαιτούνται μεγάλες πολυκεντρικές μελέτες ώστε να οδηγήσουν σε ασφαλές, ευρέως αποδεκτές κατευθυντήριες οδηγίες.Gallbladder cancer is a quite rare but lethal disease of the biliary truck with high geographic differences in incidence. This fact prevents the worldwide medical community to perform high value, prospective studies as most data considering management of gallbladder cancer comes from retrospective studies. Laparoscopic cholecystectomy for benign lesions has become more and more frequent over the last decades. Therefore, incidental gallbladder cancer after cholecystectomy for benign lesions has also become more frequent to the point that half the cases of gallbladder cancer are diagnosed this way. We reviewed papers about incidental gallbladder cancer over the last 15 years. The key point of this review is that there are not proper guidelines for some parts of the management of incidental gallbladder cancer, such as type and time of re-resection, as many authors disagree with each other, especially between East and West. Moreover, new studies suggest changes to current guidelines, but a higher number and value of studies is needed for these changes to be approved. Consequently, large prospective studies are needed to determine safe and worldwide approved guidelines for the management of incidental gallbladder cancer

A study of the role of oncogenes and tumour suppressor genes in malignant pancreatico-biliary tumours

The molecular understanding of tumour development and progression has advanced considerably with the discovery of oncogenes and tumour suppressor genes. Surgical treatment is the only therapy that offers the potential for cure in hepatopancreatobiliary malignancy. Distinct from other solid tumours, HPB malignancies are unique in that many patients are considered unresectable despite only local, small volume disease. "Curative" resection unfortunately fails in 50% or more of cases. With such poor responses from conventional medical treatments, these tumours are potentially a target for genetic manipulation. The aim of this study was to identify those protein products abnormally expressed in HPB malignancy (by immunohistochemical analysis). In order to narrow down the field of protein products to be investigated, those that are abnormally expressed commonly in foregut tumours were chosen (p53, c-myc, MIB-1, Bcl-2 and c-erbB-2). Given that the embryological derivation of HPB tumours is also foregut, these factors were investigated in this group of neoplasms looking for distinguishing or diagnostic characteristics in expression. The results were compared with expression within pre- invasive, invasive and pre-malignant lesions of the same tissues. No classification based on expression of any of the oncogene products could be used to distinguish the site of tumour origin. Based on comparisons with benign and normal tissue examples, no useful diagnostic differences were discovered between expression of any of the markers. To assess whether expression was a feature of aggressive biological behaviour, comparisons were made for each grade of tumour. Only ampullary lesions had a significant increase in expression of p53 protein with advancing grade of tumour. Confirmed was the suspicion that immunohistochemically-expressed p53 protein is not confined to malignant cells alone. There was a high percentage of expression of c-myc and p53 proteins in all tumour sites, but seemingly no relevance to cancer development. Given this, the second stage of this study was to investigate controlling mechanisms around these proteins and assess whether these dictated the progression of the cell cycle to mitosis or release to differentiation, cell death or DNA repair pathways and thus avoidance of malignant change. In-situ hybridisation techniques were used to assess the expression of mRNA (MDM-2, p21WAF-1, Bax and BCLX1 cDNA probes constructed in-house) in serial sections of ten cholangiocarcinomas and two normal gallbladders. This was compared with expression of p53, MDM-2, p21WAF-1, Bax, c-erbB-2, Bcl-2, MIB-1 and c-myc proteins by immunohistochemistry and cell death (apoptosis) by histopathological assessment and the TUNEL assay. Heterogeneity of expression resulted in no correlation between markers being of any significance or in any pattern of expression within a tumour group compared to normal biliary epithelium. The third stage of the study was to assess whether any protein expression had prognostic significance in cholangiocarcinoma compared to accepted prognostic clinical and pathological criteria by Kaplan-Meier survival analysis. No marker performed usefully in assessing aggressiveness of disease. An incidental finding during this study was that Bcl-2 plays no part in regulating cell survival within the biliary tree. This is distinct from the overwhelming majority of other tissues where Bcl-2 does regulate survival. This role, in the biliary tree, is performed by a Bcl-2-related gene - BclxL. This is now being more formally assessed in further studies as well as the response of cholangiocarcinoma cells to manipulations of these and other cell survival factors

Immunosuppression and Tolerance in Adult Liver Transplantation. A literature review on the immunosuppression-drugs after a liver transplantation; how to best provide safe treatment and good quality of life.

Background: There is increasing interest in long-term management issues in liver transplantation recipients; quality of life, complications related to extended immunosuppressants, natural development of co-morbidities and recurrent disease. IS agents are used in induction of the liver transplantation, maintenance of the organ, and reversal of organ rejection. Aim: A systematic literature search with the purpose of summaries the existing clinical research on this specific topic; immunosuppressive medications post-liver transplantation. Material and methods: Search method in PubMed; Medical Subject Headings, with the terms: ("Liver Transplantation"[Mesh]) AND "Immunosuppression" [Mesh]. The selected studies were assessed for scientific quality and relevance for the thesis. Results: Steroid-based IS are responsible for a substantial post-LTx morbidity and mortality, hence, minimization of its use is of utmost importance to improve patient’s quality of life. Because of systemic steroids impact on all organs in the human body and all its side effects that increases risk factors of morbidity. It is important to comprehend the hepatic disease and the patient, as well as understanding the efficacies and side effects/interactions of IS medication. This way the doctor and the patient can strike a balance between suppression of rejection and minimization of side effects. The patient group are very complex, and this have been shown to be a challenge when it comes to comparing the result on the effect of different studies with different immunosuppression’s as the reason for liver failure have a lot to say for graft rejection and patient survival, especially for complication accruing with lifelong IS. Conclusion: LTx recipients are an inherently complex population, with diverse and serious underlying medical concerns that have the potential to adversely affect posttransplant outcomes, thus would a general IS therapy lead to a greater rejection rate. There is a need for more clinical studies, random control trails, that can help us finding the best immunosuppressive treatment for liver transplanted patients

Colombian consensus on the diagnosis, treatment, and prevention of candida Spp. disease in children and adults

La Candidiasis Invasora (CI) y la candidemia, como su manifestación más frecuente, se ha convertido en la principal causa de micosis oportunista a nivel hospitalario. Este manuscrito realizado por miembros de la Asociación Colombiana de Infectología (ACIN), tuvo como objetivo proporcionar un conjunto de recomendaciones para manejo, seguimiento y prevención de la CI/candidemia y de la infección candidiásica de mucosas, en población adulta, pediátrica y neonatal, en un entorno hospitalario, incluyendo las unidades hemato-oncológicas y unidades de cuidado crítico. Todos los datos obtenidos mediante una búsqueda exhaustiva, fueron revisados y analizados de manera amplia por todos los miembros del grupo, y las recomendaciones emitidas se elaboraron luego de la evaluación de la literatura científica disponible, y el consenso de todos los especialistas involucrados, reconociendo el problema de la emergencia de las infecciones por Candida Spp. y brindando una correcta orientación a los profesionales de la salud sobre el manejo de pacientes con enfermedad candidiásica, de una forma racional y práctica, enfatizando en la evaluación del paciente, estrategias de diagnóstico, profilaxis, tratamiento empírico, tratamiento dirigido y terapia preventiva.Invasive Candidiasis (IC) and candidemia (as its most frequent manifestation) have become the main cause of opportunistic mycosis at hospital settings. This study, made by members of the Colombian Association of Infectious Diseases (ACIN), was aimed at providing a set of recommendations for the management, follow-up and prevention of IC / candidemia and mucous membrane candida infection in adult, pediatric and neonatal patients in a hospital setting, including the hemato-oncological and critical care units. All the data obtained through an exhaustive search were reviewed and analyzed in a comprehensive manner by all the members of the group, and the recommendations issued are being made after a careful review of the scientific literature available and the consensus of all specialists involved; the emergence of Candida Spp. problem is highlighted and a correct orientation to health professionals regarding the management of patients with candidiasis is provided in a rational and practical way, emphasizing patient evaluation, diagnostic strategies, prophylaxis, empirical treatment, directed treatment and preventative therap

The nurse of the Mediterranean

During the First World War Malta did not take an active part in the fighting. Britain was joined in an ‘entente’ a friendship agreement with France since 1904 and later with Russia in 1907. On the other hand Germany was allied to the Austrian- Hungerian Empire, hence when the Great War started in July 1914 there were France, Britain and Russia on one side and Germany and Austria-Hungary on the other. The British fleet “ruled the waves”, hence with France and Britain as allies, to be joined later by Italy, the Mediterranean was more or less an allied lake, with Malta in the centre.peer-reviewe

Microbiological aspects of enterococci isolated at King Edward VIII Hospital, Durban.

Thesis (M.Med.Sc.)-University of Natal, 1999.The increasing frequency of enterococci as a major cause of nosocomial infections and the transmission of these organisms amongst hospital patients demands a greater awareness of the Enterococcus. Therapy of enterococcal infections is complicated by the pathogens continually changing resistance patterns to many broad-spectrum antibiotics. In addition, the ability of enterococci to cause serious invasive infections including endocarditis and septicaemia with associated high mortality rates; prompted this study which was aimed at identifying the biological properties of enterococci isolated from blood cultures of patients admitted at King Edward VIII hospital, Durban. Enterococci were identified to species level by the API 20 Strep system which identified 68% and a conventional biochemical system of Facklam and Collins which identified 100% of the isolates.The emergence of beta-Iactamase producing enterococci in other countries encouraged the testing of all isolates for this enzyme. All were beta-Iactamase negative. The reported false susceptibility for aminoglycosides and cephalosporins with blood enriched media encouraged the testing of these antibiotics with and without the supplementation of 5% lysed blood. The results showed that an average false susceptibility of 55 % occurred for gentamicin and 35% for tobramycin and netilmicin. The cephalosporins affected, cefotaxime and cefuroxime showed a false susceptibility of 28% and 17% respectively. The choice of treatment for serious enterococcal infections is a syllergistic combination of a beta-Iactam antibiotic plus an aminoglycoside for enterococci with intrinsic low-level resistance. The development of high-level aminoglycoside resistance, MIC 22000,ug/ml results in loss of synergism. This study showed that 26.4 % of enterococcal isolates displayed high level aminoglycoside resistance i.e. to gentamicin and streptomycin. Time-kill study showed reduced killing rate for these organisms for the beta-Iactams and glycopeptides with low-level gentamicin resistance. The results confirmed that a cell-wall active agent combined with gentamicin can be successfully used for enterococcal therapy if the organism has intrinsic low-level resistance to this amino glycoside. Pulsed-field gel electrophoresis (PFGE) carried out on a selected number of Enterococcus faecalis and Enterococcus faecium with high-level aminoglycoside resistance showed a variability in the restriction endonucelase digestion patterns. This suggests independent development of high-level gentamicin resistance and not clonal expression. The ease and reliability with which enterococcal isolates may be typed using this technique to compare different strains represent a significant advance