Ferreira, A

Macedo, G

Pardal, F

Pereira, P

English

Repositório Comum

The American Journal of GASTROENTEROLOGY VOLUME 104 | SUPPLEMENT 3 | OCTOBER 2009   www.amjgastro.comAbstractsS310from sites within the systemic circulation. One manifestation of this is reduced renal arterial perfusion, followed in turn by reduction in the glomerular fi l-tration rate. Nephrotic syndrome (NS) may not be evident clinically unless renal arterial perfusion is such that signifi cant amounts of protein are able to traverse the damaged glomerular endothelium. Case: A 67 year old man with a 26 year history of myelofi brosis developed ascites; its characteristics were those of PHTN, i.e., low albumin and ele-vated serum ascites albumin gradient. Treatment with sodium restriction, and furosemide and spironolactone was not eff ective in controlling ascites; moreover, he developed azotemia (creatinine 3.2 gm%; normal range [NR] 0.6-1.3). Large volume paracentesis became necessary, and eventually on a weekly basis. He had sustained esophageal variceal hemorrage earlier the same year. Before consideration of transjugular intrahepatic portasystemic (TIPS) shunt insertion, the patient underwent hepatic venous pressure gradient (HVPG) assessment and liver biopsy. His HVPG was 17 mm Hg (NR: 2-5). Th e biopsy revealed stage 2 fi brosis, hepatic plate atrophy and evidence of extramedullary hematopoiesis. Th ereaft er, TIPS shunt insertion was undertaken without complication. Th e HVPG was reduced to 4 mm Hg. However, within one month the patient developed hepatic encephalopathy and required hospital admission; heavy proteinuria was demonstrated. Ten days aft er discharge, the patient had impressive, bilateral lower extremity edema, continued heavy proteinuria (3+) and further reduction in serum albumin concentration (2 gm%: NR 3.4-5). His serum creatinine concentra-tion was 1.9 gm% (NR: 0.6-1.3). Discussion with his nephrologist confi rmed that proteinuria had never been present hitherto. Th e 24 hour urine protein was 8 gm (NR: <200mg); renal biopsy confi rmed the presence of non-AL amyloid deposits. Conclusion: Clinical and laboratory evidence of NS emerged within one month of this man undergoing TIPS shunt insertion for refractory ascites for-mation. It is our contention that the presence of PHTN, and thus reduced renal blood fl ow had prevented these features from being clinically apparent until the HVPG was corrected by TIPS shunt insertion. Th e patient’s clinical course has been dominated since by hepatic encephalopathy and worsening renal function to the point of renal replacement therapy. Although a few reports exist about the co-existence of myelofi brosis, PHTN and NS, we believe that this is the fi rst account of NS emerging only aft er TIPS shunt insertion for a complication of PHTN.842A Rare Cause of Recurrent Pain Abdomen Managed by ERCPPradeepta Sethy, MD, Mahesh Goenka, MD, FACG. Gastroenterology, Apollo Gleneagles Hospital, Kolkata, India.Purpose: Recurrent pain abdomen is common presentation in gastroenterology practice. Here, we report a rare case of recurrent pain right upper quadrant.Methods: Case reportResults: A 28 years female presented with pain right upper abdomen of 2 months duration. Th ere was no history of fever or jaundice. Th ere was no history of bowel disturbance or urinary symptom. Ultrasonography showed multiple cystic lesions in both lobe of liver. Hemogram showed Hb- 9.4gm/dl, WBC count - 9100/dl with eosinophil- 36%. Liver function test showed AST - 64 IU/L, ALT - 84 IU/L and ALP - 746 IU/L. She was started on oral metrondiazole, ofl oxacin and antispasmodics. Intermittent pain continued and she started to have low grade fever. CT abdomen revealed multiple com-plex cysts on both lobe of liver (Fig 1). Aspiration revealed brownish mate-rial. Bile pigment was noted on aspirated material and culture was sterile. ERCP was done, which showed irregular fi lling defects in bile duct with communication with on of the cyst. On balloon extraction, 3 live fasciola hepatica were removed (Fig 2). She received Triclabendazole and doing well on follow up.Conclusion: The liver fluke, Fasciola hepatica presenting as recurrent pain abdomen is rare. Also, Fasciola hepatica infestation is not reported from this part of world. Finally, patient was managed by removal of live Fasciola at ERCP.843Congenital Intrahepatic Shunt Presenting as a Pseudometastatic LiverAnibal Ferreira, MD,1 Pedro Pereira, MD,1 Fernando Pardal, MD,2 Guilherme Macedo, MD, PhD, FACG1. 1. Gastroenterology, Hospital São Marcos, Braga, Portugal; 2. Pathology, Hospital São Marcos, Braga, Portugal.Purpose: A 29 year old caucasian male, with no prior medical history, was referred by his general practitioner to the hepatology outpatient clinic with the presumptive diagnosis of diff use hepatic metastization seen in abdomi-nal ultrasonography (multiple hyperecogenic nodules over the hepatic parenchyma — 1-4 cm in diameter - suggestive of secondary lesions). Th e US had been requested due to abnormal liver test Results: AST 64 U/L, ALT 98 U/L, Gamma GT (GGT) 270 U/L and Alka-line Phosphatase (Alk P) 145 U/L. Anorexia and fatigue had insidiously developed over the last 2 months and physical examination showed a nodu-lar hepatic border 3 cm below the costal margin. No other changes were noticed. Blood test results confi rmed elevated AST, ALT, GGT and Alk P with normal albumin level and coagulation tests. Serologic markers for hepatits A, B, and C were negative and tumor markers (carcinoembryonic antigen (CEA), Alpha Fetoprotein (AFP) and CA 19.9) were normal. An upper GI endoscopy and a colonoscopy proved normal too. An abdominal magnetic resonance was requested and revealed multiple hepatic nodules with diff erent sizes, distributed predominantly over the left  hepatic lobe. A magnetic resonance angiography showed a portosystemic intrahepatic shunt (between the right portal vein and the inferior vena cava - Park type 1). An ultrasound guided liver biopsy was performed and the histology was consis-tent with nodular regenerative hyperplasia of the liver. Nodular regenerative hyperplasia of the liver is a rare, benign condition in which there is hepatic micro-nodular regeneration with little or no fi brous septation. Th e hypoth-esis that this transformation may be associated with hepatic vascular defects is widely recognized. In this case a congenital vascular defect was the trigger for this transformation that can simulate hepatic metastization.Fasciola hepatica removed from bile duct at ERCP.CT abdomen showing complex cysts.

Congenital intrahepatic shunt presenting as a pseudometastatic

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Congenital intrahepatic shunt presenting as a pseudometastatic

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